Consensus on Surgical Treatment of Infective Endocarditis

Authors:
Pettersson GB, Coselli JS, Hussain ST, et al.
Citation:
2016 The American Association for Thoracic Surgery (AATS) Consensus Guidelines: Surgical Treatment of Infective Endocarditis: Executive Summary. J Thorac Cardiovasc Surg 2017;153:1241-1258.

The American Association for Thoracic Surgery Consensus Guidelines provide evidence-based recommendations addressing the perioperative management of patients with infective endocarditis (IE), including when to operate, how to prepare the patient for operation, and how to operate. The following are key points to remember:

  1. IE team. Patients with suspected IE should be cared for at centers with access to a team including cardiologists, infectious disease specialists, and cardiac surgeons; and other services needed to handle complications from IE. Surgeons should be well trained, experienced valve surgeons capable of various reconstructive techniques used in patients with advanced IE.
  2. Indications for surgery in IE. Among patients with IE, indications for surgery during the initial hospitalization include:
    • Valve dysfunction resulting in symptoms of heart failure (Class I).
    • Left-sided IE caused by S. aureus, fungal, or other highly resistant microorganisms (Class I).
    • IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions (Class I).
    • Evidence of persistent infection 5-7 days after initiation of appropriate antibiotic therapy (Class I).
    • Prosthetic valve endocarditis (PVE) with relapsing infection (Class IIa).
    • Recurrent emboli and persistent vegetations despite appropriate antibiotic therapy (Class IIa).
  3. Timing surgery in IE.
    • Once an indication for surgery is established, the patient should be operated on within days (Class I). Earlier surgery (emergency or within 48 hours) is reasonable for patients with large, mobile vegetations (Class IIa).
    • Patients should be on appropriate antibiotic therapy at the time of surgery (Class I). Once a patient is on an appropriate antibiotic regimen, further delay of surgery is unlikely to be beneficial (Class IIa).
  4. Neurologic complications and surgery for IE.
    • In the setting of a diagnosed cerebral mycotic aneurysm, treatment should be in close collaboration with neurology and neurosurgery (Class I).
    • An operative delay of 3 weeks or more is reasonable among patients with recent intracranial hemorrhage (Class IIa).
    • Patients with IE and neurologic symptoms should undergo brain imaging (Class I); it is reasonable to screen patients with left-sided IE for possible stroke or intracranial bleeding prior to operation (Class IIa).
  5. General intraoperative management of patients with IE.
    • Intraoperative transesophageal echocardiography is mandatory (Class I).
    • With few exceptions, median sternotomy is recommended (Class I).
    • All infected and necrotic tissue and foreign material should be radically debrided and removed (Class I).
    • For patients with native valve IE limited to the leaflets/cusps, repair should be performed whenever possible (Class I).
    • When simple valve replacement is required, the choice of valve (mechanical or tissue) should be based on the usual criteria (Class I). However, it is reasonable to avoid the use of a mechanical valve among patients with intracranial bleeding and in those who have suffered a major stroke (Class IIa).
  6. Prosthetic valve IE.
    • Aortic PVE. If the root and the annulus are preserved after radical debridement in prosthetic aortic valve IE, implantation of a new prosthetic valve (tissue or mechanical) is reasonable (Class IIa). If there is annular destruction and invasion outside the aortic root, then root reconstruction and use of an allograft or a biologic tissue root is preferable to a prosthetic valved conduit (Class IIa).
    • Mitral PVE. When there is annular destruction and invasion, the annulus is reconstructed and the new prosthetic valve anchored to the ventricular muscle or to the reconstruction patch in a way to prevent leakage and pseudoaneurysm development (Class IIa).
  7. Double-valve IE.
    • If the aortic root and aortic and mitral annuli are preserved after radical debridement, then it is reasonable to implant mechanical or tissue valves using the usual criteria (Class IIa).
    • If there is annulus destruction and invasion and root reconstruction/replacement is required, then an allograft or bioroot may be preferable to a prosthetic valve conduit (Class IIa).
  8. Additional considerations involving pacemakers and implantable cardioverter-defibrillators.
    • Complete removal of pacemaker and defibrillator systems, including all leads and the generator, is indicated as part of the early management plan among patients with IE and likely device infection (Class I).
    • Complete removal of pacemaker and defibrillator systems, including all leads and the generator, is reasonable in patients with IE caused by S. aureus or fungus, even without evidence of device infection (Class IIa).
  9. Special considerations.
    • Patients who have undergone surgery for IE should be informed about the increased risk of recurrent IE and the need for prophylaxis (Class I).
    • Among patients who are intravenous drug users, normal indications for surgery are reasonable; management must include treatment of the addiction (Class IIa).
    • Among patients on dialysis, normal indications for surgery are reasonable, but additional comorbidities must be factored into assessments of risks and outcomes (Class IIa). Shorter durability of bioprosthesies and allografts may be considered in the choice of valve prostheses used (Class IIa).

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