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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e162

CLINICAL STATEMENTS AND GUIDELINES Recommendations for Intervention for IE (Continued)

COR LOE Recommendations

Antibiotic therapy is most effective if the identity and sensitivities of the responsible organism are known. S. aureus is the most common pathogen responsible for prosthetic valve endocarditis but still accounts for only 23% of cases. The leading cause of “culture-negative IE” is the use of antibiotics before blood cultures are obtained. Negative blood cultures in the setting of IE delay diagnosis and often require additional serological and polymerase chain reaction testing.22,35,36

12.4. Intervention

Recommendations for Intervention for IE Referenced studies that support the recommendations are summarized in Online Data Supplement 42. COR LOE Recommendations

1 B-NR 1.  Decisions about the timing of surgical intervention for IE should be made by a Heart Valve Team.1–6

1 B-NR 2.  In patients with IE who present with valve dysfunction resulting in symptoms of HF, early surgery (during initial hospitalization and before completion of a full therapeutic course of antibiotics) is indicated.7–19

1 B-NR 3.  In patients with left-sided IE caused by S. aureus, a fungal organism, or other highly resistant organisms, early surgery (during initial hospitalization and before completion of a full therapeutic course of antibiotics) is indicated.7,9,15,20–35

1 B-NR 4.  In patients with IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions, early surgery (during initial hospitalization and before completion of a full therapeutic course of antibiotics) is indicated.7,9,36–44

1 B-NR 5.  In patients with IE and evidence of persistent infection as manifested by persistent bacteremia or fevers lasting >5 days after onset of appropriate antimicrobial therapy, early surgery (during initial hospitalization and before completion of a full therapeutic course of antibiotics) for IE is indicated.7,9,15,25,26,45–48

1 B-NR 6.  In all patients with definite endocarditis and an implanted cardiac electronic device, complete removal of the pacemaker or defibrillator systems, including all leads and the generator, is indicated.49–55

1 C-LD 7.  For patients with prosthetic valve endocarditis and relapsing infection (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequent negative blood culture results) without other identifiable source of infection, surgery is recommended.7

1 C-LD 8.  In patients with recurrent endocarditis and continued intravenous drug use, consultation with addiction medicine is recommended to discuss the long-term prognosis for the patient’s refraining from actions that risk reinfection before repeat surgical intervention is considered.56–60 2a B-NR 9.  In patients with IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy, early surgery (during initial hospitalization and before completion of a full therapeutic course of antibiotics) is reasonable.53,61–66

2b B-NR 10.  In patients with native left-sided valve endocarditis who exhibit mobile vegetations >10 mm in length (with or without clinical evidence of embolic phenomenon), early surgery (during initial hospitalization and before completion of a full therapeutic course of antibiotics) may be considered.20,61–63,67

2b B-NR 11.  In patients with IE and an indication for surgery who have suffered a stroke but have no evidence of intracranial hemorrhage or extensive neurological damage, operation without delay may be considered.68–70

2b B-NR 12.  For patients with IE and major ischemic stroke with extensive neurological damage or intracranial hemorrhage, if the patient is hemodynamically stable, delaying valve surgery for at least 4 weeks may be considered.68,71

Synopsis Management of patients with IE requires a Heart Valve MDT supplemented by inclusion of infectious disease and neurology specialists. The indications for early surgery for patients with IE include HF, persistent infection, abscess, heart block, infection with highly resistant organisms, or recurrent emboli (with persistent vegetations). In patients with implanted electronic devices, infection of the entire system is likely, even if it appears confined to the leads on imaging, and this mandates removal of the entire system to eradicate the infection. In patients with an indication for early surgery, a cerebral embolic event is not a contraindication unless there is extensive neurological damage or intracranial hemorrhage (Figure 16).

Recommendation-Specific Supportive Text

1.	 IE is best managed in an environment with ready access to specialists in the fields of cardiology, cardiothoracic surgery, and infectious disease, with the option for transfer of complicated cases to a Comprehensive Valve Center when needed. A riskscoring system using the STS database has been developed to predict surgical risk in patients with IE to help better counsel patients and more objectively define the risks associated with surgery. One trial noted that even when surgery is indicated, women were less likely to undergo a surgical procedure than men (26% versus 47%) and that women had higher in-hospital and 1-year mortality rates than men despite similar comorbidities.1,2,4–6

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