**6. Indications for surgery**

While there are a variety of resources available to assist in the decision making regarding interventions for prosthetic valve endocarditis, the key principles of therapy have been advocated by both American [68, 69] and European societies [70].

	- Valve dysfunction resulting in symptoms of heart failure (Class I).
	- Left-sided infectious endocarditis caused by S. aureus, fungal, or other highly resistant microorganisms (Class I).
	- Relapsing infection (Class IIa).
	- Recurrent emboli and persistent vegetations despite appropriate antibiotic therapy (Class IIa).

<sup>1</sup> Adapted from The American Association of Thoracic Surgeons consensus statement on the management of infectious endocarditis [68].

	- Once an indication for surgery is established, the patient should be operated on within days (Class I). Earlier surgery (emergency or within 48 hours) is reasonable for patients with large, mobile vegetations (Class IIa).

valve infections-either as a result of their initial operation, their ongoing (and potentially worsening) comorbidities, or simply as a function of patients living longer and with a cumulative annual risk. The development of prosthetic valve endocarditis is often, and appropriately so, viewed as a catastrophic event due to its association with devastating complications (i.e., strokes), substantial risk for operative morbidity and/or mortality, and baseline comorbidities and functional status at the time of presentation. More than most other medical and surgical therapies, a timely engagement by a multidisciplinary team is crucial to the establishment of a short- and long-term treatment plan. Clearly, much like native valve endocarditis, patients with prosthetic valve infections have shown benefit from early and aggressive surgical therapies-once established indications for surgery have been met or it has been demonstrated that optimized medical therapies have failed. Such therapies, despite substantial perioperative risks, must be focused on with aggressive debridement and elimination of all prosthetic and infected material. While prolonged courses of antibiotics and nonoperative management may have a role in select patients with limited disease burden, or for those in whom surgical reintervention is deemed to be a prohibitive, it must be recognized that the risk of treatment failure in such patients often results in worse complications or premature death. In conclusion, the medical and specific surgical decisions when dealing with a prosthetic valve infection must be individualized to provide the patient with the best opportunity for a cure.

None of the authors of this chapter have any disclosures or conflicts of interest to report in the

, Sarah Eapen2

[1] Wang A, Athan E, Pappas MS, et al. Contemporary clinical profile and outcome of pros-

and Michael S. Firstenberg3,4

Prosthetic Valve Endocarditis

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http://dx.doi.org/10.5772/intechopen.79758

**Conflict of interest**

**Author details**

Ahmed Fayaz<sup>1</sup>

**References**

context of the material presented.

\*, Medhat Reda Nashy<sup>1</sup>

\*Address all correspondence to: drfayaz@gmail.com

1 King Fahd Hospital of University, Khobar, Saudi Arabia 2 Summa Akron City Hospital, Akron, Ohio, United States

3 The Medical Center of Aurora, Aurora, Colorado, United States

thetic valve endocarditis. JAMA. 2007;**297**:1354-1361

4 Northeast Ohio Medical Universities, Rootstown, Ohio, United States

	- An operative delay of 3 weeks or more is reasonable among patients with recent intracranial hemorrhage (Class IIa).
	- Patients with PVE and neurologic symptoms should undergo brain imaging (Class I); it is reasonable to screen patients with left-sided IE for possible stroke or intracranial bleeding prior to operation (Class IIa).
	- Aortic PVE. If the root and the annulus are preserved after radical debridement in prosthetic aortic valve IE, implantation of a new prosthetic valve (tissue or mechanical) is reasonable (Class IIa). If there is annular destruction and invasion outside the aortic root, then the root reconstruction and use of an allograft or a biologic tissue root are preferable to a prosthetic valved conduit (Class IIa).
	- Mitral PVE.When there are annular destruction and invasion, the annulus is reconstructed and the new prosthetic valve anchored to the ventricular muscle or to the reconstruction patch in a way to prevent leakage and pseudoaneurysm development (Class IIa).
	- Among patients on dialysis, normal indications for surgery are reasonable, but additional comorbidities must be factored into assessments of risks and outcomes (Class IIa). Shorter durability of bioprostheses and allografts may be considered in the choice of valve prostheses used (Class IIa).
