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pooled peri-operative survival rate of such surgical technique is 84%.560 Even more extensive repairs may be required for cases involving the intervalvular fibrosa, central fibrous body, and mitral valve, with or without fistulation to the right-side chambers. These operations are technically complex and require a surgeon who is very experienced in IE, which may not be available in every cardiovascular surgery department. Exceptionally, heart transplantation has been utilized for carefully selected patients without other surgical options.561 10.3.1 Choice of valve prosthesis

Many patient characteristics are taken into account when deciding the type of valve prosthesis to implant in a given patient with IE. The studies published to date evaluating various valve prostheses in the setting of IE, however, suffer from numerous biases.90,559,562–566

Beyond the patient characteristics that apply in the non-IE setting,128 valve selection in IE is influenced by the presence of recent stroke, risk of new-onset bleeding, complexity of expected post-operative course,

Haemorrhagic

Ischaemic Meaningful recovery possible with

acceptable residual quality of life

Severely decreased level of

consciousnessa

Neurology and/or neurosurgery assessment and discussion with

the Endocarditis Team

(Class I)

N

Cardiogenic shock

Type of stroke

N N

Infective endocarditis with stroke

Y Y

Uncontrolled infection, heart failure or high-risk of recurrent embolization

N

Frequent follow-up and assessment, delay surgery 4 weeks, if possible

Y

Y Favourable brain bleed featuresb Conservative or

palliative care

N Continued non-surgical

management

Urgent surgery

(Class I) Y

Emergency surgery

(Class I)

Figure 11 Surgery for infective endocarditis following stroke. NIHSS, National Institutes of Health Stroke Scale Score. Surgery timing: emergency, within 24 h. Urgent, within 48–72 h. Non-urgent, within same hospital admission. aGlasgow Coma Scale ≤4 or NIHSS >18. bIntracranial haemorrhage volume <30 mL or NIHSS <12. Downloaded from academic.oup.com/eurheartj/article/44/39/3948/7243107 by guest on 07 October 2026