Surgery is the best way to minimize emblic risk. The risk depend on the vegetation size, the mobility and location (mitral>aortic). The timing with antibiotic treatment begining is allways a mater of discussion with cardiologist &surgeon(duration of treatment before surgery? Immediate?1day? 2days? more??

You can find detailed explaination in the 2009 ESC guidelines on infective endocarditis (www.escardio.org)

Please see our recent article on this subject.

What size of vegetation is an indication for surgery in endocarditis?

Interact CardioVasc Thorac Surg (2012) doi: 10.1093/icvts/ivs365 First published online: September 7, 2012

Kelechi E. Okontaa,* and

Yahaya B. Adamub

+ Author Affiliations

aDivision of Cardiothoracic Surgery, Department of Surgery, University College Hospital, Ibadan, Nigeria

bCardiothoracic Unit, Department of Surgery, National Hospital, Abuja, Nigeria

↵*Corresponding author. Division of Cardiothoracic Surgery, Department of Surgery, University College Hospital, PMB 5116, Ibadan, Nigeria.

Dear Dr. Okonta,excuse me, but I think that is more easy you report your brief opinion. An article is the opinion of the authors based in yours experiences not a guideline.

In all fairness - what dr Okonta probably was trying to point out is that yours is a very important question, so much so that it deserved a systematic review. Secondly that a number of factors need to be taken into consideration (e.g. which side of the heart, how large is "very large", etc).

Dr Okonta and colleagues have written a brilliant Systematic Review on the topic which has recently been published and is available as open access and can be freely downloaded from PubMed.

The surgery is the best way to minimize the stroke

According to ESC guidelines it is an Ic indication if the vegetation is >10mm along with other factors that are related to complicated course (HF, infection and abcess). of course if you have embolic events despite antibiotic therapy you should proceed to surgery (IB indication) and finally if the vegetation is >15 mm surgery is again the therapy of choice.

I see the key words presented are "mobile" vegetation and "emergency" surgery. There are panels which indicated hypermobile and length of vegetation as criteria for emergency surgery with excellent results. We know that emergency/urgent operation is associated with increased risk of operative death. Early diagnosis followed by appropriate antibiotic therapy forms the cornerstone of treatment. Where medical management fails or complications of endocarditis ensue, "timely" surgical intervention is crucial for patient survival. Indications for surgical intervention were one or more of the following: shock, congestive cardiac failure, cerebral embolism, and perivalvular abscess.

Dear Hafil, I agree with you.

Thanks Jose, hope to see you in Brazil

I think,that for the treatment of endocarditis is the most important timing.A patient with a large and mobile vegetation even without previous embolism is indicated for a surgery.I prefer to operate patient in good conditions and not in shock,congestive cardiac failure.I do realy agree with a Dr.Kyriakos Dimitriadis and I ussually follow the ESC guideliens.

Consciousness of the results and of the surgical challenges is the key point... The increase of surgical risk is sometime exponential. Uundue waits are often more dangerous of an early surgery.

I agree with Dr. Bena and dr. Amarelli. I believe, as dr. Abdulgani wrote, that antibiotic therapy is still the cornerstone but early operation in a "good patient" is less risky than unnecessary delay.

Let us clear things up. A very large (>15 mm, according to ESC guidelines) vegetation without previous embolism is not (and never has been) a class I indication for surgery per se. It is a class IIb indication, both in the American (ACCF/AHA/STS-2008 Focused Update Incorporated into the ACC/AHA 2006 Guidelines) and European (ESC-Guidelines on the prevention, diagnosis, and treatment of infective endocarditis-new version 2009). Hence, sound clinical judgment and individualization of care are required.

Factors such as native valve involved (aortic versus mitral, MV anterior versus posterior leaflet), existence of other cardiac pathologies that need to be taken care of during surgery, comorbidities, age, expected operative risk and so forth should be taken into account in the decision making process for surgery. In this regard, I would operate (and I have actually operated) on an otherwise healthy young woman with a “very large” mobile anterior MV vegetation, in an effort not only to avoid peripheral embolism but also to increase chance of MV repair – no one would like to put a prosthetic valve in an unmarried gal of childbearing age. I would do that “urgently”, not “emergently” (see ESC guidelines for definitions). On the other hand, I would most probably hold my horses in an 80-year-old gentleman, with a commissural vegetation and several comorbidities.

I suggest to reed : "Surgery for Infective Endocarditis : Who and When?Bernard D. Prendergast and Pilar Tornos. Circulation 2010, 121:1141-1152". Emergency surgery (within 24 hours) is limited in very few conditions. In the presented case i belive not indicated emergency surgery.

Dear Giuseppe. I agree with you. Emengency surgery to avoid a possible complication, before any antibiotic terapy is a very agressive conduct.

I think that the question should be expressed in different terms: which is the risk of a disabling stroke in a patient who has a very large and mobile vegetation? In other words, how many of these patients will have a debilitating embolic event during the period of appropriate antibiotic therapy administration? 1% ... 5% ... 50%? And which is the risk of an uncontrolled sepsis from bacterial dissemination? Streptococcal vegetations have the same likelihood of embolization compared to vegetation from staph or gram-negative or fungal infections?

Can we respond accurately to these simple questions?

"Ubi pus, evacuat" said our masters in the history of medicine ... but now we think to know much more of this simple solution!

I do agree with Gianpaolo,

we also have to consider that once the patient experience a a stroke due to an embolization of the vegetation also the timing of surgery change. How long do we have to wait to full heparinize a patient during cardiopulmonary bypass, that had a recent stroke but still has a mobile vegetation?

Always patient with a large and mobile vegetation even without previous embolism is indicated for a surgery we called this prevention... sooner o later embolism will be present. I agree with you

I think that my question allowed a great debate, and others opinions will be posted. I remember that surgery during active Endocarditis has a bigger risk of complication, including dissemination of infection and Endocarditis in prosthesis, that is a very critical disease. For this reason I prefer try antibiotic therapy and indicate surgery if there is no response to medical therapy.

I agree with Jacob and i think that surgery is justified in patients with high-risk of haemodinamic complications or uncontrolled infection.

How long will it take to obtain complete disappearance of a large vegetation? As Dr. Romano wrote: which is the risk of embolic stroke (or embolization to other organs, with risk of disseminated sepsis) in the meanwhile?

And which is the risk of surgery after a recent stroke? I.e., which is the risk to have no more chances of surgery?

I don't think that a tailored randomized study (antibiotics vs early surgery) would be impossible. About 20 years ago surgeon's attitude was "At least one month antibiotics", even if several observational studies already suggested the risk of delaying surgery.

Maybe full-dose i.v. antibiotic therapy for 2 or 3 days (enough to have negative blood cultures) and Urgent surgery thereafter could be a good compromise?

Is emergency surgery necessary for patients with Endocarditis with very large and mobile vegetation without previous embolism?

As pathogens evolve over time, so do our patients, and those with valve endocarditis have progressed to a higher degree of compromise, prompting early, aggresive and specific therapy. When a diagnosis of valve endocarditis is established and the presence of a large (>15 mm) vegetation confirmed, the risk of embolism is not precluded by appropriate ATB therapy, thus surgical treatment should, IMHO, be instituted no matter what (except in cases with severe comorbidities exceeding operative risk). When? Emergent surgery means immediate surgery, which is not always possible nor advisable. But urgent surgery (1st case tomorrow schedule) covers most dire situations.