Timing and indications for surgery

Overview of indications and timing for surgery

The indications and timing of surgery for infective endocarditis (IE) is complex and nuanced. General considerations in deciding whether to operate and when to operate include the difference between left- and right-sided pathology, the impact of the pathology on patient's hemodynamic status, risk of thromboembolic complication, and the likelihood that source control requires invasive treatment. Therefore, response to antibiotics therapy and infectious organism also dictate the indication and timing of intervention. Special considerations in terms of whether and when to intervene include history of drug use, recent stroke, and the extent of the disease requiring high-risk reconstruction such as commando operation. Increasing popularity of percutaneous aspiration thrombectomy device for right-sided vegetation also warrants consideration, although the evidence on its long-term efficacy is limited. Patient's underlying clinical condition and comorbidities as well as expected short- and long-term survival will affect decision-making independent of indications. This chapter summarizes current evidences on surgical indication in various situations.

Indications and timing to intervene on left-sided endocarditis

Broadly, there are three conceptual purposes of surgical indications in left-sided endocarditis: (1) to address hemodynamics/heart failure, (2) to control infectious source, and (3) to prevent thromboembolic complications. Indications for left-sided disease involving mitral or aortic valve are much better defined compared with those of right-sided disease. Distinction between right- and left-sided endocarditis is useful because the nature of the disease differs considerably. For example, aortic and mitral valves are closely related to left ventricular function and the compromise of either valve manifests more dramatically than right-sided valve pathology. The risk of systemic thromboembolic event is much higher in the left-sided pathology. Distinction between native- or prosthetic-valve endocarditis (PVE) matters with regard to the operative risk, with PVE having a substantially higher operative mortality risk [ ]. However, there is not a guideline-directed pathway specific to PVE.

It is important to acknowledge that the appropriate timing of intervention is poorly defined, with guidelines from major societies using different definition of what constitutes ‘early’ or ‘emergent’ intervention. The 2015 European Society of Cardiology (ESC) guideline defines ‘elective’ as those that can be treated within 2 weeks, ‘urgent’ as those requiring intervention within a few days of diagnosis, and ‘emergent’ as those requiring treatment in less than 24 h [ ]. In contrast, the 2014 American Heart Association and American College of Cardiology (AHA/ACC) guidelines distinguishe between whether the endocarditis should be treated during the same hospitalization or could be treated on a different admission [ ]. A randomized controlled trial published in 2012 on surgical intervention on left-sided endocarditis used 48 h since the time of randomization as the threshold to define early and late intervention [ ]. In this trial 76 patients with native-valve left-sided endocarditis at a high risk of embolism were randomized to surgery within or after 48 h. The rate of composite event of death or embolic event at 6 months was 3% in the early surgery arm and 28% in the late surgery arm ( P = .02). Therefore, early surgery may be beneficial when feasible.