Endocarditis surgery
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Endocarditis Microchapters |
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Diagnosis |
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Treatment |
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2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease |
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Case Studies |
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Endocarditis surgery On the Web |
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] Anum Ijaz M.B.B.S., M.D.[4]
Overview
Surgical therapy is required in approximately half of patients with infective endocarditis and is driven by three broad indications: heart failure due to valve dysfunction, uncontrolled infection (perivalvular extension, abscess, new heart block, fungal or highly resistant organisms, persistent bacteremia or fever despite appropriate antibiotic therapy), and prevention of embolism (large or mobile vegetations, particularly after an embolic event). Decisions regarding surgery should be made by a multidisciplinary Endocarditis Team. Operative management involves excision of all infected valve tissue, drainage and debridement of abscess cavities, repair or replacement of damaged valves, and repair of associated pathology such as fistulas or septal defects. Valve repair is preferred over replacement when technically feasible.[1][2]
Multidisciplinary Endocarditis Team
Decisions about the timing of surgical intervention in infective endocarditis should be made by a Heart Valve Team (Class I; LOE B per the 2020 ACC/AHA valvular heart disease guideline).[1] The 2023 ESC guidelines similarly identify the Endocarditis Team as a key determinant of prognosis.[3]
- Core members: cardiologist, cardiothoracic surgeon, infectious disease specialist, and neurologist, with additional specialists (imaging, addiction medicine, microbiology) as needed.
- Introduction of an endocarditis team has been associated with lower mortality (14.7% vs. 20.3%), shorter time to surgery (10.3 vs. 16.4 days), and shorter length of stay (31.9 vs. 40.6 days).[4]
- Complicated cases managed at centers without cardiac surgery should be transferred to a Comprehensive Valve Center.[1]
Indications for Surgery
| Indication category | Specific criteria | ACC/AHA 2020 COR/LOE | Timing |
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| Heart failure |
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Class I; LOE B | Urgent; emergent if refractory pulmonary edema or cardiogenic shock |
| Uncontrolled infection — perivalvular extension |
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Class I; LOE B | Urgent |
| Uncontrolled infection — organism |
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Class I; LOE B | Urgent |
| Persistent infection |
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Class I; LOE B | Urgent |
| Prosthetic valve endocarditis |
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Class I; LOE C | Urgent |
| Recurrent endocarditis in persons who inject drugs |
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Class I; LOE C | Before reoperation |
| Embolic prevention — recurrent emboli |
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Class IIa; LOE B | Early |
| Embolic prevention — vegetation size |
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Class IIb; LOE B | Early (within first days of therapy in selected patients) |
The 2023 ESC guidelines include additional vegetation-based indications not present in the ACC/AHA guideline:[3][5]
- Vegetation >10 mm with severe valve dysfunction and low operative risk (Class IIa; LOE B)
- Isolated very large vegetation >30 mm (Class IIa; LOE B)
- Isolated large vegetation >15 mm without other surgical indication (Class IIb; LOE C)
The ESC guidelines are generally more aggressive than the ACC/AHA guidelines regarding vegetation-based surgical indications.
