Table 1

Indications for surgery in patients with infective endocarditis2

A: Strong evidence or general agreement that cardiac surgery is useful and effective; B: Inconclusive or conflicting evidence or a divergence of opinion about the usefulness/efficacy of cardiac surgery, but weight of evidence/opinion of the majority is in favour; C: Inconclusive or conflicting evidence or a divergence of opinion; lack of clear consensus on the basis of evidence/opinion of the majority.
AR, aortic regurgitation; MR, mitral regurgitation; NYHA, New York Heart Association functional class.
Emergency indication for cardiac surgery (same day)
    Acute AR with early closure of mitral valveA
    Rupture of a sinus Valsalva aneurysm into a right heart chamberA
    Rupture into the pericardiumA
Urgent indication for cardiac surgery (within 1–2 days)
    Valvar obstructionA
    Unstable prosthesisA
    Acute AR or MR with heart failure, NYHA III–IVA
    Septal perforationA
    Evidence of annular or aortic abscess, sinus or aortic true or false aneurysm, fistula formation, or new onset conduction disturbancesA
    Major embolism+mobile vegetation >10 mm+appropriate antibiotic treatment <7–10 daysB
    Mobile vegetation >15 mm+appropriate antibiotic therapy <7–10 daysC
    No effective antimicrobial treatment availableA
Elective indication for cardiac surgery (earlier is usually better)
    Staphylococcal prosthetic valve infective endocarditisB
    Early prosthetic valve infective endocarditis (⩽2 months after surgery)B
    Evidence of progressive paravalvar prosthetic leakA
    Evidence of valve dysfunction and persistent infection after 7–10 days of appropriate antibiotic treatment, as indicated by presence of fever or bacteraemia, provided there are no non-cardiac causes for infectionA
    Fungal infective endocarditis caused by a mouldA
    Fungal infective endocarditis caused by a yeastB
    Infection with difficult-to-treat organismsB
    Vegetation growing larger during antibiotic treatment >7 daysC