Endocarditis - Surgery Indications

8/17/2005

Question:  What are current indications for surgery for infective endocarditis?

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16230221.ui or 15991151.ui or 15749175.ui or 15145858.ui or 12874896.ui or 12591827.ui or 12203180.ui or 8853133.ui or 7546807.ui or 7944753.ui or 1895511.ui or 1895510.ui or 2237111.ui or 2520012.ui or 3398745.ui or 4089501.ui or 4021066.ui or 3893114.ui

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16230221[PMID] OR 15991151[PMID] OR 15749175[PMID] OR 15145858[PMID] OR 12874896[PMID] OR 12591827[PMID] OR 12203180[PMID] OR 8853133[PMID] OR 7546807[PMID] OR 7944753[PMID] OR 1895511[PMID] OR 1895510[PMID] OR 2237111[PMID] OR 2520012[PMID] OR 3398745[PMID] OR 4089501[PMID] OR 4021066[PMID] OR 3893114[PMID]

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<1>

Unique Identifier [PMID]: 16230221

Authors: Steinbach WJ. Perfect JR. Cabell CH. Fowler VG. Corey GR. Li JS. Zaas AK. Benjamin DK Jr.

Institution: Division of Infectious Diseases, Department of Pediatrics, Duke University, Durham, NC 27710, USA. stein022@mc.duke.edu

Title: A meta-analysis of medical versus surgical therapy for Candida endocarditis.

Source: Journal of Infection. 51(3):230-47, 2005 Oct.

Abstract: OBJECTIVES: The optimal management of Candida infective endocarditis (IE) is unknown. METHODS: We reviewed all 879 cases of Candida IE reported from 1966-2002 in the peer-reviewed literature to better understand the role of medical and surgical therapies. This review included 163 patients from 105 reports that met our inclusion criteria: 31 cases treated with antifungal monotherapy, 25 cases treated with medical antifungal combination therapy, and 107 cases treated with adjunctive surgical plus medical antifungal therapy. We also used meta-analytic techniques to evaluate 22 observational case-series (72 patients) of the 105 reports with two or more patients with definite Candida IE. RESULTS: We found that in patients who underwent adjunctive surgery there was a lower reported proportion of deaths [prevalence odds ratio (POR)=0.56; 95% confidence interval (CI)=0.16, 1.99)]. Higher mortality was noted in patients treated prior to 1980 (POR=2.03; 95% CI=0.55, 7.61), treated with antifungal monotherapy (POR=1.49; 95% CI=0.39, 5.81), infected with Candida parapsilosis (POR=1.51; 95% CI=0.41, 5.52), or with left-sided endocarditis (POR=2.36; 95% CI=0.55, 10.07). CONCLUSIONS: Medical antifungal therapy of Candida IE is poorly characterized, and recent antifungal developments lend promise for those patients who cannot undergo surgery.

Publication Type: Journal Article. Meta-Analysis.

<2>

Unique Identifier [PMID]: 15991151

Authors: Ozsoyler I. Yilik L. Bozok S. El S. Emrecan B. Biceroglu S. Gurbuz A.

Institution: Department of Cardiolvascular Surgery, Ataturk Education and Research Hospital, Izmir, Turkey.

Title: Brucella endocarditis: the importance of surgical timing after medical treatment (five cases).

Source: Progress in Cardiovascular Diseases. 47(4):226-9, 2005 Jan-Feb.

Abstract: INTRODUCTION: Brucella endocarditis is a disease that is hard to treat medically and has a high mortality. Immediate surgery after medical treatment is very important because delaying surgery may lead to that are difficult to repair. METHODS: Five patients who were admitted to our institution with a diagnosis of Brucella endocarditis were medically treated with doxycycline (200 mg/d), rifampin (600 mg/d), and ceftriaxone (2 g/d). Preoperative mean medical treatment time was 5.2 weeks (range, 4-6 weeks). The patients were taken for operation when their general status improved. We report in this study the results of these patients. RESULTS: Three patients had aortic valve replacement whereas 2 had both aortic and mitral valve replacements. No mortality or morbidity was encountered in the patients. Mean postoperative hospitalization time was 15 days (range, 12-19 days). The patients were discharged with doxycycline (200 mg/d) and rifampin (600 mg/d) but without antipyretic medication. Postoperative antibiotherapy was continued up to a mean of 3.6 months (range, 2-6 months). Mean postoperative follow-up time was 15.8 months. None of the patients needed hospitalization in their follow-up time. CONCLUSION: Adequate preoperative antibiotherapy, immediate surgery, and continuation of postoperative antibiotherapy according to clinical progress seem to be a convenient treatment strategy for Brucella endocarditis.

