Infective endocarditis (IE) is associated with high rates of morbidity and mortality (early mortality risk, 15-25%). Surgery for complicated left-sided IE, performed in approximately 50% of cases in tertiary care centers, generally is indicated when antibiotic treatment alone is unlikely to be curative or may be associated with a persistent risk of complications. American College of Cardiology (ACC)/American Heart Association (AHA) and European Society of Cardiology (ESC) guideline recommendations on the use of surgery in the treatment of IE are limited by low levels of evidence. This manuscript reviews guideline-based surgical recommendations for IE, highlighting areas of differences between societal recommendations, and areas of uncertainty. The following are key points to remember:

Surgical indications: In general, surgical indications in patients with IE relate to heart failure or shock, evidence or risk of persistent infection, and embolic risk reduction.

1. Heart failure: ESC and the ACC/AHA guidelines have similar recommendations for surgical intervention in the setting of IE complicated by heart failure. Although the ESC guidelines state that medical management with clinical and echocardiographic observation can be considered among patients with New York Heart Association (NYHA) class I or II heart failure symptoms, the authors recommend pursuing surgery within a few days whenever acute, severe left-sided valve regurgitation occurs regardless of NYHA class.
2. Persistent infection: ESC and ACC/AHA guidelines both recommend surgery in the setting of a highly resistant organism, evidence of abscess or penetrating lesion, or persistent bacteremia; all predictive of persistent infection with antibiotic therapy alone.
3. Embolic risk reduction: ESC and ACC/AHA guidelines both consider vegetation size as an indication to consider intervention with a goal of reducing future embolic risk, but with different specifics. The ESC guidelines recommend urgent surgery for aortic or mitral valve vegetation >10 mm with severe stenosis or regurgitation and low operative risk (class IIa) or any vegetation >15 mm, whereas the ACC/AHA guidelines suggest consideration for early surgery for left-sided mobile vegetations >10 mm without respect to lesion severity or operative risk (class IIb). Because the benefit of surgery in reducing embolic risk is greatest in the first week of antibiotic treatment, the authors recommend nondelayed surgery if the indication is vegetation size.
4. Prosthetic valve endocarditis (PVE): ESC guidelines recommend urgent or elective surgery for PVE complicated by heart failure, severe prosthesis dysfunction, abscess, or a staphylococcal or non-HACEK gram-negative organism. ACC/AHA guidelines recommend early surgery for PVE with relapsing infection, but otherwise do not differentiate surgical indications from those for native valve IE.

Operative risk assessment:

1. Both ESC and ACC/AHA guidelines recommend that decisions regarding the indications and timing of surgical intervention for IE should be made by a multidisciplinary team including specialists in infectious disease, cardiology, and cardiac surgery.
2. Several risk models have been developed for patients with IE undergoing surgery. Similar to all cardiac surgery, age and hemodynamic instability (especially cardiogenic shock) are the strongest predictors of operative risk.
3. In clinical practice, the calculation of operative risk might not alter management for patients with IE. Even with high predicted operative risk, most indications for surgery are associated with very high rates of mortality if treated with medical therapy alone, and many conditions associated with high operative risk in IE are not modifiable.

Surgical timing: When surgery is indicated, the ESC and the ACC/AHA guidelines differ in their relative descriptions of timing.

1. ACC/AHA guidelines describe ‘early’ surgical intervention, defined as during the index hospitalization and before the cessation of antibiotic therapy.
2. In contrast, ESC guidelines describe surgical timing as ‘emergent’ (within 24 hours), ‘urgent’ (within days), or ‘elective’ (after at least 1-2 weeks of antibiotic therapy).
3. The authors recommend surgical intervention of definite left-sided IE:
• Within 24-48 hours of diagnosis for severe valve regurgitation or a destructive/penetrating lesion with hemodynamic instability or NYHA class III or IV symptoms.
• Within 1 week of diagnosis for either severe valve regurgitation or a destructive/penetrating lesion without hemodynamic instability or NYHA class 3 or 4 symptoms; or for refractory infection (defined by abscess, persistent bacteremia, resistant organism, or relapsing PVE).
• Within 24-48 hours of diagnosis for embolic prevention (defined as recurrent emboli with residual vegetation or vegetation size >10 mm without prior embolic event).

Surgical timing related to stroke:

1. Neither ESC nor ACC/AHA guidelines recommend routine brain imaging prior to surgery in the absence of signs of neurologic complications.
2. ACC/AHA guidelines recommend no delay in indicated surgery in the setting of stroke without evidence of intracranial hemorrhage or extensive neurologic damage; in the setting of hemorrhagic stroke or extensive neurologic damage, guidelines advise that surgery should be delayed ≥ 4 weeks.

Clinical Topics: Cardiac Surgery, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Vascular Medicine, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Echocardiography/Ultrasound

Keywords: Anti-Bacterial Agents, Bacteremia, Cardiac Surgical Procedures, Diagnostic Imaging, Echocardiography, Endocarditis, Bacterial, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Hemodynamics, Hemorrhagic Stroke, Intracranial Hemorrhages, Neuroimaging, Patient Care Team, Risk Assessment, Risk Reduction Behavior, Shock, Cardiogenic, Tertiary Care Centers, Uncertainty

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