100 QUESTIONS IN CARDIOLOGY

96 What are the indications for surgical

management of endocarditis?

Marc R Moon

The indications for surgical management of endocarditis fall into

six categories.

1. Congestive heart failure

Patients with moderate-to-severe heart failure require urgent

surgical intervention. With mitral regurgitation, afterload

reduction and diuretic therapy can improve symptoms and may

make it possible to postpone surgical repair until a full course of

antibiotic therapy has been completed. In contrast, acute aortic

regurgitation progresses rapidly despite an initial favourable

response to medical therapy, and early surgical intervention is

imperative.

2. Persistent sepsis

This is defined as failure to achieve bloodstream sterility after 3–5

days of appropriate antibiotic therapy or a lack of clinical

improvement after one week.

3. Recognised virulence of the infecting organism

• With native valveendocarditis, streptococcal infections can be

cured with medical therapy in 90%. However, S. aureusand

gram negative bacteria are more aggressive, requiring trans-

oesophageal echocardiography to rule out deep tissue invasion

or subtle valvular dysfunction. Fungal infections invariably

require surgical intervention

• With prosthetic valveendocarditis, streptococcal tissue valve

infections involving onlythe leaflets can be cleared in 80%

with antibiotic therapy alone; however, mechanical or tissue

valve infections involving the sewing ring generally require

valve replacement. If echocardiography demonstrates a

perivalvular leak, annular extension, or a large vegetation,

early operation is necessary