Early Surgery
The 2023 ESC guidelines define three timing categories for surgery:[3]
- Emergency: within 24 hours — refractory pulmonary edema or cardiogenic shock
- Urgent: within 3–5 days — most other surgical indications (uncontrolled infection, embolic prevention, symptomatic heart failure)
- Non-urgent (elective): during the same hospitalization, after ≥1–2 weeks of antibiotics — fungal or multidrug-resistant organisms without acute hemodynamic compromise
The 2020 ACC/AHA guideline defines "early surgery" as operation during the initial hospitalization and before completion of a full therapeutic course of antibiotics, without further temporal subcategorization.[1]
In left-sided infective endocarditis with severe valve disease and large vegetations, early surgery (within 48 hours of randomization) reduced the composite of in-hospital death and embolic events compared with conventional therapy, driven principally by reduction in systemic embolism; there was no significant difference in all-cause mortality alone.[6] Surgery should not be delayed solely to complete a predefined course of antibiotics when a Class I indication is present.[2]
Preoperative Evaluation
- Transesophageal echocardiography to define vegetation size, valve destruction, and perivalvular extension (abscess, pseudoaneurysm, fistula)
- ECG monitoring for new conduction abnormalities suggesting annular or aortic root abscess
- Neuroimaging (CT or MRI) in patients with neurologic symptoms
- Preoperative coronary evaluation in patients at risk for coronary artery disease; invasive coronary angiography should generally be avoided in the presence of large mobile aortic valve vegetations because of embolic risk (CT coronary angiography is an alternative)
- Evaluation for extracardiac foci of infection[2]
Endocarditis-specific operative risk scores (PALSUSE, STS-IE, RISK-E) have been developed to estimate operative mortality and may supplement, but do not replace, Endocarditis Team assessment; none has been prospectively validated for surgical decision-making.[5]
Surgical Principles
Surgical treatment of endocarditis includes:[2]
- Excision of all infected valve tissue and radical debridement of infected material
- Drainage and debridement of abscess cavities
- Repair or replacement of damaged valves
- Reconstruction of associated pathology such as septal defects and fistulas
- Intraoperative culture and histopathology of excised tissue to guide postoperative antimicrobial therapy
Right-Sided Endocarditis
Surgery is less frequently required in right-sided infective endocarditis and is generally reserved for:[2][7]
- Right-sided heart failure secondary to severe tricuspid regurgitation poorly responsive to diuretics
- Persistent infection with organisms difficult to eradicate (e.g., fungal endocarditis, persistent Staphylococcus aureus bacteremia >7 days despite appropriate therapy)
- Tricuspid valve vegetations >20 mm with recurrent pulmonary emboli
Valve repair is preferred over replacement, particularly in persons who inject drugs, given the risk of prosthetic reinfection with ongoing injection drug use.[7]
The 2020 ACC/AHA guideline recommends that in patients with recurrent endocarditis and continued injection drug use, consultation with addiction medicine be obtained to discuss long-term prognosis before repeat surgical intervention is considered (Class I; LOE C).[1] Surgery should not be categorically withheld on the basis of substance use alone.[7]
Percutaneous mechanical aspiration is an emerging catheter-based alternative to surgery in selected patients with right-sided infective endocarditis and large vegetations, particularly those at prohibitive surgical risk. It remains investigational, with evidence limited to observational data, and is not established as standard care.
Aortic Valve
If the infection is limited to the leaflets, the aortic valve is replaced. If infection extends to the annulus or beyond, infected tissue is debrided, abscess cavities are drained and obliterated, and aortic root replacement (homograft, stentless xenograft, or valved conduit) is performed.
Mitral and Tricuspid Valves
If infection is limited to the leaflets, vegetations are excised, perforations repaired, and annuloplasty performed as needed. Mitral valve repair is preferred over replacement when technically feasible; a meta-analysis of more than 4,000 patients and a nationwide Dutch cohort both demonstrated improved survival with repair versus replacement in active infective endocarditis.[8][9] If infection extends to the annulus or beyond, valve replacement with debridement and obliteration of abscess cavities is performed.
Isolated tricuspid valve excision without replacement (valvectomy) is generally not recommended because of significant associated morbidity, particularly in the presence of pulmonary hypertension; repair or replacement is preferred.[7]
Cardiac Implantable Electronic Device Endocarditis
Complete removal of the generator and all leads is recommended for all patients with definite CIED-associated infective endocarditis, including pocket infection and valvular endocarditis even without definite lead involvement (Class I; LOE B).[1][10]
- Complete system extraction is the standard of care; partial removal is associated with high relapse rates.
- Extraction should be performed without unnecessary delay; early extraction (within 7 days) has been associated with a three-fold reduction in 1-year mortality.[11]
- Percutaneous (transvenous) extraction is preferred unless vegetations are >20 mm or concomitant valve surgery is indicated.
