Surgery for left-sided native valve endocarditis
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
- Rakesh M Suri, MD, DPhil
Rakesh M Suri, MD, DPhil
- Professor of Surgery
- Cleveland Clinic
- Section Editors
- Scott E Kasner, MD
Scott E Kasner, MD
- Section Editor — Stroke
- Professor of Neurology
- University of Pennsylvania School of Medicine
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation; Valvular Disease
- Professor of Medicine
- University of Washington
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
Since the 1960s, valve replacement and valve repair have become common procedures for management of selected cases of infective endocarditis (IE). A review found that a mean of 32 percent of IE patients in published studies underwent valve surgery .
The indications for, efficacy of, and considerations for surgery in the setting of left-sided native valve endocarditis will be reviewed here. The medical treatment of native valve endocarditis, management of right-sided endocarditis, and the role of surgery in prosthetic valve endocarditis are discussed separately. (See "Antimicrobial therapy of native valve endocarditis" and "Infective endocarditis in injection drug users" and "Surgery for prosthetic valve endocarditis".)
APPROACH TO SURGERY
Management of patients with infective endocarditis (IE) includes determination of whether surgical treatment is indicated. Among patients with IE with indications for surgery, there is generally no benefit from delay. An exception applies to patients with hemorrhagic stroke and possibly also to patients with severe stroke. Among patients referred for valve surgery (particularly mitral), valve repair is generally preferred to valve replacement.
Determination of whether a patient with IE requires surgical treatment depends upon many clinical and prognostic factors . Patients with IE are best managed by a multispecialty heart valve team that includes an infectious disease specialist, cardiologist, and cardiac surgeon [2-5]. Prompt surgical consultation is warranted in all patients with IE as indications for surgical intervention may appear suddenly and decisions about the timing of surgery in patients with indications for surgery are often complex.
Indications — Early surgery (ie, during initial hospitalization and before completion of a full course of antibiotics) is indicated in patients with left-sided native valve IE and one or more of the following features [2-4]:
- Bin Abdulhak AA, Baddour LM, Erwin PJ, et al. Global and regional burden of infective endocarditis, 1990-2010: a systematic review of the literature. Glob Heart 2014; 9:131.
- Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2015; 132:1435.
- Hoen B, Duval X. Clinical practice. Infective endocarditis. N Engl J Med 2013; 368:1425.
- Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36:3075.
- Chirillo F, Scotton P, Rocco F, et al. Impact of a multidisciplinary management strategy on the outcome of patients with native valve infective endocarditis. Am J Cardiol 2013; 112:1171.
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
- Chu VH, Park LP, Athan E, et al. Association between surgical indications, operative risk, and clinical outcome in infective endocarditis: a prospective study from the International Collaboration on Endocarditis. Circulation 2015; 131:131.
- Barsic B, Dickerman S, Krajinovic V, et al. Influence of the timing of cardiac surgery on the outcome of patients with infective endocarditis and stroke. Clin Infect Dis 2013; 56:209.
- Snygg-Martin U, Gustafsson L, Rosengren L, et al. Cerebrovascular complications in patients with left-sided infective endocarditis are common: a prospective study using magnetic resonance imaging and neurochemical brain damage markers. Clin Infect Dis 2008; 47:23.
- Ruttmann E, Willeit J, Ulmer H, et al. Neurological outcome of septic cardioembolic stroke after infective endocarditis. Stroke 2006; 37:2094.
- Eishi K, Kawazoe K, Kuriyama Y, et al. Surgical management of infective endocarditis associated with cerebral complications. Multi-center retrospective study in Japan. J Thorac Cardiovasc Surg 1995; 110:1745.
- Gillinov AM, Shah RV, Curtis WE, et al. Valve replacement in patients with endocarditis and acute neurologic deficit. Ann Thorac Surg 1996; 61:1125.
- Matsushita K, Kuriyama Y, Sawada T, et al. Hemorrhagic and ischemic cerebrovascular complications of active infective endocarditis of native valve. Eur Neurol 1993; 33:267.
- Prendergast BD, Tornos P. Surgery for infective endocarditis: who and when? Circulation 2010; 121:1141.
- John MD, Hibberd PL, Karchmer AW, et al. Staphylococcus aureus prosthetic valve endocarditis: optimal management and risk factors for death. Clin Infect Dis 1998; 26:1302.
