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Last Update: 02/20/2025 12:58 PM
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Commit #2864232018b (Clinical Applications) 60
60. Which factor is the strongest indication for surgery in native valve bacterial endocarditis?
- Intravenous drug use and tricuspid valve endocarditis.
- Mobile vegetation of 5 mm on echocardiography.
- Pulmonary infarction.
- Staphylococcal bacteraemia for 3 days despite therapy.
- Valve regurgitation resulting in heart failure.
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Commit #286423- Intravenous drug use and tricuspid valve endocarditis.
- Mobile vegetation of 5 mm on echocardiography - >10mm + embolic event
- Pulmonary infarction - needs a larger sized vegetation?
- Staphylococcal bacteraemia for 3 days despite therapy - no, arbitrary cut off is 7 days
- Valve regurgitation resulting in heart failure.
There are 3 main reasons to undergo surgery in the setting of acute IE, in order of frequency from most to least:
- HF - urgent for NYHA class II–III, emergency for NYHA class IV
- Heart failure complicating IE is independently associated with poor in-hospital and 1-year survival, and surgical treatment is the only effective treatment that is associated with improved survival
- Uncontrolled infection ∼5–10% of patients. - Urgent
- Uncontrolled infection is considered to be present when there is:
- persistent infection or sepsis despite antibiotic therapy; The definition of persistent infection is somewhat arbitrary and consists of fever and persistent positive cultures after 7 days of appropriate antibiotic treatment. In many cases of persistent infection, antibiotics alone are insufficient to eradicate the infection. Surgery is therefore indicated for persistent infection when extracardiac abscesses (splenic, vertebral, cerebral, or renal) and other potential causes of positive cultures and fever (infected lines and embolic complications) have been excluded.
- signs of local infection that do not respond to antibiotic therapy; increasing vegetation size, abscess formation, the creation of pseudoaneurysms and/or fistulae, and new atrioventricular block (AVB).
- infection with resistant or very virulent organisms.
- Prevention of septic embolization (in particular, to the CNS). The brain and spleen are the most frequent sites of embolism for left-sided IE, while pulmonary embolism is frequent in right-sided and pacemaker lead IE. Embolic events may be clinically silent in up to 50% of patients with IE.
- the size and mobility of the vegetations are the most important independent predictors of new embolic events.
- Risk of neurological complications is particularly high in patients with very large vegetations (>30 mm in length)
Surgical need timeframe:
- Emergency = <24 hrs
- Urgent = 3 - 5 days
- Non-urgent = during the same admission