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8.3.3 Indications and timing of surgery in the presence

of uncontrolled infection Surgery should be considered for uncontrolled infection when antibiotic therapy is ineffective and extracardiac sources are ruled out. Reports in the literature demonstrate that surgery for uncontrolled infection in IE has the potential to improve 1-year survival by 15–20%.403,429,444

8.3.3.1 Persistent infection

Uncontrolled infection is present in the form of persistent infection when blood cultures remain positive for >1 week or persistent sepsis despite appropriate antimicrobial therapy and when other causes of bacteraemia have been excluded. Not performing surgery for uncontrolled infection is associated with significantly increased mortality.444

8.3.3.2 Locally uncontrolled infection

Uncontrolled infection is also present if signs of local progression, i.e. increasing vegetation size or perivalvular involvement, are observed during follow-up imaging.5,420,421,445,446 Surgery should be performed urgently (within 3–5 days) in such cases. Rarely, when there are no other reasons for surgery and fever is easily controlled with antibiotics, small abscesses or pseudoaneurysms can be treated conservatively under close clinical and echocardiographic follow-up.429,444

8.3.3.3 Infection with resistant or virulent organisms

Microorganisms causing endocarditis that are unlikely to be controlled with current antimicrobial therapy include fungi,447,448 multiresistant bacteria (e.g. MRSA or vancomycin-resistant enterococci) and, in rare cases, non-HACEK Gram-negative bacteria. S. aureus should also be included in this group due to its fast progression and ability to cause local tissue destruction and abscess formation,5,449 specifically, if a favourable early response to antibiotics is not achieved.305,312,449 The presence of these organisms should lead to discussions within the Endocarditis Team and urgent surgery.385,450

8.4 Prevention of systemic embolism

8.4.1. Incidence of embolic events in infective endocarditis Embolic events are frequent and potentially life-threatening complications of IE related to the migration of cardiac vegetations.451,452 The brain and spleen are the most frequent sites of embolism for left-sided IE, while pulmonary embolism is frequent in right-sided and pacemaker lead IE (see Section 12). Stroke may be the first clinical manifestation of IE, and is a severe complication that is associated with increased morbidity and mortality.451,453,454 Embolic events may be clinically silent in up to 50% of patients with IE.198 Emboli affecting the splenic or cerebral circulation are frequently asymptomatic, and are diagnosed by noninvasive imaging.197,200 Although whole-body CT imaging (i.e. chest, abdomen, and pelvis) is frequently performed during the work-up for surgery, diagnosis and management of patients is infrequently altered as a result of these investigations.194 However, cerebral CT may affect clinical decision-making and outcomes when surgery is considered.452 Embolic risk in IE is high, with 20–50% of patients being affected.452,455 The highest incidence of embolic strokes can be observed in the days around the initial diagnosis of IE,456 and embolic events are often what leads to the initial diagnosis of IE. Embolic risk is highest the day after therapy initiation, and is 10–20 times higher on the day before and after the start of antibiotic treatment compared with 2 weeks before and after.456 Thus, embolic events occurring after the initiation of antibiotic therapy continuously drop in incidence within the first 2 weeks of antibiotic treatment.429,455–457 The benefits of surgery to prevent embolism may therefore be greatest during the early stages of therapy, when embolic risk is at its highest.

8.4.2 Predicting the risk of embolism

Predicting the risks of embolization is important for decision-making in IE. Echocardiography plays a key role in identifying potentially embolic structures in the heart,429,455,456,458 although predicting the time point of embolization remains difficult. Several factors are associated with increased risk of embolism including the size and mobility of vegetations,455,456,458–460 the location of the vegetation on the mitral valve,455 the increasing or decreasing size of the vegetation under antibiotic therapy,455 particular microorganisms (especially S. aureus,455 S. gallolyticus,461 and Candida spp.450), previous embolism,455 multivalvular involvement,458 and biological markers.462 Among these, the size and mobility of the vegetations are the most important independent predictors of new embolic events.459,460,463 A recent study, however, demonstrated that vegetation size was predictive of worse outcomes only when present with other indications for surgery (i.e. HF or uncontrolled infection).464 Staphylococcal endocarditis is also a risk factor for embolization,465–468 which is particularly important because the incidence of S. aureus IE is increasing.78,469 Risk of neurological complications is particularly high in patients with very large vegetations (>30 mm in length).451 Additional factors may need to be taken into account and it may be helpful to use an embolic risk calculator.470 S. aureus infection, previous embolism, vegetation length, age, diabetes, and the presence of atrial fibrillation have been identified as specific risk factors for embolism.470

8.4.3 Indications and timing of surgery to prevent

embolism in infective endocarditis Surgical removal of potentially embolic material from the heart may prevent new or additional embolic events. Given the imminent risk and high rates of embolization in patients with mobile and large vegetations,5,451,455–457,460,471 surgery should be considered urgently (within 3–5 days) in such patients. A prospective randomized trial in young, low-risk patients assessed the effects of early surgery in patients with large vegetations and streptococcal IE.471 Although there was no difference in all-cause mortality at 6 months between the early surgery and conventional treatment groups, the risk of embolization was significantly reduced with early surgery. Non-randomized observational analyses including patients at higher risk also suggest that early surgery may be beneficial in patients with a high likelihood of embolization,428,459,472,473 and that initial conservative treatment is associated with increased mortality.474,475 However, prosthetic dehiscence has also been associated with early surgery in patients with S. aureus IE.429 Individualized decision-making is required to balance the risk of surgery, which is also influenced by pre-operative neurological events or other co-morbidities.5,453 The main indications and the timing of surgery to prevent embolism based on the currently available literature are given in Recommendation Table 12 and Figure 10. Downloaded from academic.oup.com/eurheartj/article/44/39/3948/7243107 by guest on 07 October 2026