- Maruyama M, Kuriyama Y, Sawada T, et al. Brain damage after open heart surgery in patients with acute cardioembolic stroke. Stroke 1989; 20:1305.
- García-Cabrera E, Fernández-Hidalgo N, Almirante B, et al. Neurological complications of infective endocarditis: risk factors, outcome, and impact of cardiac surgery: a multicenter observational study. Circulation 2013; 127:2272.
- American College of Cardiology, American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease), Society of Cardiovascular Anesthesiologists, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 2006; 48:e1.
- Zegdi R, Debièche M, Latrémouille C, et al. Long-term results of mitral valve repair in active endocarditis. Circulation 2005; 111:2532.
- Iung B, Rousseau-Paziaud J, Cormier B, et al. Contemporary results of mitral valve repair for infective endocarditis. J Am Coll Cardiol 2004; 43:386.
- Lee EM, Shapiro LM, Wells FC. Conservative operation for infective endocarditis of the mitral valve. Ann Thorac Surg 1998; 65:1087.
- Dreyfus G, Serraf A, Jebara VA, et al. Valve repair in acute endocarditis. Ann Thorac Surg 1990; 49:706.
- Delay D, Pellerin M, Carrier M, et al. Immediate and long-term results of valve replacement for native and prosthetic valve endocarditis. Ann Thorac Surg 2000; 70:1219.
- Meszaros K, Nujic S, Sodeck GH, et al. Long-term results after operations for active infective endocarditis in native and prosthetic valves. Ann Thorac Surg 2012; 94:1204.
- David TE, Gavra G, Feindel CM, et al. Surgical treatment of active infective endocarditis: a continued challenge. J Thorac Cardiovasc Surg 2007; 133:144.
- Leither MD, Shroff GR, Ding S, et al. Long-term survival of dialysis patients with bacterial endocarditis undergoing valvular replacement surgery in the United States. Circulation 2013; 128:344.
- Rabkin DG, Mokadam NA, Miller DW, et al. Long-term outcome for the surgical treatment of infective endocarditis with a focus on intravenous drug users. Ann Thorac Surg 2012; 93:51.
- Rankin JS, Milford-Beland S, O'Brien SM, et al. The risk of valve surgery for endocarditis in patients with dialysis-dependent renal failure. J Heart Valve Dis 2007; 16:617.
- Sy RW, Bannon PG, Bayfield MS, et al. Survivor treatment selection bias and outcomes research: a case study of surgery in infective endocarditis. Circ Cardiovasc Qual Outcomes 2009; 2:469.
- Tleyjeh IM, Ghomrawi HM, Steckelberg JM, et al. Conclusion about the association between valve surgery and mortality in an infective endocarditis cohort changed after adjusting for survivor bias. J Clin Epidemiol 2010; 63:130.
- Tleyjeh IM, Ghomrawi HM, Steckelberg JM, et al. The impact of valve surgery on 6-month mortality in left-sided infective endocarditis. Circulation 2007; 115:1721.
- Kiefer T, Park L, Tribouilloy C, et al. Association between valvular surgery and mortality among patients with infective endocarditis complicated by heart failure. JAMA 2011; 306:2239.
- Lalani T, Cabell CH, Benjamin DK, et al. Analysis of the impact of early surgery on in-hospital mortality of native valve endocarditis: use of propensity score and instrumental variable methods to adjust for treatment-selection bias. Circulation 2010; 121:1005.
- Bannay A, Hoen B, Duval X, et al. The impact of valve surgery on short- and long-term mortality in left-sided infective endocarditis: do differences in methodological approaches explain previous conflicting results? Eur Heart J 2011; 32:2003.
- Gálvez-Acebal J, Almendro-Delia M, Ruiz J, et al. Influence of early surgical treatment on the prognosis of left-sided infective endocarditis: a multicenter cohort study. Mayo Clin Proc 2014; 89:1397.
- Alsip SG, Blackstone EH, Kirklin JW, Cobbs CG. Indications for cardiac surgery in patients with active infective endocarditis. Am J Med 1985; 78:138.
- Mullany CJ, McIsaacs AI, Rowe MH, Hale GS. The surgical treatment of infective endocarditis. World J Surg 1989; 13:132.
