Endocarditis surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Cafer Zorkun, M.D., Ph.D. [2] Maliha Shakil, M.D. [3]


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 antibiotics, relapse of the infection despite 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 for 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. 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 fistulas or septal defects.



Indications for surgical debridement of vegetations and infected perivalvular tissue, with valve replacement or repair as needed, are listed below:[1]

  1. Moderate to severe congestive heart failure due to valve dysfunction
  2. Unstable valve prosthesis
  3. Uncontrolled infection for > 1–3 week despite maximal antimicrobial therapy
  4. Persistent bacteremia
  5. Fungal endocarditis
  6. Relapse after optimal therapy in a prosthetic valve
  7. Vegetation in Situ
  8. Prosthetic valve endocarditis with a perivalvular invasion
  9. Endocarditis caused by Pseudomonas aeruginosa or other gram-negative bacilli that have not responded after 7–10 days of maximal antimicrobial therapy
  10. Perivalvular extension of infection and abscess formation
  11. Staphylococcal infection of prosthesis
  12. Persistent fever (culture negative)
  13. Large vegetation (>10 mm is associated with an increased risk of embolism)
  14. Relapse after optimal therapy in a native valve
  15. Vegetations that obstruct the valve orifice
  16. Onset of AV block

Principles of Surgical Treatment of Endocarditis

Surgical treatment of endocarditis includes:[1]

  • Excision of all infected valve tissue
  • Drainage and debridement of abscess cavities
  • Repair or replacement of damaged valves
  • Repair of any associated pathology such as septal defect, fistulas

Aortic Valve - Surgical Options

If the infection is limited to the leaflets, then the aortic valve should be replaced. If the infection extends to the annulus or beyond, then the infected tissues should be debrided. Any abscesses should be drained and the aortic root should be replaced.

Atrioventricular Valve - Surgical Options

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 annulus 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.

Surgical Outcomes

Operative mortality is 15 - 20%. The development of an infection of a prosthetic valve during operation for 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 native valve endocarditis is 70 - 80% and for prosthetic valve endocarditis is 50 - 80%.[1]


  1. 1.0 1.1 1.2 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. (2005). "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". Circulation. 111 (23): 3167–84. PMID 15956145.

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