Phase Of Infective Endocarditis Research Articles

Role of echocardiography in the diagnosis and clinical management of infective endocarditis.

Infective endocarditis (IE) is a deadly disease, constituting both diagnostic and treatment challenges. A positive outcome requires rapid and accurate diagnosis, and for that, echocardiography unequivocally remains the cornerstone. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have complementary roles and have been markedly improved during the last decades. The transthoracic modality is the recommended first-line approach but may only be sufficient in patients where the probability of IE is low and/or with clear acoustic windows, especially in patients with right-sided IE. The transesophageal modality is superior to TTE in most aspects and is recommended for all other patients. Both TTE and TEE may delineate vegetation location and size, assess for paravalvular extension of infection, and have the added advantage of defining the hemodynamic effects of valvular or device infection. However, echocardiography still has significant limitations, and novel imaging techniques are increasingly being exploited to improve diagnostic potential. Cardiac computed tomography (CT) performs better than TEE in the detection of abscess or pseudoaneurysm, while magnetic resonance imaging (MRI) has limited value in the diagnostic phase of IE but adds knowledge to the evaluation of extracardiac events. Nuclear molecular techniques are evolving as key supplementary methods in difficult-to-diagnose cases. Although newer imaging modalities are undergoing preliminary evaluation and multimodal imaging will play an increasing role in IE, echocardiography will continue to be pivotal in patients with IE for the foreseeable future.

Clinical correlates of circulating small dense low-density lipoproteins in acute infective endocarditis.

Infective endocarditis (IE) is a complex thrombo-inflammatory disorder, the pathogenesis of which involves a multifaceted interplay between vascular damage and bacterial virulence factors. This study aimed to assess the prognostic role of small dense low-density lipoprotein (sdLDL) cholesterol in patients with IE and its correlation with various disease-related features. A cohort of 198 patients with definite IE was included in this study. Clinical, laboratory, and echocardiographic parameters were meticulously analyzed, with a specific focus on comorbidities. sdLDL levels were measured using stored plasma samples obtained upon admission during the acute phase of the disease. The median level of sdLDL was 24mg/dL [with an interquartile range of 17.9-35.2mg/dL], and this value showed a statistically significant positive correlation with LDL/HDL cholesterol and triglycerides (p < 0.01 for all). Furthermore, a remarkable inverse correlation between C-reactive protein and D-dimer levels was observed (p < 0.0001). Univariate analysis revealed that patients with sdLDL levels ≤ 24mg/dL had 2.75 times higher odds of in-hospital mortality (95% Confidence Interval:1.08-6.98, p = 0.031). In addition, nonsurvivors had significantly lower median sdLDL levels (19.7 vs. 26.0mg/dL, p = 0.041). Lower sdLDL levels were also associated with embolic complications, larger vegetation size, and positive blood cultures for Staphylococci (p = 0.019, p = 0.022, and p < 0.001, respectively). Low circulating sdLDL levels in the acute phase of IE were significantly correlated with unfavorable clinical outcomes. These results suggest that the sdLDL level may serve as an important marker of disease severity in IE and may represent a link between vascular damage, embolic complications, and disease progression.

Neurologic complications of infective endocarditis: A four's year experience of Casablanca university hospital

Clinical manifestations of infective endocarditis(IE) include systemic, cardiac, and extracardiac multiorgan symptoms and signs. Hence, neurological complications have been linked to poor outcome and remains the most frequent extracardiac signs of IE with 25% of patients experience at least one neurological event. To assess the incidence of neurological complications in patients with infective endocarditis, the risk factors for their development and their influence on the clinical outcome. Retrospective study included patients with possible or definite infective endocarditis according to the European society of cardiology modified Duke Criteria, admitted between 2016 and 2019 in the Cardiology department of Casablanca university. Seventy-one patients were male and 47 were female with a mean (SD) age = 40.3 (15.2) years. 85 episodes were designed as definite IE. Neurologic complications were identified in 24,5% patients with 22 events associated with definite IE. Nineteen complications were thought to be caused by major cerebral embolism including ischemic brain infarction and transient ischemic stroke. On the other hand, cerebral hemorrhage was found in 6 patients and no significant association between anticoagulation therapy and cerebral hemorrhage was found in our study. Neurologic complications were significantly associated with Staphylococcus aureus infection ( P = 0.017) and with IE affecting both the aortic and the mitral valves ( P = 0.03). Death during the acute phase of IE occurred in 8 episodes (30%) with neurologic complications and in 9 episodes (10%) without neurologic complications. Mortality was highly associated with neurologic complications with a P = 0.017. Our results reinforce that neurologic complications has negative impact on the outcome of patients with IE. Furthermore, appropriate antimicrobial therapy should be instituted rapidly to prevent neurologic events and reduce mortality rate.