Publication Type: Journal Article.

<3>

Unique Identifier [PMID]: 15749175

Authors: Remadi JP. Najdi G. Brahim A. Coviaux F. Majhoub Y. Tribouilloy C.

Institution: Cardiac Surgery Unit (Prof. Poulain), Hopital Sud-CHU Amiens, 80054, Amiens, France. remadi.jean-paul@chu-amiens.fr

Title: Superiority of surgical versus medical treatment in patients with Staphylococcus aureus infective endocarditis.

Source: International Journal of Cardiology. 99(2):195-9, 2005 Mar 18.

Abstract: BACKGROUND: We present here the clinical features and outcome of 54 patients affected by a Staphylococcus aureus infective endocarditis at the Amiens hospital between 1990 and 2000. The patients operated-on, group A (20 patients), were compared to the population of patients treated by exclusive antibiotherapy, group B (34 patients). PATIENTS AND METHOD: The male gender predominated with a sex ratio of 2.6. The mean age of the global population was 58.7+/-1.6 years. Time between onset of endocarditis symptoms and treatment (entire group) ranged from 1 to 120 days (mean 14.4 days). The main portal of entry were, respectively, for group A and group B: cutaneous 55% and 44.1%; intravascular material 5% and 8.8%; and rhinopharynx 5% and 8.8%. Seventy-five percent of the Staphylococcus aureus isolated were Methi-S. The main surgical treatment indication were: hemodynamic failure (HF) (30%), unstable infection with collapse (UI) (30%), UI+HF (10%), voluminous vegetation (20%) and embolism event (10%). RESULTS: The hospital mortality rate were respectively for the entire group, group A and group B: 25%, 35% and to 41% (ns). For group A, the operative mortality was lower(21%) after the first week. The actuarial survival rate (Kaplan-Meier) after 24 months was 54./+/-6.9% for the global population and 74+/-10.6% for group A and 43+/-8.5 for group B (p<0.001). The multivariate analysis finds severe sepsis and index of comorbidity as independent factors related to the global late mortality and, respectively, the age and the severe sepsis for group A, and the cardiac insufficiency for group B. CONCLUSION: The surgical treatment seems to be the best way to improve the results after Staphylococcus aureus endocarditis. The severity of the sepsis remains the most severe prognostic element, whatever the treatment adopted may be.

Publication Type: Journal Article.

<4>

Unique Identifier [PMID]: 15145858

Authors: Delahaye F. Celard M. Roth O. de Gevigney G.

Institution: Hopital cardiovasculaire et pneumologique, Lyon, France. francois.delahaye @ chu-lyon.fr

Title: Indications and optimal timing for surgery in infective endocarditis. [Review] [16 refs]

Source: Heart. 90(6):618-20, 2004 Jun.

Publication Type: Journal Article. Review.

<5>

Unique Identifier [PMID]: 12874896

Authors: Olaison L. Pettersson G.

Institution: Department of Infectious Diseases, Sahlgrenska University Hospital, S-416 85 Goteborg, Sweden. lars.olaison@medfak.gu.se

Title: Current best practices and guidelines. Indications for surgical intervention in infective endocarditis. [Review] [78 refs]

Source: Cardiology Clinics. 21(2):235-51, vii, 2003 May.

Abstract: Optimal diagnosis and management of patients with infective endocarditis requires sound clinical judgment based on extensive experience. This is especially important in regard to the indications and timing for surgery. To achieve the best possible outcomes, surgical intervention during treatment is required in 25% to 30% of patients with infective endocarditis. Heart failure and progressive left-sided valvular dysfunction are the most common indications for operation. Valve repair should be considered as an alternative to valve replacement whenever feasible, especially in younger patients. Successful management of perivalvular abscesses and prosthetic valve infections requires radical removal of infected tissue followed by reconstructive procedures performed by experienced surgeons. Emergency or urgent surgery should seldom be delayed. [References: 78]

Publication Type: Journal Article. Review.

<6>

Unique Identifier [PMID]: 12591827

Authors: Akowuah EF. Davies W. Oliver S. Stephens J. Riaz I. Zadik P. Cooper G.

