Timing of Cardiac Surgical Intervention in PTS with Endocarditis
| Indication for Surgical Intervention | ||
|---|---|---|
| Timing | Strong Supporting Evidence | Conflicting Evidence, but Majority of Opinions Favor Surgery |
| Emergent (same day) | Acute aortic regurgitation plus preclosure of mitral valve Sinus of Valsalva abscess ruptured into right heart Rupture into pericardial sac | |
| Urgent (within 1-2 days) | Valve obstruction by vegetation Unstable (dehisced) prosthesis Acute aortic or mitral regurgitation with heart failure (New York Heart Association class III or IV) Septal perforation Perivalvular extension of infection with or without new electrocardiographic conduction system changes Lack of effective antibiotic therapy | Major embolus plus persisting large vegetation (>10 mm in diameter) |
| Elective (earlier usually preferred) | Vegetation diameter >10 mm plus severe aortic or mitral valve dysfunctiona Progressive paravalvular prosthetic regurgitation Valve dysfunction plus persisting infection after ≥7-10 days of antimicrobial therapy | Staphylococcal prosthetic valve endocarditis Early prosthetic valve endocarditis (≤2 months after valve surgery) Fungal endocarditis (Candida spp.) |
| Fungal (mold) endocarditis | Antibiotic-resistant organisms | |
aSupported by a single-institution randomized trial showing benefit from early surgery. Implementation requires clinical judgment.
Source: Adapted from L Olaison, G Pettersson: Infect Dis Clin North Am 16:453, 2002.