When should we operate on patients with acute infective endocarditis?

Infective endocarditis (IE) has become a ‘surgical disease’ during the last decade since approximately half of all patients are currently operated on during the active phase of the disease (early surgery).w1,w2 Recent changes in the epidemiological profile of the disease could explain this trend, with an increase in complicated situations owing to a greater incidence of more virulent organisms and intracardiac material infections.1 2 w3 Moreover, the development of surgical techniques and publications of large studies demonstrating the beneficial effect of surgery in complicated endocarditisw4–6 have encouraged physicians to offer surgical treatment to an increasing number of patients. Cardiac surgery is essential when severe valvular damage occurs, because, in those situations, antibiotics are not sufficient to prevent acute heart failure, (cerebral) embolic events, and septic shock—the three deadliest complications of IE. Therefore, after diagnosis, immediate risk stratification is of crucial importance to determine whether early cardiac surgery is required. Thus, the predictors of the worst outcome under medical treatment and the factors associated with a high operative risk must be quickly identified. In the new 2009 guidelines from the European Society of Cardiology (ESC), the indications of early cardiac surgery have been clearly defined.w7 Moreover, for the first time, these guidelines have proposed an optimal timing of surgery in each clinical situation. This article discusses the prognosis assessment, the role, indications and timing of cardiac surgery during acute valvular IE. IE remains among the deadliest infectious diseases. In-hospital mortality varies from 9.6–26%3–5 w1 w8 w9 and 1 year mortality from 20.6–37%.1 w9 Acute heart failure and cerebral embolism are the first two causes of death during IE. Thus, the main objective of our management is to avoid these two serious complications. At admission, the immediate assessment of prognosis should be performed to identify those patients …