Surgery for infective endocarditis

Situations where urgent surgical assessment should be undertaken include (1):

• persistent pyrexia
• persistently positive blood cultures
• new murmurs
• recurrent emboli despite maximal antimicrobial therapy
• development of congestive cardiac failure - development of cardiac failure has a mortality of over 50% in patients with infective endocarditis managed with medical treatment alone (1)
• large vegetations
• persistent vegetation after a major systemic embolus
• evidence of an intracardiac abscess
• worsening renal failure may necessitate consideration of surgical intervention rather than continuation of medical therapy

Absolute indications for surgery include acute valvular regurgitation with pulmonary oedema, dehiscence of a prosthetic valve, and abscess formation (1).

Timing is critical. Ideally, infection should be eliminated beforehand but this has to be balanced against the risk of leaving the heart in a compromised haemodynamic state.

There is a 10 to 25% mortality for patients undergoing surgery during the acute phase.

Reference:

1. Drugs and Therapeutics Bulletin (2002). 40 (4), 26-30.