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| __NOTOC__
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| {{Malihas}}
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| {{CMG}}; {{AE}} {{Sapan}}
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| __NOTOC__
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| {{Endocarditis}}
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| {{CMG}}; '''Associate Editors-in-Chief:''' {{CZ}}
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| ==Overview==
| | Suppurative thrombophlebitis usually occur in peripheral veins as a result of an intravenous catheter, or dissemination from a surrounding soft tissue infection . Other causes may include intravenous drug use, abrasions, lacerations, hypercoagulable states, and burns. |
| Early valve surgery should be scheduled when there is [[heart failure]] due to the valve dysfunction, left-sided infective endocarditis due to ''[[Staphylococcus aureus]]'', fungal or highly resistant organisms, or a [[heart block]], annular or aortic [[abscess]] or destructive lesions. Other indications include persistent [[bacteremia]] or [[fever]] 5 to 7 following the initiation of the [[antibiotic]]s, relapse of the infection depsite a complete course of antibiotics in [[prosthetic valve]] endocarditis when no portal of infection can be identified, recurrent emboli and persistent vegetations despite [[antibiotic therapy]], and mobile vegetations with a length more than 10 mm in native valve endocarditis. Surgical removal of the [[valve]] is necessary in patients who fail to clear micro-organisms from their blood in response to [[antibiotic]] therapy, or in patients who develop [[cardiac failure]] resulting from destruction of a [[valve]] by [[infection]]. A removed valve is usually replaced with an artificial valve which may either be mechanical (metallic) or obtained from an animal such as a pig; the latter are termed bioprosthetic valves.<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref> Surgical treatment of endocarditis involves excision of all infected [[valve]] tissue, drainage and debridement of [[abscess]] cavities, repair or replacement of damaged valves, and repair of any associated pathology such as [[fistula]]s or septal defects.<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145}}</ref>
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| ==Surgery== | | The high risk of suppurative thrombophlebitis in burn patients is explained by the high skin susceptibility to bacterial infection, use of broad spectrum antibiotics, and impairment of local defense due to loss of skin integrity.<ref name="pmid7369818">{{cite journal| author=Pruitt BA, McManus WF, Kim SH, Treat RC| title=Diagnosis and treatment of cannula-related intravenous sepsis in burn patients. | journal=Ann Surg | year= 1980 | volume= 191 | issue= 5 | pages= 546-54 | pmid=7369818 | doi= | pmc=PMC1344732 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7369818 }} </ref> |
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| ===Indications===
| | [[Lemierre's syndrome]] also known as jugular vein suppurative thrombophlebitis,postanginal sepsis, and necrobacillosis.<ref name="pmid15192164">{{cite journal| author=Riordan T, Wilson M| title=Lemierre's syndrome: more than a historical curiosa. | journal=Postgrad Med J | year= 2004 | volume= 80 | issue= 944 | pages= 328-34 | pmid=15192164 | doi= | pmc=PMC1743018 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15192164 }} </ref> There is extension of the bacterial infection from pharyngitis, tonsillitis, or peri-tonsillar infection, to the carotid sheath vessels that contains the internal jugular vein resulting in inflammation, thrombosis, and infection.<ref name="pmid2646510">{{cite journal| author=Sinave CP, Hardy GJ, Fardy PW| title=The Lemierre syndrome: suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection. | journal=Medicine (Baltimore) | year= 1989 | volume= 68 | issue= 2 | pages= 85-94 | pmid=2646510 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2646510 }} </ref> |
| Indications for surgical debridement of vegetations and infected perivalvular tissue, with valve replacement or repair as needed are listed below:<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
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| # Moderate to severe [[congestive heart failure]] due to valve dysfunction
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| # Unstable valve prosthesis
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| # Uncontrolled infection for > 1–3 week despite maximal antimicrobial therapy
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| # Persistent [[bacteremia]]
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| #[[endocarditis|Fungal endocarditis]]
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| # Relapse after optimal therapy in a prosthetic valve
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| # Vegetation in Situ
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| # Prosthetic valve [[endocarditis]] with perivalvular invasion
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| # [[Endocarditis]] caused by [[Pseudomonas aeruginosa]] or other gram-negative bacilli that has not responded after 7–10 days of maximal antimicrobial therapy
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| # Perivalvular extension of infection and abscess formation
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| # [[Staphylococcal]] infection of prosthesis
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| # Persistent [[fever]] (culture negative)
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| # Large vegetation (>10 mm is associated with an increased risk of embolism)
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| # Relapse after optimal therapy in a native valve
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| # Vegetations that obstruct the valve orifice
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| # Onset of [[AV block]]
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| ==2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (DO NOT EDIT)==
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| ===Indications for Surgery for Native Valve Endocarditis (DO NOT EDIT)<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= 129 | issue= 23 | pages= 2440-92 | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>===
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| {|class="wikitable"
| | Vena cava suppurative thrombophlebitis usually occurs in central venous catheter settings |
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| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Decisions about timing of surgical intervention should be made by a multispecialty Heart Valve Team of [[cardiology]], cardiothoracic surgery, and [[infectious disease]] specialists (301). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Early surgery (during initial hospitalization before completion of a full therapeutic course of [[antibiotics]]) is indicated in patients with IE who present with [[valve]] dysfunction resulting in symptoms of [[heart failure]] (342-347). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Early surgery (during initial hospitalization before completion of a full therapeutic course of [[antibiotic]]s) is indicated in patients with left-sided IE caused by ''[[Staphylococcus aureus]]'', fungal, or other highly resistant organisms (347-354). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Early surgery (during initial hospitalization before completion of a full therapeutic course of [[antibiotics]]) is indicated in patients with IE complicated by[[ heart block]], annular or aortic [[abscess]], or destructive penetrating lesions (347, 355-359). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Early surgery (during initial hospitalization before completion of a full therapeutic course of [[antibiotics]]) for IE is indicated in patients with evidence of persistent [[infection]] as manifested by persistent bacteremia or [[fever]]s lasting longer than 5 to 7 days after onset of appropriate antimicrobial therapy (347, 352, 353, 360-362). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' Surgery is recommended for patients with prosthetic valve endocarditis and relapsing [[infection]] (defined as recurrence of bacteremia after a complete course of appropriate [[antibiotics]] and subsequently negative blood cultures) without other identifiable source for portal of [[infection]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']]) <nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''7.''' Complete removal of [[pacemaker]] or [[defibrillator]] systems, including all leads and the generator, is indicated as part of the early management plan in patients with IE with documented infection of the device or leads (363-366). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']]) <nowiki>"</nowiki>
