Authors:

Kang DH.
Citation:
Timing of Surgery in Infective
Endocarditis. Heart 2015;101:1786-1791.

Early surgery is recommended for patients with

complicated infective endocarditis (IE), but data from
randomized trials are scarce. The following are points to
remember about the timing of surgery among patients
with IE:

1. The main indications for early surgery in IE are heart

failure, uncontrolled infection, and prevention of
embolization. The reduction in mortality with surgery
is greatest among patients with IE and moderate to
severe heart failure.
2. Heart failure. The European Society of Cardiology
(ESC) guideline (2009) recommends emergent
surgery for heart failure with refractory pulmonary
edema or cardiogenic shock (Class I), or urgent
surgery for persistent heart failure with signs of poor
hemodynamic tolerance (Class IIa). The American
Heart Association (AHA)/American College of
Cardiology (ACC) guideline (2014) recommends
early surgery for valve dysfunction causing heart
failure (Class I).
3. Uncontrolled infection. The ESC guideline
recommends urgent surgery (Class I) for evidence of
uncontrolled infection defined as either abscess,
fistula, or pseudoaneurysm; or for an enlarging
vegetation, persistent fever, or positive blood
cultures after 7-10 days of appropriate therapy. The
 AHA/ACC guideline recommends early surgery (Class
I) for evidence of persistent infection, heart block or
abscess, or a resistant organism (S. aureus, fungi).
4. Prevention of embolization. The ESC guideline
recommends urgent surgery for a vegetation >10
mm with previous embolization or other surgical
indication (Class I), or for isolated vegetation >15
mm and feasible valve repair (Class IIb). The
AHA/ACC guideline recommends early surgery for
recurrent emboli and persistent vegetations despite
appropriate antibiotic therapy (Class IIa); or a large
mobile vegetation on a native valve (Class IIb).
5. Neurological complications. Patients with a
neurological complication may have other indications
for early surgery. However, early surgery may pose
a significant risk for perioperative neurological
deterioration (related to anticoagulation potentiating
the risk of intracerebral bleeding, and to hypotension
during cardiopulmonary bypass aggravating
neurological ischemia and edema).
6. Prosthetic valve IE. Prosthetic valve endocarditis is
the most serious form of IE, and more difficult to
treat using antibiotics alone. In general, current
guidelines support consideration of a surgical
strategy for high-risk subgroups with prosthetic
valve IE, including patients with heart failure,
abscess, or persistent fever.
7. Definitions of early surgery. There is no consensus as
to the optimal timing of early surgery. The ESC
guideline classifies surgical indications in IE as
emergent (within 24 hours), urgent (within a few
days), and elective (after 1-2 weeks of antibiotic
therapy). The AHA/ACC guideline defines early
 surgery as occurring during the initial hospitalization
and before completion of a full therapeutic course of
antibiotics.

Clinical Topics: Cardiac Surgery, Heart Failure and

Cardiomyopathies, Invasive Cardiovascular Angiography
and Intervention, Prevention, Valvular Heart
Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery
and Heart Failure,Cardiac Surgery and VHD, Acute Heart
Failure, Interventions and Structural Heart Disease

Keywords: Anti-Bacterial Agents, Cardiac Surgical

Procedures, Cardiopulmonary
Bypass, Edema, Endocarditis, Endocarditis, Bacterial, Heart
Failure, Heart Valve Diseases, Pulmonary Edema, Secondary
Prevention, Shock, Cardiogenic, Staphylococcus aureus