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More and more patients are operated on during the active phase of infective endocarditis (IE).1 Between 1991 and 1999, in France, the rate of cardiac surgery has increased from 31% to 50%.1 This may, at least in part, explain the concomitant decrease of in hospital mortality, from 22% to 17%.1 Nonetheless, the indications for cardiac surgery and its optimal timing remain difficult decisions.
The principal indications for cardiac surgery are heart failure, no control of infection, embolisms, large size of vegetations, severe valvar and perivalvar lesions, and infection caused by some microorganisms.
INDICATIONS FOR CARDIAC SURGERY
If heart failure is present, the mortality rate of native valve infective endocarditis is 55–85% in the case of medical treatment only and 10–35% in operated patients.2
The first indication for cardiac surgery in infective endocarditis is heart failure: it represents more than half of the indications. Heart failure caused by aortic regurgitation is particularly poorly tolerated (heart failure is better tolerated in the case of mitral regurgitation because the left atrium and the pulmonary vascular bed adapt better than the left ventricle to the regurgitant volume), and it progresses faster, thus needing rapid surgery.
Not only does heart failure increase the mortality rate if there is no surgery, but it also increases the perioperative mortality rate: from 5–10% in patients without heart failure to 15–35% in patients with heart failure. Moreover, delaying surgery increases the risk of perivalvar infection.
No control of infection
The first …
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