Endocarditis surgical indications

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2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Early valve surgery should be scheduled when there is heart failure due to the valve dysfunction, left-sided infective endocarditis due to Staphylococcus aureus, fungal or highly resistant organisms, or a heart block, annular or aortic abscess or destructive lesions. Other indications include persistent bacteremia or fever 5 to 7 following the initiation of the antibiotics, relapse of the infection depsite a complete course of antibiotics in prosthetic valve endocarditis when no portal of infection can be identified, recurrent emboli and persistent vegetations despite antibiotic therapy, and mobile vegetations with a length more than 10 mm in native valve endocarditis. Surgical removal of the valve is necessary in patients who fail to clear micro-organisms from their blood in response to antibiotic therapy, or in patients who develop cardiac failure resulting from destruction of a valve by infection. A removed valve is usually replaced with an artificial valve which may either be mechanical (metallic) or obtained from an animal such as a pig; the latter are termed bioprosthetic valves. Surgical treatment of endocarditis involves excision of all infected valve tissue, drainage and debridement of abscess cavities, repair or replacement of damaged valves, and repair of any associated pathology such as fistulas or septal defects.

Surgery

Indications

Indications for surgical debridement of vegetations and infected perivalvular tissue, with valve replacement or repair as needed are listed below:

1. Moderate to severe congestive heart failure due to valve dysfunction
2. Unstable valve prosthesis
3. Uncontrolled infection for > 1–3 week despite maximal antimicrobial therapy
4. Persistent bacteremia
5. Fungal endocarditis
6. Relapse after optimal therapy in a prosthetic valve
7. Vegetation in Situ
8. Prosthetic valve endocarditis with perivalvular invasion
9. Endocarditis caused by Pseudomonas aeruginosa or other gram-negative bacilli that has not responded after 7–10 days of maximal antimicrobial therapy
10. Perivalvular extension of infection and abscess formation
11. Staphylococcal infection of prosthesis
12. Persistent fever (culture negative)
13. Large vegetation (>10 mm is associated with an increased risk of embolism)
14. Relapse after optimal therapy in a native valve
15. Vegetations that obstruct the valve orifice
16. Onset of AV block

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (DO NOT EDIT)

Indications for Surgery for Native Valve Endocarditis (DO NOT EDIT)

Class I

"1. Decisions about timing of surgical intervention should be made by a multispecialty Heart Valve Team of cardiology, cardiothoracic surgery, and infectious disease specialists (301). (Level of Evidence: B) "

"2. Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE who present with valve dysfunction resulting in symptoms of heart failure (342-347). (Level of Evidence: B) "

"3. Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with left-sided IE caused by Staphylococcus aureus, fungal, or other highly resistant organisms (347-354). (Level of Evidence: B) "

"4. Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE complicated byheart block, annular or aortic abscess, or destructive penetrating lesions (347, 355-359). (Level of Evidence: B) "

"5. Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) for IE is indicated in patients with evidence of persistent infection as manifested by persistent bacteremia or fevers lasting longer than 5 to 7 days after onset of appropriate antimicrobial therapy (347, 352, 353, 360-362). (Level of Evidence: B) "

"6. Surgery is recommended for patients with prosthetic valve endocarditis and relapsing infection (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequently negative blood cultures) without other identifiable source for portal of infection. (Level of Evidence: C) "

"7. Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as part of the early management plan in patients with IE with documented infection of the device or leads (363-366). (Level of Evidence: B) "

Class IIa

"1. Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients with valvular IE caused by Staphylococcus aureus or fungi, even without evidence of device or lead infection (363-366). (Level of Evidence: B)"

"2. Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients undergoing valve surgery for valvular IE. (Level of Evidence: C) "

"3.Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is reasonable in patients with IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy (302, 367, 368). (Level of Evidence: B)"

Class IIb

"1. Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) may be considered in patients with native valve endocarditis who exhibit mobile vegetations greater than 10 mm in length (with or without clinical evidence of embolic phenomenon) (302, 367, 368). (Level of Evidence: B)"

2008 AHA/ACC Guideline for the Management of Patients With Prosthetic Valve Endocarditis (DO NOT EDIT)

Indications for Surgery for Prosthetic Valve Endocarditis (DO NOT EDIT)

Class I

"1. Consultation with a cardiac surgeon is indicated for patients with infective endocarditis of a prosthetic valve. (Level of Evidence: C)"

"2. Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with heart failure. (Level of Evidence: B)"

"3. Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with dehiscence evidenced by cine fluoroscopy or echocardiography. (Level of Evidence: B)"

"4. Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with evidence of increasing obstruction or worsening regurgitation. (Level of Evidence: C)"

"5. Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with complications (e.g., abscess formation). (Level of Evidence: C)"

Class III

"1. Routine surgery is not indicated for patients with uncomplicated infective endocarditis of a prosthetic valve caused by first infection with a sensitive organism. (Level of Evidence: C)"

Class IIa

"1. Surgery is reasonable for patients with infective endocarditis of a prosthetic valve who present with evidence of persistent bacteremia or recurrent emboli despite appropriate antibiotic treatment. (Level of Evidence: C)"

"2. Surgery is reasonable for patients with infective endocarditis of a prosthetic valve who present with relapsing infection. (Level of Evidence: C)"

Principles of Surgical Treatment of Endocarditis

Surgical treatment of endocarditis includes:

• Excision of all infected valve tissue
• Drainage and debridement of abscess cavities
• Repair or replacement of damaged valves
• Repair of any associated pathology such as septal defect, fistulas

Aortic Valve - Surgical Options

If the infection is limited to the leaflets, then the aortic valve should be replaced. If the infection extends to the anulus or beyond, then the infected tissues should be debrided. Any abscesses should be drained and the aortic root should be replaced.

Atrioventricular Valve - Surgical Options

If the infection is limited to the leaflets, then the vegetations should be excised, perforations should be repaired, and a reduction annuloplasty should be performed. If the infection extends to the anulus or beyond, then a valve replacement should be performed, and abscesses should be debrided and obliterated. In some cases the tricuspid valve may be excised.

Surgical Outcomes

Operative mortality is 15 - 20%. The development of an infection of a prosthetic valve during operation for native valve endocarditis is 4%, it is higher (12 - 16%) if active endocarditis is present at the time of the surgery. Late survival at 5 years for native valve endocarditis is 70 - 80% and for prosthetic valve endocarditis is 50 - 80%.

2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)

Intraoperative Assessment (DO NOT EDIT)

Class I

"1. Intraoperative transesophageal echocardiography is recommended for valve surgery for infective endocarditis. (Level of Evidence: B)"