Evaluating Treatment Options for Patients With Infective Endocarditis

When Is It the Right Time for Surgery?

Aneil Malhotra; Bernard D Prendergast


Future Cardiol. 2012;8(6):847-861. 

In This Article

Surgical Considerations

Preoperative Management

TTE and TOE are the first-line diagnostic tools in IE and also allow assessment of the extent of IE and anatomical characterization before surgery. TOE has superior sensitivity and specificity and is recommended in virtually all patients in whom surgery is considered.[32,79]

Coronary angiography is unnecessary for the diagnosis of IE but should be considered in men >40 years of age, postmenopausal women and those with a history of ischemic heart disease or an adverse risk factor profile. Alternative noninvasive techniques such as multislice computed tomography may be used if available.

Although the duration of appropriate preoperative antimicrobial therapy is associated with the likelihood of positive valve culture at the time of surgery, there has been no association demonstrated between the duration of prior antibiotic therapy and clinical outcome.[80] Surgery, when indicated, should not be delayed to allow prolonged antibiotic therapy.

There is an increased risk of adverse outcomes in patients with IE taking oral anticoagulants, particularly during the first 2 weeks when embolic risk is highest and surgical decisions are usually necessary.[81] Anticoagulants should be discontinued in this phase if possible; in patients for who anticoagulation is essential (e.g., metallic valves), transfer to intravenous unfractionated heparin is recommended.

Intraoperative Management

Perioperative TOE is a useful tool to determine the location and extent of infection,[18] assist the choice of reconstruction procedure, validate the surgical result and guide hemodynamic management.

The excised native or prosthetic valve should be sent for immediate culture. Molecular examination of excised valve tissue may play a role, particularly in culture-negative patients.[82]

Surgical Technique

The two primary objectives of surgery are control of infection and reconstruction of cardiac morphology.[83,84–86] The mode of surgery (replacement vs repair) or type of prosthesis used (mechanical vs biological) has no influence on operative mortality,[87] although repair techniques reduce the risk of late complications (notably recurrent IE) and avoid the need for lifelong anticoagulation.[88,89]