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| |}
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Complete removal of [[pacemaker]] or [[defibrillator]] systems, including all leads and the generator, is reasonable in patients with valvular IE caused by ''[[Staphylococcus aureus]]'' or fungi, even without evidence of device or lead [[infection]] (363-366). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Complete removal of [[pacemaker]] or [[defibrillator]] systems, including all leads and the generator, is reasonable in patients undergoing valve surgery for valvular IE. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']]) <nowiki>"</nowiki>
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.'''Early surgery (during initial hospitalization before completion of a full therapeutic course of [[antibiotics]]) is reasonable in patients with IE who present with recurrent emboli and persistent vegetations despite appropriate [[antibiotic]] therapy (302, 367, 368). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
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| |}
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) may be considered in patients with native valve endocarditis who exhibit mobile vegetations greater than 10 mm in length (with or without clinical evidence of embolic phenomenon) (302, 367, 368). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
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| |}
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| ==2008 AHA/ACC Guideline for the Management of Patients With Prosthetic Valve Endocarditis (DO NOT EDIT)==
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| ===Indications for Surgery for Prosthetic Valve Endocarditis (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>===
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Consultation with a [[cardiac surgeon]] is indicated for patients with [[infective endocarditis]] of a [[artificial heart valve|prosthetic valve]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Surgery is indicated for patients with [[infective endocarditis]] of a [[artificial heart valve|prosthetic valve]] who present with [[heart failure]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Surgery is indicated for patients with [[infective endocarditis]] of a [[artificial heart valve|prosthetic valve]] who present with [[dehiscence]] evidenced by cine [[fluoroscopy]] or [[echocardiography]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Surgery is indicated for patients with [[infective endocarditis]] of a [[artificial heart valve|prosthetic valve]] who present with evidence of increasing [[obstruction]] or worsening [[regurgitation (circulation)|regurgitation]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Surgery is indicated for patients with [[infective endocarditis]] of a [[artificial heart valve|prosthetic valve]] who present with [[complication (medicine)|complications]] (e.g., [[abscess]] formation). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
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| | bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Routine surgery is not indicated for patients with uncomplicated [[infective endocarditis]] of a [[artificial heart valve|prosthetic valve]] caused by first infection with a sensitive organism. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
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| |}
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Surgery is reasonable for patients with [[infective endocarditis]] of a [[artificial heart valve|prosthetic valve]] who present with evidence of persistent [[bacteremia]] or recurrent [[emboli]] despite appropriate antibiotic treatment. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Surgery is reasonable for patients with [[infective endocarditis]] of a [[artificial heart valve|prosthetic valve]] who present with relapsing [[infection]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
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| ==Principles of Surgical Treatment of Endocarditis==
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| Surgical treatment of endocarditis includes:<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
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| *Excision of all infected [[valve]] tissue
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| *Drainage and debridement of [[abscess]] cavities
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| *Repair or replacement of damaged valves
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| *Repair of any associated pathology such as septal defect, [[fistula]]s
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| ==Aortic Valve - Surgical Options==
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| If the [[infection]] is limited to the leaflets, then the [[aortic valve]] should be replaced. If the infection extends to the anulus or beyond, then the infected tissues should be debrided. Any abscesses should be drained and the aortic root should be replaced.
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| ==Atrioventricular Valve - Surgical Options==
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| If the infection is limited to the leaflets, then the vegetations should be excised, perforations should be repaired, and a reduction annuloplasty should be performed. If the infection extends to the anulus or beyond, then a valve replacement should be performed, and abscesses should be debrided and obliterated. In some cases the tricuspid valve may be excised.
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| ==Surgical Outcomes==
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| Operative mortality is 15 - 20%. The development of an infection of a prosthetic valve during operation for [[endocarditis|native valve endocarditis]] is 4%, it is higher (12 - 16%) if active [[endocarditis]] is present at the time of the surgery. Late survival at 5 years for [[endocarditis|native valve endocarditis]] is 70 - 80% and for [[endocarditis|prosthetic valve endocarditis]] is 50 - 80%.<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref>
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| ==2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>==
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| ===Intraoperative Assessment (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>===
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Intraoperative [[transesophageal echocardiography]] is recommended for valve surgery for [[infective endocarditis]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
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| {{WH}}
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| {{WS}}
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| ==References==
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| {{Reflist|2}}
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| [[Category:Emergency medicine]]
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| [[Category:Cardiology]]
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| [[Category:Infectious disease]]
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| [[Category:Intensive care medicine]]
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| [[Category:Up-To-Date]]
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| {{WH}}
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| {{WS}}
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