Chapter 118. Infective Endocarditis (Part 13) Timing of Cardiac Surgery In general, when indications for surgical treatment of infective endocarditis are identified, surgery should not be delayed simply to permit additional antibiotic therapy, since this course of action increases the risk of death (Table 118-6). Delay is justified only when infection is controlled and congestive heart failure is fully compensated with medical therapy. After 14 days of recommended antibiotic therapy, excised valves are culture-negative in 99% and 50% of patients with streptococcal and S. aureus endocarditis, respectively. Recrudescent endocarditis involving a new implanted prosthetic valve follows surgery in 2% of patients with culture-positive native valve endocarditis and in 6–15% of patients with active prosthetic valve endocarditis. These risks are more acceptable than the high mortality rates that result when surgery is inappropriately delayed or not performed. Among patients who have experienced a neurologic complication of endocarditis, further neurologic deterioration can occur as a consequence of cardiac surgery. The risk of significant neurologic exacerbation is related to the interval between the complication and the surgery. Whenever feasible, cardiac surgery should be delayed for 2–3 weeks after a nonhemorrhagic embolic stroke and for 4 weeks after a hemorrhagic embolic stroke. A ruptured mycotic aneurysm should be clipped and cerebral edema allowed to resolve before cardiac surgery. Antibiotic Therapy after Cardiac Surgery Bacteria visible in Gram-stained preparations of excised valves do not necessarily indicate a failure of antibiotic therapy. Organisms have been detected on Gram's stain—or their DNA has been detected by PCR—in excised valves from 45% of patients who have successfully completed the recommended therapy for endocarditis. In only 7% of these patients are the organisms, most of which are unusual and antibiotic resistant, cultured from the valve. Despite the detection of organisms or their DNA, relapse of endocarditis after surgery is uncommon. Thus, for uncomplicated native valve infection caused by susceptible organisms in conjunction with negative valve cultures, the duration of preoperative plus postoperative treatment should equal the total duration of recommended therapy, with ~2 weeks of treatment administered after surgery. For endocarditis complicated by paravalvular abscess, partially treated prosthetic valve infection, or cases with culture-positive valves, a full course of therapy should be given postoperatively. Extracardiac Complications Splenic abscess develops in 3–5% of patients with endocarditis. Effective therapy requires either image-guided percutaneous drainage or splenectomy. Mycotic aneurysms occur in 2–15% of endocarditis patients; half of these cases involve the cerebral arteries and present as headaches, focal neurologic symptoms, or hemorrhage. Cerebral aneurysms should be monitored by angiography. Some will resolve with effective antimicrobial therapy, but those that persist, enlarge, or leak should be treated surgically if possible. Extracerebral aneurysms present as local pain, a mass, local ischemia, or bleeding; these aneurysms are treated by resection. Outcome Older age, severe comorbid conditions, delayed diagnosis, involvement of prosthetic valves or the aortic valve, an invasive (S. aureus) or antibiotic-resistant (P. aeruginosa, yeast) pathogen, intracardiac complications, and major neurologic complications adversely impact outcome. Death and poor outcome often are related not to failure of antibiotic therapy but rather to the interactions of comorbidities and endocarditis-related end-organ complications. Overall survival rates for patients with native valve endocarditis caused by viridans streptococci, HACEK organisms, or enterococci (susceptible to synergistic therapy) are 85– 90%. For S. aureus native valve endocarditis in patients who do not inject drugs, survival rates are 55–70%, whereas 85–90% of injection drug users survive this infection. Prosthetic valve endocarditis beginning within 2 months of valve replacement results in mortality rates of 40–50%, whereas rates are only 10–20% in later-onset cases. Prevention Antibiotic prophylaxis has been recommended by the American Heart Association in conjunction with selected procedures considered to entail a risk for bacteremia and endocarditis. The benefits of prophylaxis, however, are not established and in fact may be modest: only 50% of patients presenting with native valve endocarditis know that they have a predisposing valve lesion, most endocarditis cases do not follow a procedure, and 35% of cases are caused by organisms not targeted by prophylaxis. Dental treatments, the procedures most widely accepted as predisposing to endocarditis, are no more frequent during the 3 months preceding endocarditis than in uninfected matched controls. Furthermore, the frequency and magnitude of bacteremia associated with dental procedures and routine daily activities (e.g., tooth brushing and flossing) are similar. Because patients undergo dental procedures infrequently, exposure of endocarditis- vulnerable cardiac structures to bacteremia-causing oral cavity organisms is notably greater from routine daily activities than from dental care. It is estimated that annual exposure of heart valves to bacteremia-causing organisms may be 5.6 million times greater from routine daily activity than from a tooth extraction. The relation of gastrointestinal and genitourinary procedures to subsequent endocarditis is more tenuous than that of dental procedures. . Chapter 118. Infective Endocarditis (Part 13) Timing of Cardiac Surgery In general, when indications for surgical treatment of infective endocarditis are identified,. and S. aureus endocarditis, respectively. Recrudescent endocarditis involving a new implanted prosthetic valve follows surgery in 2% of patients with culture-positive native valve endocarditis. develops in 3–5% of patients with endocarditis. Effective therapy requires either image-guided percutaneous drainage or splenectomy. Mycotic aneurysms occur in 2–15% of endocarditis patients; half