Indications for surgery in left-sided valve infective endocarditis

Indications for surgery	Timing*	Class^¶	Level^Δ
1. Heart failure
Aortic or mitral NVE or PVE with severe acute regurgitation, obstruction or fistula causing refractory pulmonary oedema or cardiogenic shock	Emergency	I	B
Aortic or mitral NVE or PVE with severe regurgitation or obstruction causing symptoms of HF or echocardiographic signs of poor haemodynamic tolerance	Urgent	I	B
2. Uncontrolled infection
Locally uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation)	Urgent	I	B
Infection caused by fungi or multiresistant organisms	Urgent/elective	I	C
Persisting positive blood cultures despite appropriate antibiotic therapy and adequate control of septic metastatic foci	Urgent	IIa	B
PVE caused by staphylococci or non-HACEK gram-negative bacteria	Urgent/elective	IIa	C
3. Prevention of embolism
Aortic or mitral NVE or PVE with persistent vegetations >10 mm after one or more embolic episode despite appropriate antibiotic therapy	Urgent	I	B
Aortic or mitral NVE with vegetations >10 mm, associated with severe valve stenosis or regurgitation, and low operative risk	Urgent	IIa	B
Aortic or mitral NVE or PVE with isolated very large vegetations (>30 mm)	Urgent	IIa	B
Aortic or mitral NVE or PVE with isolated large vegetations (>15 mm) and no other indication for surgery^◊	Urgent	IIb	C

HACEK: Haemophilus parainfluenzae, Haemophilus aphrophilus, Haemophilus paraphrophilus, Haemophilus influenza, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae, and Kingella denitrificans; HF: heart failure; IE: infective endocarditis; NVE: native valve endocarditis; PVE: prosthetic valve endocarditis.
* Emergency surgery: surgery performed within 24 hours; urgent surgery: within a few days; elective surgery: after at least one to two weeks of antibiotic therapy.
¶ Class of recommendation. Class I: Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective. Class II: Conflicting evidence and/or divergence of opinion about the usefulness/efficacy of the given treatment or procedure. Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion.
Δ Level of evidence. A: Data derived from multiple randomized clinical trials or meta-analyses. B: Data derived from a single randomized clinical trial or large non-randomized studies. C: Consensus of opinion of the experts and/or small studies, retrospective studies, registries.
◊ Surgery may be preferred if a procedure preserving the native valve is feasible.

Reproduced from: Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36(44):3075-3128, by permission of Oxford University Press on behalf of The European Society of Cardiology. Copyright © 2015 Oxford University Press. Available at: www.escardio.org.

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Indications for surgery in left-sided valve infective endocarditis