Infective endocarditis 2006: indications for surgery

Abstract

Infective endocarditis has challenged clinicians for centuries. Despite recent advances in diagnosis and therapy, the risks of major complications and death in many clinical situations remain unacceptably high, related in part to patient demographics and the changing microbiology of the disease. Surgery in the acute phase is indicated chiefly for the treatment of heart failure, the eradication of intra-cardiac abscess or the management of antibiotic-resistant infection. Surgery for the prevention of systemic embolization in patients with large vegetations is an evolving area of clinical practice that will merit continued scrutiny as surgical repair techniques, anesthetic management and perioperative patient outcomes steadily improve in high volume centers. The strength of treatment recommendations is limited by the absence of prospective, randomized controlled trial data, a limitation that applies broadly to the field of valvular heart disease. Ongoing multi-center registry efforts will help fill several important knowledge gaps.

Fig. 1

Relationship between 6-month mortality and prognostic classification system (point score) of adults with complicated left-sided native valve endocarditis. Five baseline clinical features independently associated with 6 month mortality were used to construct the scoring system: patient co-morbidity, abnormal mental status, moderate to severe heart failure, bacterial etiology other than viridans streptococci, and medical therapy without valve surgery. Integer scores were modified by linear transformation of the parameter coefficient taken from logistic regression and then rounded to the nearest integer. Adapted with permission (11).

Fig. 2

One-year survival among 384 consecutive patients with infective endocarditis according to vegetation length (L) as measured by TEE. Reproduced with permission (13).

Fig. 3

Six-month survival among patients with complicated left-sided native valve endocarditis and moderate to severe heart failure receiving medical or surgical therapy. Among propensity matched patients with moderate to severe heart failure, valve surgery was associated with a significant reduction in mortality compared with medical therapy (HR 0.22, 95% CI 0.08–0.53, p = 0.01). Reproduced with permission (18).