Timing of surgery in infective endocarditis

Although early surgery is performed in approximately half of patients for the treatment of infective endocarditis (IE), the optimal timing of surgery remains unclear. Appropriate early surgery can avoid death and severe complications, but nearly one-quarter of patients with indications for surgery do not receive surgical intervention. Multidisciplinary collaborations among cardiologists, cardiac surgeons and infectious disease specialists are required for appropriate decisions about indication and timing of surgical intervention. Moreover, the potential benefits of early surgery should be weighed against its operative risks and long-term consequences. The main indications for early surgery in patients with IE are heart failure (HF), uncontrolled infection and prevention of embolism. Role of early surgery has been expanding and a recent randomised trial demonstrated that early surgery performed within 48 h after the diagnosis of IE effectively reduced systemic embolisms without increasing operative mortality or recurrence of IE. Urgent surgery is indicated in patients who have moderate to severe HF, uncontrolled infection and large vegetations associated with severe valvular disease. However, surgery should be delayed for 2-4 weeks in patients with large cerebral infarction and for at least 4 weeks in those with intracerebral haemorrhage if possible, because early surgery may pose significant risks of neurological deterioration and perioperative cerebral bleeding. The decision for surgical timing should be based on individual risk-benefit analysis, and early surgery is strongly indicated if its benefits exceed operative risks.