Determinants and consequences of positive valve culture when cardiac surgery is performed during the acute phase of infective endocarditis.

The optimal timing of cardiac surgery in infective endocarditis (IE) remains debated: Early surgery decreases the risk of embolism, and heart failure, but is associated with an increased rate of positive valve culture. To determine the determinants, and the consequences, of positive valve culture when cardiac surgery is performed during the acute phase of IE, we performed a retrospective study of adult patients who underwent cardiac surgery for definite left-sided IE (Duke Criteria), in two referral centres. During the study period (2002-2016), 148 patients fulfilled inclusion criteria. Median age was 65 years [interquartile range, 53-73], male-to-female ratio was 2.9 (110/38). Cardiac surgery was performed after 14 days [5-26] of appropriate antibiotics. Valve cultures returned positive in 46 cases (31.1%). Factors independently associated with positive valve culture were vegetation size ≥ 10 mm (OR 2.83 [1.16-6.89], P = 0.022) and < 14 days of appropriate antibacterial treatment before surgery (OR 4.68 [2.04-10.7], P < 0.001). Positive valve culture was associated with increased risk of postoperative acute respiratory distress syndrome (37.0% vs. 15.7%, P = 0.008) but was associated neither with an increased risk of postoperative relapse nor with the need for additional cardiac surgery. Duration of appropriate antibacterial treatment and vegetation size are independently predictive of positive valve culture in patients operated during the acute phase of IE. Positive valve culture is associated with increased risk of postoperative acute respiratory distress syndrome.

In-hospital metabolite changes in infective endocarditis-a longitudinal 1H NMR-based study.

Treatment of infective endocarditis (IE) is a 4-6-week provided course of intravenously administered antibiotics. The aim of this study was to investigate how serum metabolites as measured by proton nuclear magnetic resonance (1H NMR) spectroscopy are changing over time during the active phase of IE, and to see whether these metabolite changes might be used to monitor recovery in these patients. Patients hospitalized with first-time IE at Herlev Hospital, Denmark, from September 2015 to June 2017 were included. Longitudinal blood sampling was performed and serum was analyzed using 1H NMR. Orthogonal projection to latent structures discriminant analysis (OPLS-DA) was used to separate sample groups and analyze differences in metabolite profiles. Thirteen patients were included in the study (77% men, median age 62years (IQR 53-77)). All patients were cured during the hospitalization without any relapse during 6months of follow-up. We analyzed 61 serum samples (median 5 samples, range 2-8 per person) drawn in the treatment period after IE diagnosis. The main changes during the in-hospital period were decreased levels of glucose, mannose, leucine, isoleucine, phenylalanine, tyrosine, and signals from polyols and N-acetylated protein. The metabolomic changes could in contrast to the routinely used parameters CRP and leucocyte levels distinguish between the early and late stages of disease treatment. We present the first longitudinal study of 1H NMR metabolomics in patients with infective endocarditis. The metabolomic changes show a promising strength compared to routinely used clinical parameters.

Инфекционный эндокардит: проблемы диагностики и лечения

Results of the clinical study involving 458 patients (from 12 to 75 years, mean age 49 +/- 9.3 years) with various forms of infective endocarditis (IE) have been summarized. Integrated echocardiography was the principal non-invasive method of presurgical diagnosis of the disease. Sensitivity of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were 96% and 97.9% in patients with primary IE, 59% and 92% in patients with secondary IE and 2.7% and 90% in patients with prosthetic endocarditis, respectively. Results of echocardiography were confirmed during intrasurgical revision and histological study of removed valves. However, we have not found correlation between size, location, shape, mobility of vegetations, and risk of embolic events. Integrated echocardiography contributed to the correct diagnosis and also provided the possibility to determine the necessity of surgery and to schedule it in time. The main goals of surgery in IE heart valves are complete removal/sanitation of infected tissue and restoration or replacement of damaged heart valves. Overall hospital mortality was 8.1%. Mortality among patients operated in the active stage of IE and during remission was 10.5 and 7.1%, respectively. Surgical treatment in the active phase of IE is indicated in patients with factors of high risk, when the possibility of cure with antibiotics is unlikely, as well as in patients with high chances of recovery according to the state of organs and systems.

