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Repair Versus Replacement Repair is possible in at least 70% of the pediatric IE cases, with favorable outcomes of postsurgical 5-year survival and freedom from reoperation being approximately 80%.113 In a recent study from China, the results of valve replacement for pediatric IE have been reported to be much better than expected.114 In adults, tricuspid valve repair (annuloplasty, bicupidalization, deVega repair, vegetation resection) is possible in only approximately 20% of the cases, with the rest necessitating tricuspid valve replacement with bioprosthesis115; in children, tricuspid valve repair is much more often possible The results of aortic valve repair versus replacement have been reviewed in adults.116,117 Indications for Infective Endocarditis Surgery The indications for surgery during the initial hospitalization are summarized in Box 56.5 Box 56.5 Indications for Surgery During Initial Hospitalization Recommendations for Surgery During Initial Hospitalization ■ 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) ■ PVE with relapsing infection (class IIa) ■ Recurrent emboli and persistent vegetations despite appropriate antibiotic therapy (class IIa) Echocardiographic and Clinical Features Suggesting Potential Need of Urgent Surgical Intervention Risk of Emboli (Systemic or Pulmonary) ■ Anterior mitral leaflet vegetation with significant size (>10 mm) ■ One or more embolic events during first 2 weeks of antimicrobial therapy ■ Increase of vegetation size after 4 weeks of antimicrobial therapy Valvar Dysfunction ■ Acute insufficiency (especially mitral and aortic) with signs of ventricular dysfunction ■ Intractable heart failure ■ Valve rupture or significant perforation Perivalvar Extension ■ Valvar dehiscence, rupture, or fistula ■ New heart block ■ Large abscess or extension of abscess despite therapy IE, Infective endocarditis; PVE, prosthetic valve endocarditis Modified from references 3, 6, and 7 The recommendation of 10 mm as the size of the vegetation above which there is increased risk of embolization has shown validity in pediatric IE,118 but there is a general impression that this might need to be adjusted in increasingly younger and smaller pediatric patients Surgery to prevent a primary embolic event in the absence of risk factors has not been recommended given the lack of proven benefit and long-term risks of valve replacement in childhood.3 However, there is a growing understanding that there might be need of widening of indications Recent studies in adults have suggested that surgery in patients with left-sided IE, even when not considered urgent, may produce better outcomes and lower mortality than medical therapy alone.119,120 Surgery for the first event of PVE with blocked motion of leaflets or dehiscence with new paravalvar leak warrants early operation It is more difficult to decide on the indication and timing of surgery for prosthetic valves with preserved function and without complications, and it has to be individualized If the annulus is preserved after the debridement and resection, it is acceptable to implant a new mechanical prosthesis If there is intracranial bleeding, biologic prosthesis should be implanted Surgery for relapsing PVE is recommended even if valvar function remains intact after prolonged medical therapy The decision on when to replace an infected prosthetic valve is individual and probably should be early for left heart prosthetic valve IE Surgery for IE on tricuspid valve indications are not well delineated, but this should certainly be performed early in cases of acute right ventricular dysfunction because of severe regurgitation, large vegetations greater than 20 mm, and lack of response to antibiotic therapy for more than 7 days for resistant organisms like fungi, S aureus, and Pseudomonas aeruginosa The majority of tricuspid valve IE surgeries remain elective Surgery for IE on right ventricle-to-pulmonary artery (RV-PA) conduit is urgent in cases of obstruction and ineffective antibiotic therapy Elective surgery even after resolution of infection is currently considered of benefit as per the notion of higher rates of recurrence and reinfection, although this has not been investigated in large studies Surgery for lead-associated endocarditis (LAE) has given way to transcatheter interventional procedures for removal of leads and is currently rarely necessary Major complications were associated with an open surgical approach for device removal, and the risk was increased in a vegetation size greater than 1 cm.121 Surgery for neonatal IE is a higher risk surgery compared with older children, and every attempt should be made at success of medical management and removing the provoking or predisposing factor, namely lines Timing of Infective Endocarditis Surgery (Early Infective Endocarditis Surgery)  ... there is increased risk of embolization has shown validity in pediatric IE,118 but there is a general impression that this might need to be adjusted in increasingly younger and smaller pediatric patients Surgery to prevent a primary embolic event in the absence of risk factors