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September 25, 2017
Infective Endocarditis Surgical Indications

Surgical Indications

Surgical intervention plays an important role in the overall management of patients with native mitral valve endocarditis and is indicated in 15-25% of patients with infective endocarditis. Several clinical presentations are considered absolute indications for surgical intervention:

1) Significant mitral regurgitation with or without symptoms of congestive heart failure

2) Extensive structural damages such as evidence of mitral annular abscess, extension of infection to
    intervalvular fibrous body, or formation of intracardiac fistulas

3) New high-grade conduction disturbance not resolving with appropriate medical therapy

4) Uncontrolled sepsis despite appropriate antibiotic therapy

5) Presence of antibiotic resistant micro-organism(s)

6) Fungal, staphylococcal aureus, or gram negative bacilli endocarditis (very aggressive micro-organisms)

7) Large vegetations (>1 cm), particularly those that are mobile and localized on the anterior leaflet, at high
     risk for embolic complications

8) Multiple episode of embolization

Indications for surgical intervention in patients with prosthetic valve endocarditis include those stated above and unstable prosthesis with paravalvular leak. In all these clinical situations, surgical therapy has dramatically improved both morbidity and mortality over medical treatment alone.

Timing of surgery

When there is an indication for surgery, the procedure should be performed soon after the diagnosis is made regardless of the duration of antimicrobial therapy in order to prevent extensive structural destruction.

In the presence of severe symptoms such as pulmonary edema or intractable cardiogenic shock, immediate surgical intervention is warranted. In asymptomatic patients with severe valvular regurgitation, surgery can be delayed to obtain negative blood culture. Even in that scenario, it is preferable to proceed with early intervention to avoid extension of valvular lesions or left ventricular function impairment.

The timing of surgery should also be carefully discussed in the setting of infective endocarditis complicated with a recent neurologic injury. Patients who have suffered an ischemic cerebral injury are safe to undergo early intervention as recent studies have shown that surgical procedure was not associated with a worsening of neurological symptoms or the occurrence of a new neurologic event. Surgical intervention, however, should be delayed in patients with hemorrhagic stroke, particularly if the size of the intracranial bleed is greater than 2 cm. Similarly, in the presence of a cerebral mycotic aneurysm, cardiac surgical intervention should be delayed. It is critical to obtain an early neurosurgical consult in these patients as they may be candidate for endovascular treatment of this condition. Daily neurologic examination, CT scans and MRI at regular intervals should be performed to assess the evolution of the neurologic injury and determine the appropriate timing of surgery.




REFERENCES

Di Salvo G, Habib G, Pergola V, et al. Echocardiography predicts embolic events in infective endocarditis. J Am Coll Cardiol 2001;37:1069-1076

Filsoufi F, Adams DH. Surgical Treatment of Mitral Valve Endocarditis. In: Cardiac Surgery in Adult 2nd Edition, Cohn LH and Edmunds LH, (eds). New York, McGraw Hill, 2003,39:987-997.

Thuny F, Di Salvo G, Belliard O, et al. Risk of embolism and death in infective endocarditis: Prognostic value of echocardiography: A prospective multicenter study. Circulation 2005;112:69-75

Ruttmann E, Willeit J, Ulmer H, et al. Neurological outcome of septic cardioembolic stroke after infective endocarditis. Stroke 2006; 37:2094-2099

Peters PJ, Harrison T, Lennox JL. A dangerous dilemma: Management of infectious intracranial aneurysms complicating endocarditis. Lancet Infect Dis 2006;6:742-748

Cabell CH, Abrutyn E, Fowler VG,Jr, et al. Use of surgery in patients with native valve infective endocarditis: Results from the international collaboration on endocarditis merged database. Am Heart J 2005;150:1092-1098

Aksoy O, Sexton DJ, Wang A, et al. Early surgery in patients with infective endocarditis: A propensity score analysis. Clin Infect Dis 2007;44:364-372

Tleyjeh IM, Kashour T, Zimmerman V, et al. The role of valve surgery in infective endocarditis management: A systematic review of observational studies that included propensity score analysis. Am Heart J 2008;156:901-909

San Roman JA, Lopez J, Revilla A, et al. Rationale, design, and methods for the early surgery in infective endocarditis study (ENDOVAL 1): A multicenter, prospective, randomized trial comparing the state-of-the-art therapeutic strategy versus early surgery strategy in infective endocarditis. Am Heart J 2008;156:431-436

Shang E, Forrest GN, Chizmar T, et al. Mitral valve infective endocarditis: Benefit of early operation and aggressive use of repair. Ann Thorac Surg 2009;87:1728-33

Cooper HA, Thompson EC, Laureno R, et al. Subclinical brain embolization in left-sided infective endocarditis: Results from the evaluation by MRI of the brains of patients with left- sided intracardiac solid masses (EMBOLISM) pilot study. Circulation 2009;120:585-591


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