Things to know about Infective Endocarditis - Indications of Surgery and Preventive Options

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When do we need to perform surgery for infective endocarditis?

By any chance, if the infection is severe enough to damage native heart valves, you may suffer from symptoms related to valvular dysfunctions and complications. That is why, surgery is recommended to treat persistent infections that is not cured by antibiotics or to replace a damaged valve.

Approximately 15-25% of patients with IE eventually require surgery.

Indications for surgery in infective endocarditis:

Persistent sepsis even after 72 hours of appropriate antibiotic treatment

Recurrent septic emboli

Congestive heart failure that can not be managed by medical therapy

Endocarditis caused by Fungus (except Histoplasma capsulatum)

Rupture of an aneurysm of the sinus of Valsalva

Heart block caused by aortic root or septal abscess

Kissing infection of the anterior mitral leaflet with endocarditis of the aortic valve

Paravalvular abscess and intracardiac fistula.

Culture-negative native valve endocarditis who remained febrile in spite of therapy for more than 10 days.

Valvular surgery should also be considered in patients with multiresistant organisms like enterococci.

Vegetations along mitral valve caused by bacterial endocarditis

What type of surgery is required in infective endocarditis?

Depending on severity and symptoms, heart valves need either repairing or replacing it with an artificial valve made of animal tissue or man-made materials.

What are the types of heart valves for replacement?

Mechanical Valve
These types of valves are made of strong durable materials. They stay functional for a longer duration. In fact, most of these manufactured valves last throughout the remainder of the patients' lifetime.

Patients who receive this types of valves nearly always require a blood thinning medication (also known as anticoagulants like heparin, warfarin etc) life long after the surgery. These medications keep clots from forming, as foreign artificial valves are usually thrombogenic. These clots can lodge in the valve flaps or sometimes even break off and form into an embolism resulting in a stroke or myocardial infarction (heart attack).

Tissue Valve or 'bioprosthetic' valves

The functional properties of bioprosthetic valves (e.g, hemodynamics, resistance to thrombosis) are quite similar to those of native valves.

They are created from animal donors' valves. They do not usually last for more than 10-20 years. Most importantly, they do not require the long-term use of anticoagulation. These valves are usually favored for old aged patients who can not tolerate blood thinner. If bioprosthetic valves are used for a young patient, it is highly likely that additional surgery or another valve replacement later in life will be required.

Donor Valve
A human donor valve is the least common choice and can be expected to last 10-20 years.

What type of prosthetic valve should be used in a patient is determined by the anticipated longevity of the patient. It also depends upon patient's ability to tolerate oral, subcutaneous or intravenous anticoagulation. Most mechanical valves are not prone to structural valve deterioration. They generally carry a lower risk of reoperation.

Should we routinely anticoagulate a patient of infective endocarditis?

No. Usually not. Only if an established reason for anticoagulation like deep vein thrombosis, mechanical prosthetic valve exists, patient should be anticoagulated routinely. But endocarditis itself does not require any anticoagulation. Recent evidence suggest that patients who are anticoagulated have worse outcomes (intracerebral bleeding and so on) than those who are not anticoagulated.

Prevention of infective endocarditis

A good hygiene is the first rule.

Dental health is a very important issue. Brush and floss your teeth and gums often.

Stay away from any procedures that may lead to skin infections, such as body piercings or tattoos.

About preventive (prophylactic) antibiotic therapy:

People who are at risk of suffering from disastrous complications from endocarditis are:

Patients with Artificial (prosthetic) heart valve

A previous endocarditis infection

Certain types of congenital heart defects

That is why, it is often advised to take preventive antibiotics before certain medical or dental procedures. These procedures are associated with escape of bacteria into your bloodstream resulting in a spread of infection to different sites of the body. Antibiotics should be taken before these procedures to kill those harmful bacteria that may lead to endocarditis.

Antibiotics are recommended only before the following procedures:

Certain dental procedures that are associated with cutting your gum tissue or part of the teeth

Procedures involving the respiratory tract or infected skin.

Previously, antibiotics were recommended before all dental procedures as well as for procedures of the urinary tract or gastrointestinal system. This recommendation has been changed substantially in the recent years. As endocarditis is much more likely to occur from exposure to random germs than from a typical dental exam or surgery.

Still it is very important to take good care of your teeth through brushing and flossing. As poor oral hygiene is always the best source of organisms entering your bloodstream. Yearly regular dental exams are also an important part of preventing an endocarditis.

About the Author

Dr Rezahaider's picture
Author: Dr Rezahaider

I am a physician by profession. I dream to work on medicine in the near future. I have completed my residency three years back. Now, I am planning to obtain MRCP. This is very hard exam and surely, I am always scared of it. I have also decided to do my specialization on cardiology. Before medical school, I never thought that our heart could be so complex! So pray for me. I usually don't have enough time to write due to my studies. But whenever I get time I love to write. I write on medical related issues. I try to make it simple for you.

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