Surgical management of mitral valve infective endocarditis.

Active mitral valve infective endocarditis is a challenging clinical problem with a high rate of mortality. Surgery is currently performed in more than 40% of patients, and selecting those patients who will benefit from surgical intervention and performing a technically sound operation at the proper time are keys to optimizing outcomes. Moderate-to-severe and severe mitral regurgitation, large, mobile vegetations, paravalvular abscess, embolic events, failure of antibiotic therapy, and infection with a fungal organism are indications for prompt operation. The use of computed tomography imaging is important to determine whether there are noncardiac sources of infection, and transesophageal echocardiography is essential to delineate valvular dysfunction, identify paravalvular abscesses, rule out involvement of other valves, and plan operative therapy. In most cases, surgery should not be delayed because of cerebrovascular emboli. Mitral valve repair is favored over replacement whenever possible, is associated with superior short- and long-term outcomes, and should be possible in most cases. Operative mortality is <10% and 5-year survival is >80%.