5. Indications for operation

Indications for operation are based in the hemodynamic state of the valvar lesion or defect. When active NVE is present, a lack of consensus exists about some of the specific indications for surgery [61]. General indications for operation, however, exist from both the American and European societies (Table 3) [8, 24]. As for timing of surgery, specific recommendations are outlined in Table 4 [26]. However it is important to remember that no randomized controlled

Congestive heart failure\*

• Congestive heart failure as a result of prosthetic dehiscence or obstruction

Periannular extension

• Most patients with abscess formation or fistulous tract formation

Systemic embolism†


Cerebrovascular complications‡


Persistent sepsis


Difficult organisms


<sup>•</sup> Congestive heart failure caused by severe aortic or mitral regurgitation or, more rarely, by valve obstruction caused by vegetations

<sup>•</sup> Severe acute aortic or mitral regurgitation with echocardiographic signs of elevated left ventricular end-diastolic pressure or significant pulmonary hypertension


Freedom from reoperation is higher when the mitral valve is involved (compared with the aortic valve) probably for less annular involvement. In a series from Brigham and Women's Hospital (Boston) reporting freedom from reoperation for mitral valve IE, the results found 92 and 62% at 5 and 10 years for acute endocarditis and 94% and 84% for healed endocarditis (p = 0.7), respectively [59]. A serious complication after valve replacement for IE is a new or worsening neurologic deficit. Friable vegetation may dislodge and cause CNS deficits. Moreover, an existing CNS deficit is aggravated by operation. A study from university of Illinois found evidence of cerebral septic emboli in 42% of patients who underwent valve replacement for IE. Complications

Indications for operation are based in the hemodynamic state of the valvar lesion or defect. When active NVE is present, a lack of consensus exists about some of the specific indications for surgery [61]. General indications for operation, however, exist from both the American and European societies (Table 3) [8, 24]. As for timing of surgery, specific recommendations are outlined in Table 4 [26]. However it is important to remember that no randomized controlled

• Congestive heart failure caused by severe aortic or mitral regurgitation or, more rarely, by valve obstruction caused

• Severe acute aortic or mitral regurgitation with echocardiographic signs of elevated left ventricular end-diastolic

• Large vegetations (10 mm) after one or more clinical or silent embolic events after initiation of antibiotic therapy

• Silent neurological complication or transient ischemic attack and other surgical indications

• S. aureus IE involving a prosthetic valve and most cases involving a left-sided native valve

• IE caused by other aggressive organisms (Brucella, Staphylococcus lugdunensis)

• Very large vegetations (15 mm) without embolic complications, especially if valve-sparing surgery is likely (remains

• Ischemic stroke and other surgical indications, provided that cerebral hemorrhage has been excluded and neuro-

• Fever or positive blood cultures persisting for >5 to 7 days despite an appropriate antibiotic regimen, assuming that vegetations or other lesions requiring surgery persist and that extracardiac sources of sepsis have been excluded • Relapsing IE, especially when caused by organisms other than sensitive streptococci or in patients with prosthetic

included postoperative strokes in 6%, brain abscesses in 2%, and seizures in 1% [60].

5. Indications for operation

94 Advanced Concepts in Endocarditis

Congestive heart failure\*

by vegetations

Periannular extension

Systemic embolism†

controversial) Cerebrovascular complications‡

Persistent sepsis

valves Difficult organisms

pressure or significant pulmonary hypertension

• Recurrent emboli despite appropriate antibiotic therapy

logical complications are not severe (e.g., coma)

• Congestive heart failure as a result of prosthetic dehiscence or obstruction

• Most patients with abscess formation or fistulous tract formation

• Large vegetations and other predictors of a complicated course

• Q fever IE and other relative indications for intervention

Prosthetic valve endocarditis


\* Surgery should be performed immediately, irrespective of antibiotic therapy, in patients with persistent pulmonary edema or cardiogenic shock. If congestive heart failure disappears with medical therapy and there are no other surgical indications, intervention can be postponed to allow a period of days or weeks of antibiotic treatment under careful clinical and echocardiographic observation. In patients with well-tolerated severe valvular regurgitation or prosthetic dehiscence and no other reasons for surgery, conservative therapy under careful clinical and echocardiographic observation is recommended with consideration of deferred surgery after resolution of the infection, depending upon tolerance of the valve lesion.

† In all cases, surgery for the prevention of embolism must be performed very early since embolic risk is highest during the first days of therapy.

‡ Surgery is contraindicated for at least 1 month after intracranial hemorrhage unless neurosurgical or endovascular intervention can be performed to reduce bleeding risk.

Adapted from ACC/AHA 2014 Guidelines [8].

Table 3. Indications for surgery for infective endocarditis.

Emergency surgery (within 24 h)

	- Acute valvular regurgitation
	- Severe prosthetic dysfunction (dehiscence or obstruction)
	- Fistula into a cardiac chamber or the pericardial space

Urgent surgery (within days)


Early elective surgery (during the in-hospital stay)


Adapted from Prendergast et al. [26].

Table 4. Timing of surgery.

trials are available to guide current practice. Among the indications for surgery in IE, operation for acute heart failure provides the greatest survival benefit [62, 63].

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Infective endocarditis is a serious condition associated with significant morbidity and mortality. Adequate management requires intervention of multiple specialists. Correct and timed diagnosis and antibiotics are necessary, but an important percentage of patients still require surgery. Surgical mortality is high, but long-term results continue to improve with increased number of patient undergoing valve conserving surgery.
