Infective%20endocarditis%20(pediatric) Treatment

Principles of Surgical Treatment

• Combined medical & surgical therapy for infective endocarditis can decrease mortality among patients who have congestive heart faillure, perivalvular invasive disease, or uncontrolled infection despite maximal antimicrobial therapy
•  The decision to perform surgery & its timing is dependent upon the cardiac & systemic complications caused by the infection, the microorganism’s virulence & the response to antimicrobial therapy
  • The optimal time to perform surgery is before severe hemodynamic disability or spread of the infection to perivalvular tissue occurs
• Congestive heart failure is the strongest indication for surgery in infective endocarditis
• The main objectives in performing surgery in infective endocarditis patients are:
  • To remove infected cardiac tissues
  • To replace or repair damaged tissues

• Native valve endocarditis patients with acute aortic or mitral regurgitation with:
  • Refractory pulmonary edema/cardiogenic shock secondary to severe acute regurgitation/valve obstruction or cardiac chamber/pericardial fistula
  • Severe regurgitation but without congestive heart failure
  • Severe acute regurgitation/valve obstruction & congestive heart failure with diagnostic signs of hemodynamic compromise
• Evidence of perivalvular extension (valvular dehiscence/rupture/fistula, new obstructions, large/extensive abscess despite antibiotic therapy)
• Persistent infection after 7-10 days of adequate antimicrobial therapy
• Infection with microorganisms that have poor response to antibiotic therapy (eg fungi, Brucella sp, Coxiella sp, Staphylococcus lugdunensis, Enterococcus sp with high-level resistance to Gentamicin, gram-negative organisms)
• Native valve endocarditis patients with large mobile vegetation >10 mm, ≥1 embolic episode during the 1st 2 weeks of antibiotic therapy, or ≥2 embolic episode during or after antimicrobial therapy
• Native valve endocarditis patients with highly large vegetations >15 mm
• Vegetations increasing in size or recurrent emboli despite adequate antibiotic therapy
• Obstructive vegetations
• Early prosthetic valve endocarditis
• Prosthetic valve endocarditis caused by S aureus
• Relapsing prosthetic valve endocarditis after prolonged medical therapy
• Hemodynamically significant prosthetic valve

• Native valve endocarditis patients with refractory pulmonary edema/cardiogenic shock secondary to severe acute regurgitation/valve obstruction
• Native valve endocarditis patients with cardiac chamber/pericardial fistula causing refractory pulmonary edema/cardiogenic shock