Andersons pediatric cardiology 1494

Repair is possible in at least 70% of the pediatric IE cases, with favorable outcomes of postsurgical 5-year survival and freedom from reoperation being approximately 80%.113 In a recent

Repair is possible in at least 70% of the pediatric IE cases, with favorable

outcomes of postsurgical 5-year survival and freedom from reoperation being approximately 80%.113 In a recent study from China, the results of valve

replacement for pediatric IE have been reported to be much better than

expected.114 In adults, tricuspid valve repair (annuloplasty, bicupidalization, deVega repair, vegetation resection) is possible in only approximately 20% of the cases, with the rest necessitating tricuspid valve replacement with

bioprosthesis115; in children, tricuspid valve repair is much more often possible The results of aortic valve repair versus replacement have been reviewed in adults.116,117

Indications for Infective Endocarditis Surgery.

The indications for surgery during the initial hospitalization are summarized in

Box 56.5

Box 56.5

Indications for Surgery During Initial

Hospitalization

Recommendations for Surgery During Initial

Hospitalization

■ Valve dysfunction resulting in symptoms of heart failure (class I)

■ Left-sided IE caused by S aureus, fungal, or other highly resistant

microorganisms (class I)

■ IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions (class I)

■ Evidence of persistent infection 5–7 days after initiation of appropriate antibiotic therapy (class I)

■ PVE with relapsing infection (class IIa)

■ Recurrent emboli and persistent vegetations despite appropriate antibiotic

Echocardiographic and Clinical Features Suggesting Potential Need of Urgent Surgical Intervention

Risk of Emboli (Systemic or Pulmonary)

■ Anterior mitral leaflet vegetation with significant size (>10 mm)

■ One or more embolic events during first 2 weeks of antimicrobial therapy

■ Increase of vegetation size after 4 weeks of antimicrobial therapy

Valvar Dysfunction

■ Acute insufficiency (especially mitral and aortic) with signs of ventricular dysfunction

■ Intractable heart failure

■ Valve rupture or significant perforation

Perivalvar Extension

■ Valvar dehiscence, rupture, or fistula

■ New heart block

■ Large abscess or extension of abscess despite therapy

IE, Infective endocarditis; PVE, prosthetic valve endocarditis.

Modified from references 3, 6, and 7

The recommendation of 10 mm as the size of the vegetation above which there is increased risk of embolization has shown validity in pediatric IE,118 but there is a general impression that this might need to be adjusted in increasingly younger and smaller pediatric patients

Surgery to prevent a primary embolic event in the absence of risk factors

has not been recommended given the lack of proven benefit and long-term risks

that there might be need of widening of indications Recent studies in adults

have suggested that surgery in patients with left-sided IE, even when not

considered urgent, may produce better outcomes and lower mortality than

medical therapy alone.119,120

Surgery for the first event of PVE with blocked motion of leaflets or

dehiscence with new paravalvar leak warrants early operation It is more difficult

to decide on the indication and timing of surgery for prosthetic valves with

preserved function and without complications, and it has to be individualized If the annulus is preserved after the debridement and resection, it is acceptable to implant a new mechanical prosthesis If there is intracranial bleeding, biologic prosthesis should be implanted

Surgery for relapsing PVE is recommended even if valvar function remains intact after prolonged medical therapy The decision on when to replace an

infected prosthetic valve is individual and probably should be early for left heart prosthetic valve IE

Surgery for IE on tricuspid valve indications are not well delineated, but this should certainly be performed early in cases of acute right ventricular

dysfunction because of severe regurgitation, large vegetations greater than 20

mm, and lack of response to antibiotic therapy for more than 7 days for resistant

organisms like fungi, S aureus, and Pseudomonas aeruginosa The majority of

tricuspid valve IE surgeries remain elective

Surgery for IE on right ventricle-to-pulmonary artery (RV-PA) conduit is

urgent in cases of obstruction and ineffective antibiotic therapy Elective surgery even after resolution of infection is currently considered of benefit as per the notion of higher rates of recurrence and reinfection, although this has not been investigated in large studies

Surgery for lead-associated endocarditis (LAE) has given way to transcatheter interventional procedures for removal of leads and is currently rarely necessary Major complications were associated with an open surgical approach for device removal, and the risk was increased in a vegetation size greater than 1 cm.121 Surgery for neonatal IE is a higher risk surgery compared with older children, and every attempt should be made at success of medical management and

removing the provoking or predisposing factor, namely lines

Timing of Infective Endocarditis Surgery (Early Infective

Endocarditis Surgery).