Surgery in the Acute Phase of Infective Endocarditis: 5 Years after Our Initial Experience

Aim: Comparing the results of acute phase infectious endocarditis surgery between two periods. Methods and Results: The study is about 2 series, series A between 1993 and 1997, and series B between 1998 and 2012, respectively 13 and 51 patients. The two periods were similar concerning the number of patients per year, which was 3.12 cases/year for series A and 3.64 cases/year for series B. The authors noted a change in epidemiological profile, with an increase of median age (31 y.o for series A and 37 y.o for series B), and the emergency of endocarditis on prosthetic valve (none on series A and 8 cases for series B). Surgical indications and results didn’t change too much, hospital mortality rate was 15.3% for series A and 17.6% for series B. Conclusion: Infectious endocarditis is still a major public healthcare problem in developing countries, despite the development of diagnostic tools and patient care. Prevention is still the major asset in the treatment of this disease.

EuroSCORE II underestimates mortality after cardiac surgery for infective endocarditis.

To better select for patients who most likely will benefit from cardiac surgery among those with infective endocarditis (IE), we aimed to identify preoperative markers associated with poor outcome after cardiac surgery for IE, and to evaluate the accuracy of European System for Cardiac Operative Risk Evaluation (EuroSCORE) II to predict mortality. We enrolled all adult patients who underwent cardiac surgery during the acute phase of definite IE (Duke Criteria) in two referral centres for cardiac surgery. Patients were identified through intensive care unit (ICU) electronic databases, and data were collected from medical charts on standardized questionnaire. Between 2002 and 2013, 149 patients (117 males), with a median age of 64 years [interquartile range 52-73], fulfilled the inclusion criteria. Main complications before surgery were left ventricular dysfunction (23%), central nervous system symptomatic events (34%) and septic shock (24%). Most patients (95%) presented with valve regurgitation, and 49% had perivalvular abscess. Surgery was performed with a median delay of 12 days [5-24] after IE diagnosis, and mean EuroSCORE II was 15.8 (13.4-18.1). In-hospital mortality was 21%. Preoperative variables associated with mortality in multivariate analysis were obesity [odds ratio (OR) 3.67 [1.10-12.19], P = 0.03], vegetation >15 mm (OR 6.72 [1.46-30.98], P = 0.01), septic shock (OR 4.87 [1.67-14.28], P = 0.004) and mechanical prosthetic valve IE (OR 4.99 [1.72-28.57], P = 0.007). EuroSCORE II underestimated mortality in patients with predicted mortality over 10%. Factors independently predictive of mortality after cardiac surgery for IE are obesity, septic shock, large vegetation and a mechanical prosthetic valve IE. EuroSCORE II underestimates post-cardiac surgery mortality in patients with IE.

Association between type of valve prosthesis and one year mortality in IE: an analysis of 1467 patients from the International collaboration on endocarditis prospective cohort study