Institution: Department of Cardiothoracic Surgery, Northern General Hospital, Herries Road, Sheffield, UK.

Title: Prosthetic valve endocarditis: early and late outcome following medical or surgical treatment.[see comment].

Source: Heart. 89(3):269-72, 2003 Mar.

Abstract: OBJECTIVE: To compare the early and late outcome of medical and surgical treatment in patients with prosthetic valve endocarditis within a single unit. DESIGN: All patients with proven prosthetic valve endocarditis treated in one institution between 1989 and 1999 were studied. RESULTS: There were 66 patients (24 female, 42 male), mean (SD) age 57 (14) years. Of these, 28 were treated with antibiotics alone and 38 with a combination of antibiotics and surgery. The in-hospital mortality for the antibiotic group was 46% and for the surgical group, 24%. However, seven patients in the antibiotic group were considered too sick for curative treatment. The mortality in the remaining 21 medically treated patients (6/21; 29%) was not significantly different from that in the surgically treated patients (p = 0.15). Six patients in the medically treated group and one in the surgically treated group required late reoperation. Endocarditis recurred in three patients in the medically treated group, two of whom were treated surgically, and in one patient in the surgically treated group. Kaplan-Meier survival at 10 years was 28% in the medically treated group v 58% in the surgically treated group (p = 0.04). Freedom from endocarditis at five years was 60% in the surgically treated group and 65% in the medically treated group. CONCLUSIONS: Prosthetic valve endocarditis is a serious condition with high early and late mortality, irrespective of the treatment employed. These data show that selected patients with prosthetic valve endocarditis can be successfully treated with antibiotics alone. If required, surgery in this difficult group of patients can provide satisfactory freedom from recurrent infection.

Publication Type: Journal Article.

<7>

Unique Identifier [PMID]: 12203180

Authors: Tattevin P. Volatron AC. Jouneau S. Arvieux C. Michelet C.

Title: Indications for surgery for elderly patients with infective endocarditis.[comment].

Source: Clinical Infectious Diseases. 35(6):775, 2002 Sep 15.

Publication Type: Comment. Letter.

<8>

Unique Identifier [PMID]: 8853133

Authors: Blaustein AS. Lee JR.

Institution: Cardiac Non-Invasive Laboratory, Veterans Affairs Medical Center, Houston, Texas, USA.

Title: Indications for and timing of surgical intervention in infective endocarditis. [Review] [60 refs]

Source: Cardiology Clinics. 14(3):393-404, 1996 Aug.

Abstract: Infective endocarditis, especially when it involves prosthetic valves, is a serious, often fatal illness. Although antibiotics are essential in management, surgery is required in many patients who develop even incipient heart failure and structural complications. Early identification and referral results in improved mortality and morbidity rates, and there is evidence that surgery should play a larger role in managing infective endocarditis. Patients with intracardiac pacemakers and cardioverting devices represent a growing reservoir of patients with the potential to develop endocarditis. [References: 60]

Publication Type: Journal Article. Review.

<9>

Unique Identifier [PMID]: 7546807

Authors: Dodge A. Hurni M. Ruchat P. Stumpe F. Fischer AP. Van Melle G. Sadeghi H.

Institution: Department of Cardiovascular Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.

Title: Surgery in native valve endocarditis: indications, results and risk factors.

Source: European Journal of Cardio-Thoracic Surgery. 9(6):330-4, 1995.

Abstract: Seventy-nine patients (mean age 49 years) underwent valve replacement or repair for active (58.2%) or healed (41.8%) native valve endocarditis between 1976 and 1992. The most common indication for surgery was congestive heart failure (73.4%), followed by multiple systemic emboli (21.5%). Emergency operation was necessary in 27.8% of the cases. Operative mortality was 3.8% (3 patients) and late mortality 15.1% (12 patients). Streptococci were the most common infecting agents (41.8%), followed by Staphylococcus aureus (11.4%). No organisms were isolated in 27 cases (34.2%). Follow-up spanned 379.8 patient-years with a maximum of 15.8 years. Fifteen late valve-related events (periprosthetic leak, recurrent endocarditis, thrombo-embolic events and hemolysis) and 20 other late complications (anticoagulant-related hemorrhage, arrhythmias or congestive heart failure) occurred in 22 patients. The linearized rate for all late complications is 5.8% per patient-year. The influence of eight preoperative variables on overall mortality and late valve-related complications was assessed: age, valve(s) affected, active or healed infection, bacteriology, annular abscess, emergency or elective surgery, preoperative renal function and NYHA class. Only Staphylococcus aureus (P = 0.0012) was a significant predictor of late valve-related complications. Furthermore, no difference in survival or in valve-related complications was found between the active and healed infections.

