infective%20endocarditis%20(pediatric)
INFECTIVE ENDOCARDITIS (PEDIATRIC)
Infective endocarditis is an infection of the endocardial surface of the heart including infections of the large thoracic vessels and intracardiac foreign bodies characterized by the presence of vegetation which is a nidus for microorganism invasion.
Native valve endocarditis is an endovascular microbial infection of native heart valves that may be local including valvular and perivalvular destruction or distal due to detachment of septic vegetations with embolism, metastatic infection and septicemia.
Prosthetic valve endocarditis is an endovascular microbial infection of prosthetic heart valves and may be classified as an infection likely to have been acquired perioperatively and thus being nosocomial or likely to have been community-acquired.

Surgical Intervention

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
Surgery should be considered in the following:
  • 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
Emergency Surgery (within 24 hours) is recommended for the following:
  • 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
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