Purpose: Infective Endocarditis (IE) is a disease which continues to have high mortality and morbidity, including nearly half of patients requiring cardiac surgery during the acute phase of IE. There has been no large, multicenter, prospective series comparing mechanical and biological prostheses in IE. Our objectives were to describe the characteristics of patients according to the type of valve replacement (mechanical or biological), and to examine whether the type of prosthesis was independently associated with in-hospital and 1-year mortality. Methods: The International Collaboration on Endocarditis - Prospective Cohort Study is a prospective, multicenter, international registry of IE cases. Among 5,591 patients 18 years or older, 1,467 patients with definite IE were operated on during the active phase of disease and had a biological (550; 37%) or mechanical (917; 63%) valve replacement. Results: As compared to patients who received mechanical prostheses, those who received bioprostheses were older (62 vs 54 years; p<.0001), more often had a history of cancer (9% vs 6%; p=0.009), and had moderate or severe renal disease (9% vs 4%; p=0.0003). Proportion of health care-associated IE was higher in the bioprosthesis group (26% vs 17%; p<.0001). Intracardiac abscesses were more frequent in the bioprosthesis group (30% vs 23%; p=0.0044). Both in-hospital and 1-year death rates were higher in the bioprosthesis group, 20.5% vs 14.0% (p=0.0009) and 25.3% vs 16.6% (p<.0001), respectively. Only 3 variables were independently associated with the type of prosthesis implanted. Mechanical prostheses were less commonly implanted in older patients (odds ratio: 0.64 for every 10 years; 0.56 - 0.73), and in patients with a history of cancer (0.72; 0.53 - 0.98), but were more commonly implanted in mitral position (1.60; 1.29 - 2.00). In the multivariable analysis, bioprosthesis was independently associated with 1-year mortality (hazard ratio: 1.298; 1.011-1.665; p=0.041). In sub-group analysis, biologic valve replacement remained independently associated with 1 year mortality in patients less than 65 years old, but not in older patients. Conclusion: Patients with IE who receive a biologic valve replacement have significant differences in clinical characteristics compared to patients who receive a mechanical prosthesis. Biologic valve replacement is independently associated with a higher in-hospital and 1-year mortality, a result which is likely related to patient characteristics rather than valve dysfunction.

Reparación valvular mitral en el curso de una endocarditis infecciosa activa. Estudio de cuatro pacientes

Background and objectiveMitral valve (MV) repair is the preferred surgical treatment for degenerative mitral regurgitation (MR). However, questions remain about the efficacy of MV repair when performed for MR caused by infective endocarditis (IE), particularly during its active phase. Although several observational studies have suggested the superiority of MV repair over replacement in patients undergoing surgery for IE, many centres are still opting for valve replacement because of its technical feasibility and reproducibility. In the following document we expose the experience of our hospital. Patients and methodWe present a series of 4 patients who recently underwent surgery for IE during its active phase. Epidemiological and clinical characteristics are discussed. ResultsAll patients underwent different MV repair techniques. No relapse or reinfection has been reported. All patients present MR grades 0 or iI/ivIV at follow up. ConclusionsEven during the active phase of IE, MV repair is a feasible technique with good postoperatory results.

The EASE trial: surgery for infective endocarditis, have we found the right timing?

Despite recent advances in diagnosis and treatment, infective endocarditis (IE) is still a hazardous condition with high in-hospital mortality, reaching 12.6% (1) in the Euro Heart Survey programme. Surgical treatment is a potentially lifesaving treatment and is required in nearly 50% of patients (2). Indications for surgery are well defined in guidelines (3,4) but there is a lack of recommendations about the time when it must be done and, in general terms, prognosis is better if surgery is undertaken in the acute or active phase of IE, before cardiac tissue destruction takes place.

Management of neurological complications of infective endocarditis in ICU patients

Patients with infective endocarditis (IE) are generally referred to the intensive care unit (ICU) for one or more organ dysfunctions caused by complications of IE. Neurologic events are frequent causes of ICU admission in patients with IE. They can arise through various mechanisms consisting of stroke or transient ischemic attack, cerebral hemorrhage, mycotic aneurysm, meningitis, cerebral abscess, or encephalopathy. Most complications occur early during the course of IE and are a hallmark of left-sided abnormalities of native or prosthetic valves. Occlusion of cerebral arteries, with stroke or transient ischemic attack, accounts for 40% to 50% of the central nervous system complications of IE. CT scan is the most easily feasible neuroimaging in critically unstable patients. However, magnetic resonance imaging is more sensitive and when performed should follow a standardized protocol. In patients with ischemic stroke who are already receiving oral anticoagulant therapy, this treatment should be replaced by unfractionated heparin for at least 2 weeks with a close monitoring of coagulation tests. Mounting evidence shows that, for both complicated left-sided native valve endocarditis and Staphylococcus aureus prosthetic valve endocarditis, valve replacement combined with medical therapy is associated with a better outcome than medical treatment alone. In a recent series, approximately 50% of patients underwent valve replacement during the acute phase of IE before completion of antibiotic treatment. After a neurological event, most patients have at least one indication for cardiac surgery. Recent data from literature suggest that after a stroke, surgery indicated for heart failure, uncontrolled infection, abscess, or persisting high emboli risk should not be delayed, provided that the patient is not comatose or has no severe deficit. Neurologic complications of IE contribute to a severe prognosis in ICU patients. However, patients with only silent or transient stroke had a better prognosis than patients with symptomatic events. In addition, more than neurologic event per se, a better predictor of mortality is neurologic dysfunction, which is associated with location and extension of brain damage. Patients with severe neurological impairment and those with brain hemorrhage have the worse outcome.

