surgical treatment for infective endocarditis

Indications

Indications for surgery in left-sided native valve endocarditis include valve dysfunction resulting in heart failure, heart block, annular or aortic abscess, destructive penetrating lesions, mobile vegetations larger than 10 mm, infection with fungi or highly resistant organisms, persistent infection despite appropriate antimicrobial therapy as evidenced by persistent bacteremia, recurrent septic emboli, or enlarging vegetations. This patient has developed severe mitral regurgitation with signs of heart failure; thus, surgical consultation is indicated.

For patients with IE and indications for surgical treatment, a delay in valve surgery is sometimes warranted if the patient has severe or unstable critical illness with multiorgan failure or if the patient experiences either a major ischemic stroke or intracranial hemorrhage as an embolic complication of the IE.

For patients with IE diagnosed, the role of follow-up echocardiograms is typically to monitor for the development of complications of IE that require surgical treatment. For patients in whom surgical indications are not present at the initial evaluation, a repeat echocardiogram should be obtained if there is any unfavorable change in clinical condition (eg, new signs or symptoms of heart failure, heart block) or persistence of fever despite adequate antimicrobial therapy. Many experts also recommend repeating echocardiography after approximately 1 week of therapy and again after completion of antimicrobial therapy, even in patients with a favorable trend in clinical signs and symptoms, to monitor for complications that are less clinically apparent. The patient in this question already has an indication for surgical treatment (annular abscess), so waiting for a repeat echocardiogram in 7 days to determine surgical candidacy is not the most appropriate next step in management (choice C is incorrect).1234

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Footnotes

  1. SEEK Questionnaires ↩

  2. AATS Surgical Treatment of Infective Endocarditis Consensus Guidelines Writing Committee Chairs; Pettersson GB, Coselli JS, et al. 2016 the American Association for Thoracic Surgery (AATS) consensus guidelines: surgical treatment of infective endocarditis: executive summary. J Thorac Cardiovasc Surg. 2017;153(6):1241-1258.e29. PubMed ↩

  3. Baddour LM, Wilson WR, Bayer AS, et al; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015;132(15):1435-1486. PubMed ↩

  4. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5):e35-e71. PubMed ↩