The Role of Surgery

Surgery may be required for urgent treatment of both intra-cardiac and neurological complications. There are no absolute indications for surgery though, and its use must be evaluated after careful analysis of risks and benefits. It is important for the emergency physician to be able to recognise when urgent surgery may be required to treat a complication of endocarditis [5].

This table details cardiac indications for surgical intervention in endocarditis.

Timing Strong evidence Moderate evidence
Emergent (same day)
  • Sinus of Valvsalva Abscess
  • Rupture into pericardium
  • Preclosure of Mitral Valve with Acute Aortic Regurgitation
Urgent (1-2 days)
  • Valve obstruction by vegetation
  • Acute Aortic or Mitral Regurgitation with NYHA Class 3 or 4 failure
  • Septal Perforation
  • Peri-valvular extension of abscess
  • Lack of effective antibiotic therapy
  • Major embolisation
  • Large >10 mm vegetation
Elective
  • Progressive peri-valvular regurgitation
  • Valve dysfunction associated with persistent infection >7-10 days after treatment
  • Fungal endocarditis
  • Staphylococcal Prosthetic valve infection
  • Antibiotic resistant organisms
  • Early Prosthetic Valve infection <2 months post op
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