Reply to Acar Early surgery in active valve endocarditis

We thank Dr Acar for his thoughtful comments [1] on our recently published work focusing on mitral valve (MV) repair for active infective endocarditis (IE) [2]. Dr Acar has suggested that an early surgical approach could blind the potential eradication successes ofmedical treatment aloneandbelieves that repair is easier during the healed phase of IE than during the active one. Effectively, our current approach is to operate on patients with active IE very early during the course of the disease, even after only a few days of antibiotic therapy. Herein, we insist on the fact that if we had operated on the patient earlier compared to our historical controls, we have not broadened the classical indications for surgical treatment. According to the recently published ACC/AHA guidelines [3], the level of evidence for surgical exploration presented by our study population was class I in 43 patients, class IIA in 18 and class IIB in 2 patients, respectively. During the study period, a total of 127 patients were treated for native MV IE in our institution. Eighty-one (64%) were operated on during the active phase (63 repairs = our study cohort [2] and 18 replacement) and 46 (36%) received medical treatment only. Comparing this with the recent study referenced by Dr Acar [4], and taking account of the fact that the later study combined aortic and mitral native IE, it seems that we do not over treat patients as the rate of surgery was lower in our experience (64% vs 71%). Beside commonly accepted indications for urgent surgery, we applied early surgery in other indications for the following reasons: Firstly, as a preventative tool for any new complicating events that may impair patients prognosis. We agree with Dr Acar that themajority of complications occur before diagnosis and that the risk of a newcomplicationdecreaseswithmedical therapy. However, the study cited here above reported a persistent risk of complication even after initiation of medical therapy [4]. The authors showed that almost half of the heart failures and septic shocks, and two thirds of the cardiovascular collapses occurred during medical treatment. Secondly, as a tool to improve the reparability rate of the valve. Indeed, since repair has proven to be superior to replacement in degenerative disease, we believe that surgeons should be at ease with the reconstructive approach in the setting of more difficult situations as well. In IE, destruction of the mitral valve is progressive but more rapid than in any other non-infectious disease. Since valve repair is highly dependant of the quantity and quality of residual tissues, early intervention is of interest for saving more tissues. In our opinion, fresh and bulky lesions are not too difficult to manage and at this early stage lesion margins are well circumscribed allowing easy resection and tissue preservation. Furthermore, annular abscesses, present in one third of the patients [2,4], are currently considered as a formal indication [3] because of their morbidity and the relative inefficacy of antibiotics to eradicate them [5]. Therefore, we found no reason to delay surgery when diagnostics of an abscess is suggested. In conclusion, since a prospective randomised trial on medical versus surgical approach for NVE in unlikely to happen, no evidence will ever be undisputable, and clinician decision-making will rely on available literature. Our study shows that in an experienced centre early surgery seems to be safe and for this reason may be performed in selected patients presenting recommended indications. Obviously, other studies are necessary to define the place of early surgery in the wide spectrum of IE disease.

Neurologic manifestations of infective endocarditis: a 17-year experience in a teaching hospital in Finland.

Many previous studies have endeavored to find appropriate means to reduce the occurrence of neurologic manifestations in patients with infective endocarditis (IE). We evaluated patients with IE-associated neurologic complications and compared them with patients with IE who did not have neurologic symptoms. Particular attention was focused on assessing the impact of cardiac surgery and the presence of potential risk factors for complications on the outcome of the patients. A total of 218 episodes designated as definite or possible IE according to Duke criteria and treated during the years 1980 through 1996 in a Finnish teaching hospital were retrospectively evaluated for neurologic manifestations. Neurologic complications were identified in 55 episodes (25%), with an embolic event as the most frequent manifestation (23/55; 42%). In the majority (76%) of episodes, the neurologic manifestation was evident before antimicrobial treatment was started, being the first sign of IE in 47% of episodes. Only 1 recurrent cerebral embolization was observed. Neurologic complications were significantly associated with Staphylococcus aureus infection (29% vs 10%; P =.001) and with IE affecting both the aortic and the mitral valves (56% vs 23%; P<.01), but not with echocardiographic detection of vegetations or anticoagulant therapy. Death during the acute phase of IE occurred in 13 episodes (24%) with neurologic complications and in 17 episodes (10%) without neurologic complications (P<.03). In episodes with neurologic complications, the IE-associated mortality rate was 25% (10/40) in the medical treatment group and 20% (3/15) in the surgical group. No neurologic deterioration was observed in these surgically treated patients postoperatively. Our results reinforce the belief that rapid diagnosis and initiation of antimicrobial therapy may still be the most effective means to prevent neurologic complications. These data underscore the importance of diagnostic alertness to the prognosis of patients with IE.

