Surgical intervention plays an important role in the overall management of patients with native mitral valve endocarditis and is indicated in 15-25% of patients with infective endocarditis. Several clinical presentations are considered absolute indications for surgical intervention:
1) Significant mitral regurgitation with or without symptoms of congestive heart failure
2) Extensive structural damages such as evidence of mitral annular abscess, extension of infection to
intervalvular fibrous body, or formation of intracardiac fistulas
3) New high-grade conduction disturbance not resolving with appropriate medical therapy
4) Uncontrolled sepsis despite appropriate antibiotic therapy
5) Presence of antibiotic resistant micro-organism(s)
6) Fungal, staphylococcal aureus, or gram negative bacilli endocarditis (very aggressive micro-organisms)
7) Large vegetations (>1 cm), particularly those that are mobile and localized on the anterior leaflet, at high
risk for embolic complications
8) Multiple episode of embolization
Indications for surgical intervention in patients with prosthetic valve endocarditis include those stated above and unstable prosthesis with paravalvular leak. In all these clinical situations, surgical therapy has dramatically improved both morbidity and mortality over medical treatment alone.
Timing of surgery
When there is an indication for surgery, the procedure should be performed soon after the diagnosis is made regardless of the duration of antimicrobial therapy in order to prevent extensive structural destruction.
In the presence of severe symptoms such as pulmonary edema or intractable cardiogenic shock, immediate surgical intervention is warranted. In asymptomatic patients with severe valvular regurgitation, surgery can be delayed to obtain negative blood culture. Even in that scenario, it is preferable to proceed with early intervention to avoid extension of valvular lesions or left ventricular function impairment.
The timing of surgery should also be carefully discussed in the setting of infective endocarditis complicated with a recent neurologic injury. Patients who have suffered an ischemic cerebral injury are safe to undergo early intervention as recent studies have shown that surgical procedure was not associated with a worsening of neurological symptoms or the occurrence of a new neurologic event. Surgical intervention, however, should be delayed in patients with hemorrhagic stroke, particularly if the size of the intracranial bleed is greater than 2 cm. Similarly, in the presence of a cerebral mycotic aneurysm, cardiac surgical intervention should be delayed. It is critical to obtain an early neurosurgical consult in these patients as they may be candidate for endovascular treatment of this condition. Daily neurologic examination, CT scans and MRI at regular intervals should be performed to assess the evolution of the neurologic injury and determine the appropriate timing of surgery.
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