Publication Type: Journal Article.

<10>

Unique Identifier [PMID]: 7944753

Authors: Yu VL. Fang GD. Keys TF. Harris AA. Gentry LO. Fuchs PC. Wagener MM. Wong ES.

Institution: Division of Infectious Diseases, University of Pittsburgh Medical Center, PA 15213.

Title: Prosthetic valve endocarditis: superiority of surgical valve replacement versus medical therapy only.

Source: Annals of Thoracic Surgery. 58(4):1073-7, 1994 Oct.

Abstract: The objective of our study was to assess the long-term outcome of patients with prosthetic valve endocarditis. We used a multicenter, prospective, observational study design. Six university teaching hospitals with high volume cardiothoracic surgery participated. Seventy-four patients with prosthetic valve endocarditis as defined by explicit, objective criteria were selected for participation. All patients were followed up prospectively for 1 year. Thirty-one percent and 69% had development of endocarditis within 60 days of valve insertion ("early") and after 60 days ("late"), respectively. The most common causes were Staphylococcus epidermidis (40%), Staphylococcus aureus (20%), streptococcal species (18%), and aerobic gram-negative bacilli (11%). Physical signs of endocarditis (new or changing murmur, stigmata, emboli) were seen in 58%. At 6 months and 12 months, mortality was 46% and 47%, respectively. Surgical replacement of the infected valve led to significantly lower mortality (23%) as compared with medical therapy alone (56%), as assessed by both univariate and multivariate analyses (p < 0.05). Improved outcome was seen for the surgical group even when controlling for severity of illness at time of diagnosis. From these findings we conclude that accurate assessment of outcome in prosthetic valve endocarditis requires long-term follow-up of at least 6 months following diagnosis. Surgical therapy warrants greater scrutiny; evaluation in controlled clinical trials is appropriate.

Publication Type: Journal Article. Multicenter Study.

<11>

Unique Identifier [PMID]: 1895511

Authors: Soma Y. Handa S. Iwanaga S.

Institution: Department of Surgery, School of Medicine, Keio University, Tokyo, Japan.

Title: Medical treatment or surgical intervention? A cooperative retrospective study on infective endocarditis--timing of operation.

Source: Japanese Circulation Journal. 55(8):799-803, 1991 Aug.

Abstract: Two hundred and five patients treated for infective endocarditis over the last 10 years were reviewed. There were 185 cases of native valve endocarditis (NVE) and 20 of prosthetic valve endocarditis (PVE). In the NVE group there were 175 clinically active patients and 10 non-active patients. The mortalities among 108 non-surgical and 57 surgical patients were 15.7% and 14.0%, respectively. Leading causes of deaths in the former were cardiac failure, embolism and cerebral hemorrhage. Patients with embolism showed significantly higher mortality. Culture negative endocarditis resulted in almost the same incidence of hospital death and urgent operation as staphylococcal endocarditis, and a higher incidence than streptococcal endocarditis. In 9 of 33 patients operated at our hospital, surgery was performed on an urgent basis and one NYHA class IV patient died. Indications for operation were intractable cardiac failure, uncontrollable infection and angina. In the PVE group, 3 of 4 patients operated in the active stage died of severe cardiac failure generated preoperatively. The only survivor was a patient operated early under stable hemodynamics. These results suggest that culture negative endocarditis should be observed as closely as staphylococcal endocarditis and early operation should be considered for patients with progressive cardiac failure, embolism and uncontrollable infection.

Publication Type: Journal Article.

<12>

Unique Identifier [PMID]: 1895510

Authors: Yoshida K. Yoshikawa J. Akasaka T. Hozumi T. Maeda K. Okumachi F. Shiratori K. Koizumi K. Kato H. Okada Y. et al.

Institution: Department of Cardiology and Cardiothoracic Surgery, Kobe General Hospital, Japan.

Title: Infective endocarditis--analysis of 116 surgically and 26 medically treated patients.

Source: Japanese Circulation Journal. 55(8):794-8, 1991 Aug.