Chirurgie der akuten Aortenklappenendokarditis: Prognose bei paravalvulären Abszessen

The occurrence of paravalvular abscesses in the course of an acute endocarditis of the aortic valve indicates an advanced stadium of the disease. The infection has spread beyond the limits of the valve leaflets, and ongoing destruction of the paravalvular tissue is to be expected, if the endocarditis is continually treated by antibiotics alone. Surgery of acute endocarditis with paravalvular abscess, however, supposedly carries an increased risk of early mortality and late morbidity. The following prospective study was carried out to determine whether a radical surgical approach together with aggressive postoperative antibiotic therapy could help to improve results. Between 1988 and 1995, 138 patients were operated during the acute phase of infective endocarditis; in 102 the aortic valve was involved. Among these, 44 had paravalvular abscesses at the time of surgery. The mean age of both groups was the same, but there was a higher rate of concomitant coronary artery disease, multiple valve involvement, advanced NYHA-class, and staphylococcal disease among the patients with abscesses. All interventions were carried out with cardiopulmonary bypass and cardioplegic arrest. The aortic valve was resected, abscesses were removed, and each part of potentially infected or necrotic tissue was resected as complete as possible, irrespective of the possibility to jeopardize the conduction system or to create large tissue defects. The aortic valve was replaced with a mechanical prosthesis in each case. The postoperative antibiotic regimen was specifically directed against the microorganisms isolated preoperatively; therapy was only modified, if signs of systemic infection did not disappear three days after surgery. The operative mortality was 10% among patients without an abscess and 11% in patients with a paravalvular abscess. Early recurrent endocarditis was recorded in two patients without and in only one patient with an abscess. Late recurrent endocarditis was noted in three patients; none of them had abscesses at the time of surgery. We conclude that the operative risk of acute endocarditis of the aortic valve with a paravalvular abscess does not have to be inevitably higher compared to cases without paravalvular involvement. To achieve these results, it is necessary to use a radical surgical approach and to adjust postoperative antibiotic therapy, if infectious signs do not disappear shortly after surgery.

感染性心内膜炎の活動期における外科治療の検討

感染性心内膜炎の活動期における外科治療の検討

Surgery in active infective endocarditis.

Controversy persists concerning the role of early surgical intervention in severe infective endocarditis (IE). We therefore reviewed 163 episodes of well-documented IE in which 32 cardiac operations were performed during the active phase of IE. Congestive heart failure (CHF) was the principal indication for surgery in 88% (28/32); systemic emboli, 1/32; and persisting sepsis, 3/32. Staphylococcus and enterococcus were the most common infecting organisms in the operative group (44% and 16% respectively). Surgical mortality (11/32,37%) did not differ (p greater than 0.05) from medical mortality (26/131,20%). All 11 operative deaths occurred in patients moribund prior to surgery, including three with preoperative cardiac arrest. Surgical patients undergoing preoperative cardiac catheterization demonstrated marked CHF: a mean left ventricular end-diastolic pressure of 25.3 mm Hg. The mean cardiac index in 8/11 surgical deaths was lower (p less than 0.05) vs surgical survivors: 2.21/min/m2 vs. 3.21/min/m2. Postoperative complications were rare in the 21 surgical survivors. There were no episodes of continued infection, prosthetic dehiscence, or advanced heart block; only one paravalvular leak; and one systemic embolus. These findings emphasize the high medical and surgical mortality in patients with IE, suggest that delayed operative intervention may be a major causative factor resulting in a high surgical mortality, and justify an aggressive surgical approach in patients with valve dysfunction and heart failure. These data indicate that survivors of surgical intervention during active IE have eradication of infection and few postoperative complications.