Infective endocarditis is a serious clinical cardiac problem. The disease has evolved over many decades and now we are witnessing the most virulent forms of the disease . Infection of heart , can occur in a native healthy valve, native diseased valve, or a prosthetic valve. Further, IE can occur either as an acute (usually non diseased valve) , or sub acute form (usually in diseased valve).The changing microbial pattern has made this entity very complex. The vigorous treatment protocols are available for IE. Still the prognosis and outcome with medical management is dismal even in best centers.So the role of surgery in IE has increased over the years.We propose here, a radically different approach to the problem.
Traditionally there is a set of criteria for surgery in IE : These include
- Abscess formation
- Worsening valve lesion
- Refractory cardiac failure
- Persistent fever even after 2 weeks of appropriate and adequate anti microbial therapy .
- Vegetation of more than 10mm size.
- Failed medical treatment
(The list is not exclusive)
In any large tertiary hospital series, if you apply the above rule more than 50 % of all patients with IE will be the candidates for immediate surgery.
In the remaining 50% the mortality in medical management is very high. The reason being, the medical treatment is often prolonged over weeks. Many of the complications occur during the course of medical treatment.The common ones are abscess formation, embolic episodes, renal failure etc.Once a complication set in we call it as failed medical treatment and ask our surgical colleagues to operate.By this time patient’s general condition deteriorates and either the surgeon refuses to take up the case or patient dies on the table.
So the key point is , failure of medical treatment is so common , it is simply not acceptable to delay the surgery in these patients as majority of them are doomed to fail the trial of medical therapy.
What is the incidence of failed medical management, how to recognise it ? what is the impact of recognising it late ?
- Failed medical therapy is around 60-70% even in best centers.
- Failed medical patients constitute the greatest surgical risk .
- So it is proposed all IE patients should be triaged early and the dominant theme should be surgery (Commonly valve replacement, or valve repair) .
- If there is large vegetation surgery may be done for the sole purpose of physical removal of the vegetation*.
In Infective endocarditis experience has taught us, surgery should be the default management protocol and medical therapy should be offered to selected few who don’t require surgery.This is especially true in preexisting rheumatic valve disease.
*The fundamental principle of management of infectious diseases, state that when there is a resistant focus of infection .Always remove the focus whenever possible.