Surgical Management Of Endocarditis

Publication Date: June 1, 2011
Last Updated: March 14, 2022

Recommendations

Neurologic Complications in Endocarditis

Radiographic evaluation of patients with stroke and endocarditis

Brain imaging is required if there is suspicion of stroke in the setting of endocarditis. Either magnetic resonance imaging (MRI) or computed tomography (CT) is an acceptable initial study. (B, Class I)
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If MRI is chosen, diffusion weighted imaging, FLAIR imaging, gradient echo imaging, and a postcontrast study, should be performed. (B, Class I)
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If MRI is not feasible, CT should be performed. (B, Class I)
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Vascular imaging should be performed contemporaneously with brain imaging. Magnetic resonance angiography (MRA) and computed tomography angiography (CTA) are both acceptable vascular imaging modalities to screen for mycotic aneurysm in patients without evidence of intracranial hemorrhage. (C, Class I)
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It is reasonable to reserve catheter angiography for patients with evidence of intracranial bleeding, or noninvasive vascular imaging suggestive of mycotic aneurysm. (C, Class IIa)
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Timing of surgery in patients with neurologic complications

In patients who have had a major ischemic stroke or any intracranial hemorrhage, it is reasonable to delay valve replacement for at least 4 weeks from the stroke, if possible. (C, Class IIa)
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If there is a decline in cardiac function, recurrent stroke or systemic embolism or uncontrolled infection despite adequate antibiotic therapy, a delay of less than 4 weeks may be reasonable, particularly in patients with small areas of brain infarction. (C, Class IIb)
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Intracranial hemorrhage and mycotic aneurysms

Heparin is the major modifiable risk factor for brain hemorrhage in IE. It should be used cautiously in all patients, and should be withheld for 4 weeks after brain hemorrhage in the context of IE. (B, Class I)
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For patients with IE and intracranial hemorrhage, catheter angiography should be performed to rule out MA with consideration of surgical or endovascular therapy. (B, Class I)
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Once patients with IE but without neurologic symptoms have been screened to identify MA, it may be reasonable to follow mycotic aneurysms noninvasively to rule out aneurysmal expansion during antibiotic therapy. (C, Class IIb)
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Aneurysms that expand during antibiotic therapy may be considered for surgical therapy. It may be reasonable to follow conservatively aneurysms that remain stable or decrease in size during antibiotic treatment. (C, Class IIb)
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Aortic Valve Endocarditis

Native aortic valve endocarditis

When surgery is indicated, a mechanical or stented tissue valve is reasonable in native aortic valve endocarditis if the infection is limited to the native aortic valve or to the aortic annulus. Valve choice should be based on age, life expectancy, comorbidities, and compliance with anticoagulation. (B, Class IIa)
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A homograft may be considered in native aortic valve endocarditis when the infection is limited to the native aortic valve or to the aortic annulus. (B, Class IIb)
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Native aortic valve endocarditis with periannular abscess

When periannular abscess is associated with IE, it is reasonable to use a mechanical or stented tissue valve if radical debridement is carried out and the valve can be anchored to healthy and strong tissue. (B, Class IIa)
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It may be reasonable to use a homograft in native aortic valve endocarditis with periannular abscess and extensive annular or aortic wall destruction requiring aortic root replacement/reconstruction or extensive aortic-ventricular discontinuity. (B, Class IIb)
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Prosthetic aortic valve endocarditis

When surgery is indicated, in patients with aortic PVE limited to the prosthesis without aortic root abscess, and no annular destruction, it is reasonable to implant a mechanical or stented tissue valve. (B, Class IIa)
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Prosthetic valve endocarditis with periannular abscess

A homograft can be beneficial in aortic PVE when periannular abscess or extensive ventricular-aortic discontinuity is present, or when aortic root replacement/reconstruction is necessary because of annular destruction or destruction of anatomical structures. (B, Class IIa)
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Mitral Valve Endocarditis

Native mitral valve endocarditis

When technically feasible, mitral valve repair is recommended to treat native mitral valve endocarditis. (B, Class I)
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When surgery is indicated, mechanical or stented tissue valves can be useful for mitral valve replacement as appropriate given age, life expectancy, and comorbidities. (B, Class IIa)
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Mitral prosthetic valve endocarditis

When surgery is indicated for prosthetic mitral valve endocarditis, either mechanical or stented tissue valves may be considered for valve replacement. The choice of whether either a tissue or mechanical valve should be implanted should be based primarily on consideration of age, life expectancy, and presence of comorbidities. (C, Class IIb)
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Tricuspid Valve Endocarditis

Native tricuspid valve endocarditis

When surgery is indicated, tricuspid valve repair is recommended for native tricuspid valve endocarditis. (B, Class I)
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Mechanical or stented tissue valves can be useful in native tricuspid valve endocarditis, if the valve cannot be repaired. (C, Class IIa)
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Multiple Valve Endocarditis

In the presence of multiple valve endocarditis involving the aortic valve, the decision to choose a homograft for the aortic valve should follow the same algorithm outlined for isolated aortic valve endocarditis. (C, Class I)
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In the presence of concomitant aortic or mitral or tricuspid valve endocarditis, in the aortic, mitral, and tricuspid positions, either a stented tissue or mechanical valve can be implanted. The choice of valve should follow the same algorithm outlined independently for aortic, mitral, and tricuspid valve endocarditis. (B, Class I)
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When surgery of the mitral and tricuspid valves is indicated for multiple valve endocarditis, it can be beneficial to perform mitral and tricuspid valve repair whenever feasible. (B, Class IIa)
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Recommendation Grading

Overview

Title

Surgical Management Of Endocarditis

Authoring Organization

Society of Thoracic Surgeons

Publication Month/Year

June 1, 2011

Last Updated Month/Year

May 15, 2023

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Based upon a review of the literature from January 2000 to December 2010, this guideline focusing on the management of endocarditis in common and complex clinical situations includes recommendations regarding the management of native and prosthetic valve infections, septic neurologic manifestations, and reviews the valve selection options and replacement criteria.

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D004696 - Endocarditis, D004697 - Endocarditis, Bacterial, D004698 - Endocarditis, Subacute Bacterial

Keywords

endocarditis

Source Citation

Surgical Management of Endocarditis: The Society of Thoracic Surgeons Clinical Practice Guideline

Byrne, John G. et al.
The Annals of Thoracic Surgery, Volume 91, Issue 6, 2012 - 2019

Methodology

Number of Source Documents
145
Literature Search Start Date
January 1, 2000
Literature Search End Date
December 1, 2010