Contents

**Preface XI**


#### Chapter 7 **Surgical Treatment for Tricuspid Valve Infective Endocarditis 103** Takashi Murashita

Chapter 8 **Prosthetic Valve Endocarditis 115** Ahmed Fayaz, Medhat Reda Nashy, Sarah Eapen and Michael S. Firstenberg

Preface

toward noncompliance.

Endocarditis is an infection of the heart and is often characterized by the involvement of the cardiac valves, other intracardiac structures, or implantable devices that support cardiac function. Infections are defined by the involvement of either native cardiac structures or prosthetic or artificial materials or implants. Systemic complications, acute heart failure, and sepsis are common presenting signs and symptoms. The advances in imaging technologies such as echocardiography, computed tomography, and magnetic resonance imaging have facilitated the diagnosis and management of patients with suspected and proven infections. Nevertheless, the management of infected patients remains a formidable challenge. While patients often require a prolonged course of antibiotic (or antifungal) therapy, many cases require surgical intervention to appropriately "cure" them of their infections. The difficulty is in determining the timing of surgical intervention, often in the setting of recent or ongoing bacteremia, embolic complications such as recent stroke, acute heart failure, or evidence on worsening infection despite appropriate medical antibiotic therapy. Historical paradigms of care suggested a prolonged period of antibiotics with the goal of sterilization of the infected structures prior to surgery; however, this often resulted in substantial morbidity and/or mortality in those awaiting surgery. The obvious selection bias that occurs from withhold‐ ing surgical therapy, while reasonable in patients for whom surgery is deemed to be too high risk or who show signs of improvement, has been shown to potentially deprive some patients of the chance of a definitive cure. Hence, currently, treatment plans will often con‐ sider early surgical intervention‑even in those patients historically viewed as having highrisk characteristics. In fact, it is often those high-risk factors (as mentioned above) that serve as strong indicators that surgery should be considered. The growing difficulty in the current era of endocarditis management is the ethical dilemma in dealing with patients with infec‐ tions, and sometimes reinfections, that are the result of "undesirable" (as viewed by some) social habits or lifestyle choices, such as intravenous substance abuse (IVDA). Such patients can be extremely difficult to manage in the acute (or perioperative) phase and their endocar‐ ditis can be very difficult to eradicate long-term. Without a doubt, patients with IVDA are at an extremely high risk for recurrence of their infections. Regardless of whether such abuse is viewed as a medical problem, a social problem, or a lifestyle decision, much debate is fo‐ cused on how much time, energy, and resources should be devoted to treat a patient who many view as having an incurable problem‑namely, their substance abuse and tendencies

In addition, there is a growing recognition of unusual causes of cardiac infections. Historically, a small subset of patients, despite imaging and clinical evidence of an infection, does not have positive cultures that can be used to guide antimicrobial therapy. With advances in genetic testing, molecular and biological markers, and other sophisticated techniques for growing and detecting unusual organisms, clinicians have better tools to use in adequately identifying caus‐

ative agents and, therefore, allowing for more appropriate and targeted therapies.