- al Jubair K, al Fagih MR, Ashmeg A, et al. Cardiac operations during active endocarditis. J Thorac Cardiovasc Surg 1992; 104:487.
- Larbalestier RI, Kinchla NM, Aranki SF, et al. Acute bacterial endocarditis. Optimizing surgical results. Circulation 1992; 86:II68.
- Blaustein AS, Lee JR. Indications for and timing of surgical intervention in infective endocarditis. Cardiol Clin 1996; 14:393.
- Karalis DG, Blumberg EA, Vilaro JF, et al. Prognostic significance of valvular regurgitation in patients with infective endocarditis. Am J Med 1991; 90:193.
- Carpenter JL. Perivalvular extension of infection in patients with infectious endocarditis. Rev Infect Dis 1991; 13:127.
- Moon MR, Stinson EB, Miller DC. Surgical treatment of endocarditis. Prog Cardiovasc Dis 1997; 40:239.
- Choussat R, Thomas D, Isnard R, et al. Perivalvular abscesses associated with endocarditis; clinical features and prognostic factors of overall survival in a series of 233 cases. Perivalvular Abscesses French Multicentre Study. Eur Heart J 1999; 20:232.
- Rohmann S, Seifert T, Erbel R, et al. Identification of abscess formation in native-valve infective endocarditis using transesophageal echocardiography: implications for surgical treatment. Thorac Cardiovasc Surg 1991; 39:273.
- Daniel WG, Mügge A, Martin RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med 1991; 324:795.
- Arnett EN, Roberts WC. Valve ring abscess in active infective endocarditis. Frequency, location, and clues to clinical diagnosis from the study of 95 necropsy patients. Circulation 1976; 54:140.
- Omari B, Shapiro S, Ginzton L, et al. Predictive risk factors for periannular extension of native valve endocarditis. Clinical and echocardiographic analyses. Chest 1989; 96:1273.
- Kanawaty DS, Stalker MJ, Munt PW. Nonsurgical treatment of Histoplasma endocarditis involving a bioprosthetic valve. Chest 1991; 99:253.
- Faix RG, Feick HJ, Frommelt P, Snider AR. Successful medical treatment of Candida parapsilosis endocarditis in a premature infant. Am J Perinatol 1990; 7:272.
- Mayrer AR, Brown A, Weintraub RA, et al. Successful medical therapy for endocarditis due to Candida parapsilosis. A clinical and epidemiologic study. Chest 1978; 73:546.
- Curlier E, Hoen B, Alla F, et al. Relationships between sex, early valve surgery and mortality in patients with left-sided infective endocarditis analysed in a population-based cohort study. Heart 2014; 100:1173.
- Steckelberg JM, Murphy JG, Ballard D, et al. Emboli in infective endocarditis: the prognostic value of echocardiography. Ann Intern Med 1991; 114:635.
- De Castro S, Magni G, Beni S, et al. Role of transthoracic and transesophageal echocardiography in predicting embolic events in patients with active infective endocarditis involving native cardiac valves. Am J Cardiol 1997; 80:1030.
- Rohmann S, Erbel R, Darius H, et al. Prediction of rapid versus prolonged healing of infective endocarditis by monitoring vegetation size. J Am Soc Echocardiogr 1991; 4:465.
- Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med 2012; 366:2466.
- Ragnarsson S, Sjögren J, Stagmo M, et al. Clinical Presentation of Native Mitral Valve Infective Endocarditis Determines Long-Term Outcome after Surgery. J Card Surg 2015; 30:669.
- Wilbring M, Alexiou K, Tuan Nguyen M, et al. Clinical course after surgical treatment of active isolated native mitral valve endocarditis. J Cardiovasc Surg (Torino) 2014; 55:279.
- Ternhag A, Cederström A, Törner A, Westling K. A nationwide cohort study of mortality risk and long-term prognosis in infective endocarditis in Sweden. PLoS One 2013; 8:e67519.
- APPROACH TO SURGERY
- - General approach
- - Timing following stroke
- Choice of procedure
- - Valve repair
- - Valve replacement
- Preoperative imaging
- Heart failure
- Complicated infection
- - Paravalvular extension
- - Difficult-to-treat pathogens
- - Persistent infection
- To avoid embolization
- ANTIBIOTIC THERAPY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS