Timing of Cardiac Surgical Intervention in Pts with Endocarditis | ||
| TIMING | INDICATION FOR SURGICAL INTERVENTION | |
|---|---|---|
| STRONG SUPPORTING EVIDENCE | CONFLICTING EVIDENCE, BUT MAJORITY OF OPINIONS FAVOR SURGERY | |
| Emergent (same day) | Valve dysfunction with pulmonary edema or cardiogenic shock 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) | Vegetation diameter >10 mm plus severe but not urgent aortic or mitral valve dysfunctiona Major embolus plus persisting large vegetation (>10 mm) |
| Septal perforation | Mobile vegetation >30 mm | |
| Perivalvular extension of infection with or without new electrocardiographic conduction system changes | ||
| Lack of effective antibiotic therapy | ||
| Elective (earlier usually preferred) | Progressive paravalvular prosthetic regurgitation Valve dysfunction plus persisting infection after ≥7-10 days of antimicrobial therapy Fungal (mold) endocarditis | Staphylococcal prosthetic-valve endocarditis with intracardiac complications Early prosthetic-valve endocarditis (≤2 months after valve surgery) Candida spp. endocarditis Antibiotic-resistant organisms |
a Supported by a single-institution randomized trial showing benefit from early surgery. Implementation requires clinical judgment. If surgery is elected, it must be done early.
Source: Adapted from Olaison L, Pettersson G: Current best practices and guidelines indications for surgical intervention in infective endocarditis. Infect Dis Clin North Am 16:453, 2002.