Surgery for Infective Endocarditis

Abstract

Infective endocarditis (IE) remains a dangerous condition with unchanging incidence and a mortality approaching 30% at 1 year.1,2 Surgery is potentially lifesaving3 and is required in 25% to 50% of cases during acute infection and 20% to 40% during convalescence.4–7 Operative procedures are often technically difficult and associated with high risk, not least because patients are frequently extremely sick with multisystem disease. Nevertheless, indications for surgery are clear in many patients, and international guidelines8,9 provide strong recommendations that are applicable for the majority. These guidelines are not supported by robust clinical evidence, however, and clinical decision making is often hampered by diverse considerations, including advancing age of the overall patient cohort, the presence of extracardiac complications or preexistent comorbidity, prior antibiotic therapy of varying duration, and the availability of appropriate surgical expertise. In this article, we review the evidence base that supports current clinical practice and attempt to provide recommendations in areas where doubt persists. The role of surgery in active IE has expanded progressively since early reports of successful outcome.10 Subsequent declines in mortality may be attributed to a variety of improvements in management, although expeditious surgery in carefully selected patients has played a major role. Contemporary data in Europe indicate that surgery is now undertaken in approximately 50% of patients with IE; the most frequent indications are congestive heart failure (60%), refractory sepsis (40%), embolic complications (18%), and vegetation size (48%), with a combination of these factors being present in many patients.11 Overall surgical mortality in active IE is 6% to 25%, with long-term survival rates of approximately 70% in most series.4–7,12–31 Assessment of the impact of surgery on outcome is difficult, because the patients referred are frequently those with severe complications related to virulent organisms. Conversely, the most ill patients …