Surgical aspects of endocarditis.

Endocarditis represents a difficult medical problem that must occasionally be treated surgically. Constitutional symptoms of infection are important and are usually the reason that the patient seeks medical attention. Fever is the most common sign of infective endocarditis and a heart murmur, which changes in character or is new, is a significant hallmark. The diagnosis for infective endocarditis is made by high index of suspicion in a patient with valvular heart disease or a prosthetic heart valve and in the presence of fever and a cardiac murmur. A positive blood culture is the hallmark of the diagnosis. The absolute indications for operative intervention are congestive heart failure, unstable prosthetic valve, uncontrolled infection, and relapse after optimal therapy (prosthetic valve). Relative indications for operative intervention are perivalvular extension of the infection, staphylococcal infection of a prosthesis, persistent fever (culture negative), large vegetation, or relapse after optimal therapy (native valve). The principles of surgical management are to remove all infected tissue by thorough debridement back to normal tissue. This is combined with replacement of damaged valves and repair of associated defects. The mortality after operation for infective endocarditis is 15-20%. Late survival after operation for infective endocarditis on a native heart valve is 70-80% at 5 years. Survival falls to 50-80% at 5 years for surgery on an infected prosthetic heart valve.