Infective Endocarditis

Surgical Intervention

Patrick T. O’Gara, MD, MACC

Watkins Family Distinguished Chair in Cardiology
Brigham and Women’s Hospital
Professor of Medicine, Harvard Medical School
 Disclosures
• Exec. Cmte., Early TAVR Trial, Edwards
LifeSciences
• Exec. Cmte., Medtronic, Intrepid/Apollo
TMVR Trials
 Infective Endocarditis
Indications for Surgery
NATIVE VALVE IE
Class I
– Heart Failure
– Abscess, Fistula, Pseudo-Aneurysm
– S. aureus, Fungal or highly resistant bacterial IE
– Persistent bacteremia after 5 days Ab Rx
– PVE, relapsing infection
– CIED (complete removal)

ACC/AHA 2006/2014/2017/2020; ESC 2009,2015

EURO-ENDO Survey

Habib G et al. EHJ 2019; 40:3222

 RCT: Early Surgery for IE

• N=78
• Mean age 47 y
• Severe L-sided VHD
• ~ 1/2 w/ emboli on adm
• ~1/3 w/ size >15mm
• ~ 60% streptococci
• 10 EP= in-hosp death +
embolic events @ 6wks

Kang D et al. N Engl J Med 2012;366466-2473.

 Infective Endocarditis
Indications for Surgery

NATIVE VALVE IE

Class II
– Recurrent emboli and persistent vegetation
despite appropriate AB Rx (IIa)
– Large ( > 10mm) mobile vegetation,
particularly on AMVL (IIb)

ACC/AHA 2006/2014/2017/2020; ESC 2009, 2015

 Intervention of Patients with IE
COR LOE Recommendations
1. In patients with IE and an indication for surgery who have suffered
a stroke but have no evidence of intracranial hemorrhage or
2b B-NR
extensive neurological damage, operation without delay may be
considered.
2. For patients with IE and major ischemic stroke with extensive
neurological damage or intracranial hemorrhage, if the patient is
2b B-NR
hemodynamically stable, delaying valve surgery for at least 4
weeks may be considered.

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Yanagawa B et al. Circulation 2016;134:1280-92
Yanagawa B et al. Circulation 2016;134:1280-92
TV Endocarditis

Surgery? Conservative
Therapy?
 Intervention of Patients with IE
COR LOE Recommendations

1. In all patients with definite endocarditis and an

implanted cardiac electronic device, complete
1 B-NR
removal of the pacemaker or defibrillator systems,
including all leads and the generator, is indicated.

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Footnote text located
on the next slide

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