Abstract: We have reviewed 116 cases of bacterial endocarditis treated surgically and 26 cases treated medically since 1973. There were 123 patients with native valve endocarditis and 19 patients with prosthetic valve endocarditis. Overall, the left-sided valves were infected most frequently. There were 10 cases with right-sided valves involved. Multiple valves were infected in 6 patients. There were 6 perioperative deaths in the surgical group. The most common cause of death was multi-organ failure associated with uncontrollable sepsis. The overall operative mortality for active endocarditis was 7.7% (4/55), and for healed endocarditis, 3.3% (2/61). For active native valve endocarditis, the mortality was 4.2% (2/48), for healed native valve endocarditis, 3.6% (2/55), for active prosthetic valve endocarditis, 28.6% (2/7), and for healed prosthetic valve endocarditis, 0%. There was no difference in the operative mortality between active native valve endocarditis and healed native valve endocarditis. The mortality of active prosthetic valve endocarditis was significantly higher than that of active native valve endocarditis (p less than 0.01). Of the 26 patients treated medically, 7 died during the initial hospitalization. The major factor related to mortality in the medically treated patients was persistent sepsis (four patients), and congestive heart failure (three patients). The overall mortality of the medical group for active valve endocarditis was 15% (3/20), and for active prosthetic valve endocarditis, 67% (4/6). We conclude that patients with infective endocarditis with significant valve lesions who are unresponsive to medical therapy should be considered for urgent surgery.

Publication Type: Journal Article.

<13>

Unique Identifier [PMID]: 2237111

Authors: Jacobs F. Abramowicz D. Vereerstraeten P. Le Clerc JL. Zech F. Thys JP.

Institution: Nephrology Surgery Department, Erasme University Hospital, Brussels, Belgium.

Title: Brucella endocarditis: the role of combined medical and surgical treatment. [Review] [44 refs]

Source: Reviews of Infectious Diseases. 12(5):740-4, 1990 Sep-Oct.

Abstract: Brucella endocarditis, although a rare complication of brucellosis, is the main cause of death related to this disease. This report describes a case of aortic endocarditis due to Brucella abortus in an elderly farmer with known aortic stenosis. Urgent valve replacement was performed because of progressive heart failure despite appropriate antimicrobial treatment. The infection was cured with trimethoprim-sulfamethoxazole and rifampin given for 3 months after surgery. A review of the literature reports on the 38 other cases of cured brucella endocarditis made clear the need for combined antimicrobial treatment and surgical valve replacement. [References: 44]

Publication Type: Case Reports. Journal Article. Review.

<14>

Unique Identifier [PMID]: 2520012

Authors: Turley K.

Institution: Department of Surgery, University of California, San Francisco 94143-0118.

Title: Surgery of right-sided endocarditis: valve preservation versus replacement.

Source: Journal of Cardiac Surgery. 4(4):317-20, 1989 Dec.

Abstract: Surgical treatment of right-sided endocarditis has in the past been centered on valve resection or resection with valve replacement. From 1981 to 1989, we attempted tricuspid valve repair in 19 patients with right-sided endocarditis. Fourteen of these were successful. The methods of valve repair and classification of the lesions that allow evaluation for repair are discussed, including the use of transesophageal echo and a hand-held color Doppler unit for intraoperative assessment.

Publication Type: Journal Article.

<15>

Unique Identifier [PMID]: 3398745

Authors: Abrams HB. Detsky AS. Roos LL Jr. Wajda A.

Institution: Department of Medicine, University of Toronto, Ontario, Canada.

Title: Is there a role for surgery in the acute management of infective endocarditis? A decision analysis and medical claims database approach.

Source: Medical Decision Making. 8(3):165-74, 1988 Jul-Sep.

Abstract: In the absence of good clinical evidence from a randomized trial, the authors performed a decision analysis to determine the potential value of early elective surgery (OPNOW) for patients with left-sided Staphylococcus aureus infective endocarditis. Initial impressions (before performance of decision analysis) and initial runs at the formal models using probability estimates derived from clinicians suggested that OPNOW (i.e., within a few days of starting antibiotics) offered no advantage over attempted medical cure (WAIT) (life expectancy: WAIT = 325 weeks; OPNOW = 255 weeks). Extensive sensitivity analyses identified critical variables that needed further empirical estimation. The Manitoba Health Services Commission database identified 127 incident cases of endocarditis between April 1, 1979, and March 31, 1985, enabling estimation of values for these critical variables. With these estimates, the early surgery strategy appeared much better than the previous analyses had suggested (life expectancy: WAIT = 208 weeks, OPNOW = 256 weeks). The authors believe that this approach of combining decision analysis with medical claims databases is useful as an alternative or precursor to randomized trials, especially where the resource requirements and logistic difficulties of performing randomized trials are great.

