Surgery for left-sided native valve infective endocarditis
- Andrew Wang, MD
Andrew Wang, MD
- Professor of Medicine
- Duke University Health System
- Section Editors
- Scott E Kasner, MD
Scott E Kasner, MD
- Section Editor — Stroke
- Professor of Neurology
- University of Pennsylvania School of Medicine
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
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  but the percentage of patients undergoing valve surgery approaches nearly 50 percent in contemporary studies of predominantly left-sided IE .
The indications for, efficacy of, and considerations for surgery in the setting of left-sided native valve endocarditis will be reviewed here. The evaluation and medical treatment of native valve endocarditis, management of right-sided endocarditis, and the role of surgery in prosthetic valve endocarditis are discussed separately. (See "Clinical manifestations and evaluation of adults with suspected native valve endocarditis" and "Antimicrobial therapy of native valve endocarditis" and "Infective endocarditis in injection drug users" and "Surgery for prosthetic valve endocarditis".)
Surgical consultation is warranted for all patients with infective endocarditis (IE), since indications for surgery may develop or clinical status may worsen quickly. Determination of whether an indication for early surgical intervention in IE is present is a critical aspect in the management of IE patients. In general, surgery is warranted in the setting of complications for which antibiotic treatment alone is unlikely to cure the condition or prevent further complications or death. For patients with IE with an indication for surgical intervention, an individualized risk-benefit analysis is performed by a multispecialty heart valve team to determine whether, when and what surgical procedure should be performed to improve patient outcome.
Indications for surgical consultation — Prompt surgical consultation is warranted in all patients with infective endocarditis (IE), as indications for surgical intervention may appear or progress rapidly. Patients with IE are best managed by a multispecialty heart valve team that includes an infectious disease specialist, cardiologist, and cardiac surgeon, with input from neurology, neurosurgery, radiology, and other specialists based on the individual case [3-7]. Multidisciplinary treatment of IE has been found to reduce mortality in IE by improving the use of surgery based on indications and consideration of operative risk and optimal timing [6,8].
Surgical indications — Determination of whether a patient with IE requires early surgical treatment depends upon many clinical and prognostic factors . Early surgery in IE has been broadly defined as surgery performed before completion of a full course of antibiotics . The following recommendations are similar to those in guidelines established by United States and European cardiology societies [3,5,10].
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- SURGICAL REFERRAL
- Indications for surgical consultation
- Surgical indications
- Evidence for surgical indications
- - Heart failure
- - Complicated infection
- Paravalvular extension
- Difficult-to-treat pathogens
- Persistent infection
- - Vegetation characteristics and risk of embolization
- PREOPERATIVE ASSESSMENT
- Preoperative imaging
- Operative risk/benefit assessment
- TIMING OF SURGERY
- Approach to timing surgery
- Evidence for timing of surgery
- - General timing
- - Timing following stroke
- CHOICE OF PROCEDURE
- Approach to choice of procedure
- Evidence on choice of valve procedure
- ANTIBIOTIC THERAPY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS