INFECTIVE

ENDOCARDITIS
SURGICAL
INDICATIONS
(ESC Guidelines)
By :
Dr Aaqib
PGR cardiology
PIC

Infective endocarditis is associated with certain risks and complications that can only be controlled with surgical
intervention. Despite the risks of surgery in these patients, current evidence suggests that surgical treatment may generate a
survival advantage of up to 20% in the first year.

 Time line
 Urgent surgery
 intervention within 3–5 days
 A significant proportion of surgical procedures for IE are performed on an urgent basis.
 Emergency surgery
 Within 24 hours
 Delayed OR Non urgent surgery
 within the same hospital admission
 Pre-operative risk assessment

 The risk of surgical therapy during the active phase of IE can be significant. It depends on pre-existing co-
morbidities and current organ function.
 The decision to operate should therefore be made by the Endocarditis Team considering urgency of the
patient’s clinical condition, peri-operative risk, the potential to recover from the infection, and the patient’s
associated long-term prognosis.
 A significant proportion of patients with clear indications for surgery for IE may have multiple risk factors or
other reasons that lead to surgery not being performed, and these patients have the worst prognosis. So the
complex decision of not offering surgery when indicated should therefore be made in the setting of an
Endocarditis Team with experienced surgical input.
Scoring system:

 There are several scoring systems that are designed specifically for the setting of
surgery in IE to predict mortality. It includes;
 AEPEI (association for the study and prevention of infective endocarditis study) score,
 The STS (society of thoracic surgeons) IE score,
 The PALSUSE (prosthetic valve, age ≥70, large intracardiac destruction, staphylococcus spp.,
Urgent surgery, sex [female],
 Euro SCORE ≥10) score,
 The de feo score, and
 The ANCLA (anemia, NYHA [New York Heart Association] class IV, critical state, large
intracardiac destruction, surgery of thoracic aorta) score,
Guidelines for surgical intervention
Recommendations C1ass Leve1
(i) Heart fai1ure

Emergency surgery is recommended in aortic or mitral NVE or PVE

with severe acute regurgitation, obstruction, or fistula causing I B
refractory pulmonary oedema or cardiogenic shock.

Urgent surgery is recommended in aortic or mitral NVE or PVE with

severe acute regurgitation or obstruction causing symptoms of HF or I B
echocardiographic signs of poor hemodynamic tolerance.
Recommendations Class Level
(ii) Uncontro1led infection
Urgent surgery is recommended in locally uncontrolled infection
(abscess, false aneurysm, fistula, enlarging vegetation, prosthetic I B
dehiscence, new AVB).

Urgent or non-urgent surgery is recommended in IE caused by fungi

or multi-resistant organisms according to the hemodynamic condition I C
of the patient.

Urgent surgery should be considered in IE with persistently

positive blood cultures >1 week or persistent sepsis despite IIa B
appropriate antibiotic therapy and adequate control of metastatic
foci.

Urgent surgery should be considered in PVE caused by S. aureus or

non-HACEK Gram-negative bacteria. IIa C
 Recomandations Class Level
(iii) Prevention of embo1ism
Urgent surgery is recommended in aortic or mitral NVE or PVE
with persistent vegetations ≥10 mm after one or more embolic I B
episodes despite appropriate antibiotic therapy.

Urgent surgery is recommended in IE with vegetation ≥10 mm and

other indications for surgery. I C

Urgent surgery may be considered in aortic or mitral IE with

vegetation ≥10 mm and without severe valve dysfunction or IIb B
without clinical evidence of embolism and low surgical risk.
`
Indications and timing of
cardiac surgery after
neurological
complications in active
infective endocarditis
Indications and timing of cardiac surgery after neurological
complications in active infective endocarditis
THANK YOU