5. Therapy

Early involvement of a multidisciplinary team, as discussed below, is critical to the successful management of these complex patients. As many of these patients will require prolonged course of targeted antibiotics, compliance can be an issue even in the most motivated patients. These patients often require close follow-up to ensure that recommended treatment plans are not only adhered to but, more importantly, successful in eradicating the infection resulting in symptomatic valvular destruction. While it might be easy for the provider to "prescribe" a prolonged course of antibiotic therapy, successful completion often involves a recognition of the multiple socioeconomic issues that are keys to success. Many patients do not have the ability or resources to comply with daily (or more frequent) outpatient therapies—and clearly, prolonged hospital stays to complete a course of antibiotics is no longer reasonable nor practical. As such, care teams are often forced to become "creative" in discharge and treatment planning to individualize therapy within the framework of social support, financial resources, and patient factors. Such care plans might not follow established guidelines strictly, but as long as all involved—especially the patient through shared decision-making—understand the risks, benefits, goals, and options, then unconventional plans might be more likely to clinically succeed in the long run than guideline-based therapies that are, at an individual level, unreasonable and unlikely to succeed.

Even though there is some variability in the specific indications, and level of evidence to support for surgical therapy, in general early surgery should be considered in those patients

Introductory Chapter: Introduction to Advanced Concepts in Endocarditis

http://dx.doi.org/10.5772/intechopen.79883

7

1. Early surgery is recommended for those patients with fungal infections or highly resistant

3. Those patients who present with cardiovascular complications directly associated with their infections including new heart block, aortic or root, or annular abscess cavities or penetrating infectious complications such as fistula might benefit from early surgery. 4. Surgery is indicated in the setting of persistent bacteremia or fever greater than 5–7 days in the absence of another identifiable primary source in the setting of appropriate targeted

5. Enlarging vegetations despite appropriate antibiotic therapy or evidence of recurrent

6. Vegetations that are mobile and greater than 1 cm and/or with evidence of severe valve

7. Mobile vegetations that are greater than 1 cm especially in the setting of other relative indications for surgery and when involving the anterior leaflet of the mitral valve.

Similar recommendations are used to guide therapy in patients with prosthetic valve endocarditis [26]. As discussed at length in the chapter on prosthetic valve infectious, it must be recognized that medical management is rarely successful, and despite what might be considered prohibitive surgical risks, the best chance at a long-term durable cure of infected pros-

As previously mentioned, the worldwide substance abuse epidemic has resulted in a significant increase in patients presenting with right-sided endocarditis (i.e., involvement of the tricuspid valve). Because of historical concerns of relapse, noncompliance, and unclear indications for surgical intervention, many of these patients were treated medically—with treatment failures often blamed on the patient's social issues. However, as more and more patients present with right-sided disease, there is a growing body of the literature focusing on how to best treat this difficult patient population. Contemporary guidelines and indications for rightsided interventions follow those for left-sided disease [27]. Nevertheless, the specific surgical procedures considered for these patients, despite decades of experience, remain unclear [28, 29]. Options included "vegectomy," "valvectomy," valve repair, and valve replacement [30]. The historical literature on simply removing the infected tricuspid valve and leaving the patient with "wide-open" tricuspid regurgitation is still frequently utilized despite concerns for the development of severe right-heart failure and its devastating pathophysiologic consequences [31]. Even though there are a small subset of patients who not only survived this surgical approach AND complete a course of drug rehabilitation AND are deemed to be reasonable surgical candidates for eventual valve replacement AND have an uncomplicated surgical course, some advocate

2. Valvular dysfunction resulting in signs or symptoms of acute heart failure.

who present with the following signs and symptoms [25]:

thetic material often requires removal and replacement.

organisms.

antibiotic therapy.

regurgitation.

embolic complications.

Probably one of the most important aspects in the management of endocarditis is identifying those patients who might benefit from surgical management. While current guidelines, as discussed below and in several chapters in this text, can help provide indications for surgery, the decision to operate is not always so simple. Patients often present critically ill, neurologic complications such as embolic strokes are common, and often there are complex comorbidities and surgical technical issues (i.e., previous cardiac surgery) that must be considered in the decisionmaking process of when to operate—and, just as importantly, what operation to perform.

Case by case surgical judgment (and experience) is often required to determine which structures can and should be preserved as opposed to which structures might require aggressive debridement and replacement. Surgeons must caution against the concept of "exercises in technique over judgement." While repairing an infected valve might limit the risk of reinfected prosthetic material or the need for re-intervention for a failing (or infected) artificial heart value, it must be also recognized that failed repairs are not without short- and long-term risks and complications either both in terms of reinfection from inadequate debridement of infected tissue and from the development of heart failure or structure complications from valvular dysfunction. A significant challenge is also the timing of surgery in the setting of systemic infections and complications especially neurologic complication [21]. As discussed, each case requires a delicate balance when evaluating the potential risks and benefits of early versus delayed surgical therapy. However, without a doubt, early and aggressive intervention has been shown to improve overall outcomes at both the individual and population level. Such changes in the paradigm from delayed surgical management to earlier intervention are well established in current European and American Society guidelines, based upon randomized trials and extensive clinical experience, and discussed in further detail throughout this text [22–24].

