Indications for Valve Replacement in Infective Endocarditis

Native Valve Endocarditis

• The American College of Cardiology recommends surgery for patients with valve stenosis or regurgitation resulting in heart failure or hemodynamic compromise, with evidence of aortic or mitral regurgitation with elevated LV end-diastolic or left atrial pressures 2, 3
• The American Heart Association suggests surgery is indicated for endocarditis caused by fungi or other highly resistant organisms, as well as for structural complications such as heart block, annular or aortic abscess, or destructive penetrating lesions 2, 3
• Surgery is reasonable in patients with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy, according to the American Heart Association 4, 5

Prosthetic Valve Endocarditis

• The American College of Cardiology indicates consultation with a cardiac surgeon is necessary for all patients with prosthetic valve endocarditis, and surgery is indicated for patients with heart failure, valve dehiscence, worsening function, or complications such as abscess formation 6, 7
• The American College of Cardiology suggests surgery is reasonable for patients with evidence of persistent bacteremia or recurrent emboli despite appropriate antibiotic treatment, as well as for patients with relapsing infection 6, 7

Timing of Surgery

• The European Society of Cardiology recommends emergency surgery (within 24 hours) for patients with severe acute regurgitation, obstruction or fistula causing refractory pulmonary edema or cardiogenic shock, and urgent surgery (within days) for patients with heart failure, uncontrolled local infection, or persistent vegetations >10mm after embolic episode despite antibiotics 1, 8

Special Considerations

• The American College of Cardiology notes that both prosthetic valve endocarditis and native valve endocarditis caused by S. aureus are almost always surgical diseases 9
• The European Society of Cardiology recommends valve repair (especially for mitral valve) is preferable to replacement to reduce risk of prosthetic material infection, when possible 1, 8
• The American College of Cardiology advises patients on warfarin should have it discontinued and replaced with heparin when endocarditis is diagnosed, in case urgent surgery is needed 9
• Patients with vegetation diameter >10mm have significantly higher incidence of embolization, particularly with mitral valve involvement, according to the American College of Cardiology and European Society of Cardiology 9, 1