Andersons pediatric cardiology 1495

Timing of the operation is likely crucial for the outcome It differs significantly between centers throughout the world The benefit of early surgery has become well established during the past decade This is defined as: emergency (within 24 hours), urgent (within a few days), and early elective surgery (after 1 to 2 weeks of diagnosis and before completion of the full course of antibiotics) The indications for emergency and urgent surgery are well outlined in the currently used guidelines Intractable, severe, and complicated heart failure is an emergency indication It is usually caused by acute or increasing valvar regurgitation The addition of ventricular dysfunction is an unfavorable prognostic sign The presence of risk factors for systemic embolism is another group of indications: it seems that large vegetations (>10 mm), especially on the anterior mitral leaflet, are the best described risk factor An adapted summary of the indications for early surgery in left-sided IE is shown in Table 56.10 Table 56.10 Indications for Early Surgery in Left-Sided Infective Endocarditis HEART FAILURE Aortic or mitral IE with severe acute regurgitation or valve obstruction causing refractory pulmonary edema or cardiogenic shock Aortic or mitral IE with fistula into a cardiac chamber or pericardium causing refractory pulmonary edema or shock Aortic or mitral IE with severe acute regurgitation or valve obstruction and persisting heart failure or poor hemodynamic tolerance (early mitral closure, pulmonary hypertension) Aortic or mitral IE with severe regurgitation and no HF UNCONTROLLED INFECTION Locally uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation) Persisting fever and positive blood cultures >10 days on appropriate antibiotic Infection caused by fungi or multiresistant organisms PREVENTION OF EMBOLISM Aortic or mitral IE with large vegetations (>10 mm) following one or more embolic episodes despite appropriate antibiotic therapy Aortic or mitral IE with large vegetations (>10 mm) and other predictors of complicated course (HF, persistent infection, abscess) Isolated very large vegetations (>15 mm) Emergencya Emergency Urgenta Electivea Urgent Urgent Urgent/elective Urgent Urgent Urgent aEmergency