- Antimicrobial duration is counted from the day of device explantation: approximately 7 days for pocket erosion without purulence, 10–14 days for pocket infection with purulence, and 4–6 weeks of parenteral therapy for valvular endocarditis.[12]
- Reimplantation should be deferred until blood cultures have been negative for ≥72 hours, and for ≥14 days when valvular vegetations are present. Reassess the ongoing need for the device before reimplantation.
Postoperative Antimicrobial Therapy
The total duration of antimicrobial therapy is determined by the duration of therapy completed before surgery and by intraoperative culture results:[2]
- If valve cultures are positive, a complete course directed at the recovered organism is given, counted from the day of surgery.
- If intraoperative cultures are negative, preoperative days of therapy count toward the total duration.
- When native valve endocarditis is treated surgically, the postoperative regimen remains that for native valve endocarditis; it is not converted to a prosthetic valve endocarditis regimen solely because a prosthesis was implanted.
The 2023 ESC guidelines permit consideration of transition to oral antibiotics in selected clinically stable patients who have completed at least 7 days of intravenous therapy after surgery.[3]
Outcomes and Complications
- Contemporary Society of Thoracic Surgeons database data (2011–2019) for aortic valve infective endocarditis show declining operative mortality, from 10.9% to 8.5% for native valve endocarditis and from 22.5% to 10.4% for prosthetic valve endocarditis.[13] A separate STS analysis of all-valve infective endocarditis reported left-sided operative mortality of approximately 8% for native valve and 12% for prosthetic valve endocarditis.[14]
- Contemporary series of double-valve surgery for infective endocarditis report approximately 14% 30-day mortality.[15]
- In the nationwide Danish NIDUS registry, approximately 40% of patients with left-sided infective endocarditis had a surgical indication but only about half underwent surgery. Among those with an indication, in-hospital mortality was 31.8% without surgery versus 12.5% with surgery, and 1-year mortality was 50.5% versus 17.0%.[16]
- Complications include prosthetic valve endocarditis, perivalvular leak, complete heart block requiring permanent pacemaker implantation, stroke, acute kidney injury, and reoperation.
- Relapse and recurrent endocarditis are increased with ongoing injection drug use, prosthetic valve infection, and incomplete debridement.
Neurologic Complications and Timing
Neurologic events are common and influence operative timing:[1][3]
- Silent cerebral embolism or transient ischemic attack: surgery may proceed without delay if otherwise indicated.
- Ischemic stroke without hemorrhage or extensive neurologic damage: per ACC/AHA 2020, operation without delay may be considered (Class IIb; LOE B). The 2023 ESC guidelines take a stronger position: ischemic stroke should not delay surgery once an indication has been identified.
- Intracranial hemorrhage or major ischemic stroke with extensive neurologic damage: delaying valve surgery for at least 4 weeks may be considered if the patient is hemodynamically stable (Class IIb; LOE B-NR). One multicenter observational study reported mortality of 75% when surgery was performed within 4 weeks of hemorrhagic stroke versus 40% when delayed beyond 4 weeks.[17]
- Mycotic aneurysm: vascular imaging of the brain should be considered before cardiopulmonary bypass when neurologic symptoms are present.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A, Toly C (2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol. 77 (4): e25–e197. doi:10.1016/j.jacc.2020.11.018.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Tleyjeh IM, Rybak MJ, Barsic B, Lockhart PB, Gewitz MH, Levison ME, Bolger AF, Steckelberg JM, Baltimore RS, Fink AM, O'Gara P, Taubert KA (2015). "Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association". Circulation. 132 (15): 1435–86. PMID 26373316.
- ↑ 3.0 3.1 3.2 3.3 3.4 de la Cuesta M, Marin-Cuartas M, de Waha S; et al. (2025). "Surgical implications of the 2023 ESC endocarditis guidelines endorsed by EACTS: bridging guidelines and practice". Eur J Cardiothorac Surg. 67 (7): ezaf225. doi:10.1093/ejcts/ezaf225.
- ↑ Dalebout EM, Budde RPJ, Galema TW; et al. (2026). "Evolution of Management and Outcomes of Infective Endocarditis After Introducing the Endocarditis Team". JACC Adv. 5 (2): 102579. doi:10.1016/j.jacadv.2025.102579.