Publication Type: Case Reports. Journal Article.

<16>

Unique Identifier [PMID]: 4089501

Authors: Branzan L. Streian C. Popa IP. Cristodorescu R. Rab I.

Title: Indication of cardiac surgery in infective endocarditis.

Source: Medecine Interne. 23(4):277-84, 1985 Oct-Dec.

Abstract: From the 33 patients with infective endocarditis (IE) hospitalized in the 1st Clinic of Internal Diseases, Timisoara between 1981 and 1984, in 5 (4 men and one woman) ranging in age from 21 to 52 years (mean 38) cardiac surgery was indicated and aortic (3) and mitral (2) valve replacements were performed. Valve replacement was performed for: 1) rapid/slow progressive hemodynamic deterioration with intractable congestive heart failure associated with ruptured chordae on posterior leaflet of mitral value (1 case); perforated aortic cusp (1 case); 2) prosthesis endocarditis (1 case); 3) precocious recurrence of IE (1 case); 4) uncontrollable infections (1 case). Echocardiography was helpful in all the cases by permitting recognition and evaluation of the preexistent lesions, and by the supplying of characteristic vegetations (all echocardiographic findings were confirmed by open heart surgery). Likewise it proved an accurate method in assessing pre- and post-operative left ventricular performance. In conclusion it is considered that early valve surgery in IE is indicated in hemodynamic deterioration, prosthetic endocarditis or impossibility to control septicemia. Echocardiography is the most useful noninvasive method for the pre- and postoperative evaluation of the patients investigated.

Publication Type: Case Reports. Journal Article.

<17>

Unique Identifier [PMID]: 4021066

Authors: Koga Y. Shibata J. Yamasaki T. Ohkita Y. Toshima H.

Title: Medical management of infective endocarditis; limitations and indication for surgery.

Source: Japanese Circulation Journal. 49(5):535-44, 1985 May.

Abstract: Problems and limitations of medical management for infective endocarditis were studied and surgical indications were discussed based on the retrospective analysis of 55 episodes. Since perioperative complications still occur during highly active infection, antibiotic treatment was suggested as the primary management. Intractable or progressing heart failure appeared to be a definite indication for emergency surgery, but medical therapy was recommended for mild to moderate heart failure. For uncontrolled infection of more than one month duration despite the best available antibiotics, surgical debridement of the infected tissue was indicated. Occurrence of peripheral or fatal emboli was difficult to predict from clinical features and echocardiogram and therefore presented a therapeutic dilemma. Since major or fatal emboli frequently occurred during highly active infection, early initiation of effective antibiotic therapy was considered to be of primary importance. Demonstration of vegetation by echocardiography alone did not seem to justify urgent surgery. In addition, disseminated intravascular coagulation appeared to be a serious complication and thus sedimentation rate should be followed carefully. In the healed stage, prophylactic surgery seemed unnecessary for prevention of recurrent infection or embolization, as they were relatively rare.

Publication Type: Journal Article.

<18>

Unique Identifier [PMID]: 3893114

Authors: Alsip SG. Blackstone EH. Kirklin JW. Cobbs CG.

Title: Indications for cardiac surgery in patients with active infective endocarditis. [Review] [67 refs]

Source: American Journal of Medicine. 78(6B):138-48, 1985 Jun 28.

Abstract: Currently, absolute indications for valve replacement during active infective endocarditis include severe heart failure, the presence of an infecting microorganism that is not susceptible to available antimicrobial agents, and, in patients with an infected prosthetic valve, an unstable device. Relative indications include an etiologic microorganism other than a susceptible Streptococcus, relapse after presumed effective therapy, evidence of intracardiac extension of the infection, two or more systemic emboli, vegetations large enough to be demonstrated by echocardiography, and, in patients with an infected prosthetic device, early disease and periprosthetic leak. With use of data from the medical literature, a study generated by the cardiovascular surgical group at the University of Alabama School of Medicine, and a brief cost analysis, a point system was constructed to assist in decision-making concerning surgery in patients with active infective endocarditis. The usefulness of this system will depend on experience generated from its utilization in a larger number of patients as well as new data relative to a more complete understanding of the risks and benefits of surgery in this condition. [References: 67]

Publication Type: Journal Article. Review.