Evaluating Treatment Options for Patients With Infective Endocarditis

When Is It the Right Time for Surgery?

Aneil Malhotra; Bernard D Prendergast

Disclosures

Future Cardiol. 2012;8(6):847-861. 

In This Article

Congestive Cardiac Failure

CCF is the most frequent complication and indication for surgery in IE.[8] The condition is observed in more than half of all cases and occurs more often when the aortic rather than mitral valve is affected (29 vs 20% respectively).[7] CCF also has the greatest impact on prognosis.[11,12] Studies from the 1970s and 1980s compared medical and surgical treatment of CCF complicating IE and demonstrated a consistent reduction in mortality after surgery from 56–86% to 11–35%.[33,34] Although no correction was made for underlying comorbidity, similar results were reported in two more recent Scandinavian studies[23,35] in which best results were obtained with early intervention within 1 week of presentation. Prompt intervention is important before severe or refractory hemodynamic deterioration occurs and valve surgery in CCF patients is associated with reduced mortality when compared with medical therapy alone.[4,13,19,20,36] This scenario is now the most common and clearest indication for surgery, being present in 72% of patients who underwent early intervention in a recent European series.[17] There is a significant decrease in mortality associated with early surgery in those patients with the strongest and most numerous indications for surgery.[30]

CCF is usually caused by severe aortic or mitral regurgitation which may develop acutely as a result of leaflet perforation or chordal rupture, or as a consequence of coaptation disruption. Rarer causes include intracardiac shunts from fistulating tracts, prosthetic dehiscence or valve obstruction by large vegetations.

Patients with CCF may present clinically with acute dyspnea, pulmonary edema and cardiogenic shock. Transthoracic echocardiography (TTE) will help evaluate flow velocities and deceleration times which are usually low and short, respectively, in the left atrium in mitral regurgitation and left ventricle in aortic regurgitation. TTE also helps quantification of the degree of valvular dysfunction and its hemodynamic impact.[37] Transesophageal echocardiography (TOE) is particularly useful in cases of valve leaflet perforation, secondary mitral lesions and aneurysm assessment and is nowadays indicated in virtually all cases of IE.[37]

Although surgery is indicated in those with clinical evidence of CCF complicating IE, there are other issues that ought to be considered. Patients with less dramatic presentations of CCF may respond to appropriate medical management with diuretics and after load reduction with vasodilators. There is no clear evidence to guide management of these patients and both cardiologists and surgeons are reluctant to subject patients to early surgery; intervention can therefore often be postponed to allow a brief period of antibiotic therapy under close clinical and echocardiographic observation. However, even mild CCF can insidiously progress despite appropriate medical therapy. Delayed surgery in these circumstances is associated with a substantial operative mortality[38] as a consequence of progressive cardiac decompensation and increasing secondary risks of IE.

In rarer groups of patients with well-tolerated valvular insufficiency and no other surgical indication, medical management under close surveillance can be recommended. This is a particularly suitable option for the elderly, frail patient with multiple comorbidities for whom surgery would be hazardous, or in the young female of childbearing age for whom valve replacement may pose a lifelong problem.

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