- ↑ 5.0 5.1 Cahill TJ, Baddour LM, Habib G; et al. (2017). "Challenges in Infective Endocarditis". J Am Coll Cardiol. 69 (3): 325–344. doi:10.1016/j.jacc.2016.10.066.
- ↑ Kang DH, Kim YJ, Kim SH, Sun BJ, Kim DH, Yun SC, Song JM, Choo SJ, Chung CH, Song JK, Lee JW, Sohn DW (2012). "Early surgery versus conventional treatment for infective endocarditis". N Engl J Med. 366 (26): 2466–73. PMID 22738096.
- ↑ 7.0 7.1 7.2 7.3 Yucel E, Bearnot B, Paras ML; et al. (2022). "Diagnosis and Management of Infective Endocarditis in People Who Inject Drugs: JACC State-of-the-Art Review". J Am Coll Cardiol. 79 (20): 2037–2057. doi:10.1016/j.jacc.2022.03.349.
- ↑ Comentale G, Ahmadi-Hadad A, Moldon HJ; et al. (2025). "Comparative Outcomes of Mitral Valve Repair Versus Replacement in Infective Endocarditis: A 16-Year Meta-Analysis of Time-to-Event Data From Over 4000 Patients". Am J Cardiol. 246: 33–42. doi:10.1016/j.amjcard.2025.03.004.
- ↑ Tomšič A, de Weger A, van der Stoel M, Klautz RJM, Palmen M (2024). "A Nationwide Study on Mitral Valve Repair vs Replacement for Active Endocarditis". Ann Thorac Surg. 117 (1): 120–126. doi:10.1016/j.athoracsur.2023.08.032.
- ↑ Baddour LM, Esquer Garrigos Z, Rizwan Sohail M; et al. (2024). "Update on Cardiovascular Implantable Electronic Device Infections and Their Prevention, Diagnosis, and Management: A Scientific Statement From the American Heart Association". Circulation. 149 (2): e201–e216. doi:10.1161/CIR.0000000000001187.
- ↑ Lakkireddy DR, Segar DS, Sood A; et al. (2023). "Early Lead Extraction for Infected Implanted Cardiac Electronic Devices: JACC Review Topic of the Week". J Am Coll Cardiol. 81 (13): 1283–1295. doi:10.1016/j.jacc.2023.01.038.
- ↑ Chesdachai S, Esquer Garrigos Z, DeSimone CV, DeSimone DC, Baddour LM (2024). "Infective Endocarditis Involving Implanted Cardiac Electronic Devices: JACC Focus Seminar 1/4". J Am Coll Cardiol. 83 (14): 1326–1337. doi:10.1016/j.jacc.2023.11.036.
- ↑ Caceres Polo M, Thibault D, Jawitz OK; et al. (2022). "Aortic Prosthetic Valve Endocarditis: Analysis of the Society of Thoracic Surgeons Database". Ann Thorac Surg. 114 (6): 2140–2147. doi:10.1016/j.athoracsur.2021.10.045.
- ↑ Williams JB, Shah AA, Zhang S; et al. (2019). "Impact of Microbiological Organism Type on Surgically Managed Endocarditis". Ann Thorac Surg. 108 (5): 1325–1329. doi:10.1016/j.athoracsur.2019.04.025.
- ↑ Miller PC, Schulte LJ, Marghitu T; et al. (2024). "Outcomes of double-valve surgery for infective endocarditis are improving in the modern era". J Thorac Cardiovasc Surg. 168 (3): 832–842. doi:10.1016/j.jtcvs.2023.09.072.
- ↑ Graversen PL, Østergaard L, Hadji-Turdeghal K; et al. (2025). "Clinical Practice of Surgical Treatment for Left-Sided Infective Endocarditis: Nationwide Data From the NIDUS Registry". Circulation. doi:10.1161/CIRCULATIONAHA.125.074608.
- ↑ Nishimura RA, Otto CM, Bonow RO; et al. (2017). "2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease". J Am Coll Cardiol. 70 (2): 252–289. doi:10.1016/j.jacc.2017.03.011.