Even though there is some variability in the specific indications, and level of evidence to support for surgical therapy, in general early surgery should be considered in those patients who present with the following signs and symptoms [25]:


5. Therapy

6 Advanced Concepts in Endocarditis

sonable and unlikely to succeed.

sed in further detail throughout this text [22–24].

Early involvement of a multidisciplinary team, as discussed below, is critical to the successful management of these complex patients. As many of these patients will require prolonged course of targeted antibiotics, compliance can be an issue even in the most motivated patients. These patients often require close follow-up to ensure that recommended treatment plans are not only adhered to but, more importantly, successful in eradicating the infection resulting in symptomatic valvular destruction. While it might be easy for the provider to "prescribe" a prolonged course of antibiotic therapy, successful completion often involves a recognition of the multiple socioeconomic issues that are keys to success. Many patients do not have the ability or resources to comply with daily (or more frequent) outpatient therapies—and clearly, prolonged hospital stays to complete a course of antibiotics is no longer reasonable nor practical. As such, care teams are often forced to become "creative" in discharge and treatment planning to individualize therapy within the framework of social support, financial resources, and patient factors. Such care plans might not follow established guidelines strictly, but as long as all involved—especially the patient through shared decision-making—understand the risks, benefits, goals, and options, then unconventional plans might be more likely to clinically succeed in the long run than guideline-based therapies that are, at an individual level, unrea-

Probably one of the most important aspects in the management of endocarditis is identifying those patients who might benefit from surgical management. While current guidelines, as discussed below and in several chapters in this text, can help provide indications for surgery, the decision to operate is not always so simple. Patients often present critically ill, neurologic complications such as embolic strokes are common, and often there are complex comorbidities and surgical technical issues (i.e., previous cardiac surgery) that must be considered in the decisionmaking process of when to operate—and, just as importantly, what operation to perform.

Case by case surgical judgment (and experience) is often required to determine which structures can and should be preserved as opposed to which structures might require aggressive debridement and replacement. Surgeons must caution against the concept of "exercises in technique over judgement." While repairing an infected valve might limit the risk of reinfected prosthetic material or the need for re-intervention for a failing (or infected) artificial heart value, it must be also recognized that failed repairs are not without short- and long-term risks and complications either both in terms of reinfection from inadequate debridement of infected tissue and from the development of heart failure or structure complications from valvular dysfunction. A significant challenge is also the timing of surgery in the setting of systemic infections and complications especially neurologic complication [21]. As discussed, each case requires a delicate balance when evaluating the potential risks and benefits of early versus delayed surgical therapy. However, without a doubt, early and aggressive intervention has been shown to improve overall outcomes at both the individual and population level. Such changes in the paradigm from delayed surgical management to earlier intervention are well established in current European and American Society guidelines, based upon randomized trials and extensive clinical experience, and discus-


Similar recommendations are used to guide therapy in patients with prosthetic valve endocarditis [26]. As discussed at length in the chapter on prosthetic valve infectious, it must be recognized that medical management is rarely successful, and despite what might be considered prohibitive surgical risks, the best chance at a long-term durable cure of infected prosthetic material often requires removal and replacement.

As previously mentioned, the worldwide substance abuse epidemic has resulted in a significant increase in patients presenting with right-sided endocarditis (i.e., involvement of the tricuspid valve). Because of historical concerns of relapse, noncompliance, and unclear indications for surgical intervention, many of these patients were treated medically—with treatment failures often blamed on the patient's social issues. However, as more and more patients present with right-sided disease, there is a growing body of the literature focusing on how to best treat this difficult patient population. Contemporary guidelines and indications for rightsided interventions follow those for left-sided disease [27]. Nevertheless, the specific surgical procedures considered for these patients, despite decades of experience, remain unclear [28, 29]. Options included "vegectomy," "valvectomy," valve repair, and valve replacement [30]. The historical literature on simply removing the infected tricuspid valve and leaving the patient with "wide-open" tricuspid regurgitation is still frequently utilized despite concerns for the development of severe right-heart failure and its devastating pathophysiologic consequences [31]. Even though there are a small subset of patients who not only survived this surgical approach AND complete a course of drug rehabilitation AND are deemed to be reasonable surgical candidates for eventual valve replacement AND have an uncomplicated surgical course, some advocate (including this author) that this approach is completely against surgical and medical wisdom, inappropriate ethically, and predisposes patients to unreasonable postoperative complications and that operative intervention must involve appropriate debridement of all infected tissues but, as importantly, not predispose the patient to the catastrophic sequelae of "wide-open" tricuspid regurgitation. The technical and ethical aspects of right-sided disease and the management of patients with substance abuse are discussed in this text. Rarely is right-side infections managed with procedures that result in severe regurgitation—a pathophysiology that is often the initial indication for intervention.
