Andersons pediatric cardiology 1494

RepairVersusReplacement.
Repairispossibleinatleast70%ofthepediatricIEcases,withfavorable
outcomesofpostsurgical5-yearsurvivalandfreedomfromreoperationbeing
approximately80%.113InarecentstudyfromChina,theresultsofvalve
replacementforpediatricIEhavebeenreportedtobemuchbetterthan
expected.114Inadults,tricuspidvalverepair(annuloplasty,bicupidalization,
deVegarepair,vegetationresection)ispossibleinonlyapproximately20%ofthe
cases,withtherestnecessitatingtricuspidvalvereplacementwith
bioprosthesis115;inchildren,tricuspidvalverepairismuchmoreoftenpossible.
Theresultsofaorticvalverepairversusreplacementhavebeenreviewedin
adults.116,117
IndicationsforInfectiveEndocarditisSurgery.
Theindicationsforsurgeryduringtheinitialhospitalizationaresummarizedin
Box56.5.


Box56.5

IndicationsforSurgeryDuringInitial
Hospitalization
RecommendationsforSurgeryDuringInitial
Hospitalization
■Valvedysfunctionresultinginsymptomsofheartfailure(classI).
■Left-sidedIEcausedbyS.aureus,fungal,orotherhighlyresistant
microorganisms(classI).
■IEcomplicatedbyheartblock,annularoraorticabscess,ordestructive
penetratinglesions(classI).
■Evidenceofpersistentinfection5–7daysafterinitiationofappropriate
antibiotictherapy(classI).
■PVEwithrelapsinginfection(classIIa).
■Recurrentemboliandpersistentvegetationsdespiteappropriateantibiotic

therapy(classIIa).

EchocardiographicandClinicalFeaturesSuggesting
PotentialNeedofUrgentSurgicalIntervention
RiskofEmboli(SystemicorPulmonary)
■Anteriormitralleafletvegetationwithsignificantsize(>10mm)
■Oneormoreemboliceventsduringfirst2weeksofantimicrobialtherapy
■Increaseofvegetationsizeafter4weeksofantimicrobialtherapy
ValvarDysfunction
■Acuteinsufficiency(especiallymitralandaortic)withsignsofventricular
dysfunction
■Intractableheartfailure
■Valveruptureorsignificantperforation
PerivalvarExtension
■Valvardehiscence,rupture,orfistula
■Newheartblock
■Largeabscessorextensionofabscessdespitetherapy
IE,Infectiveendocarditis;PVE,prostheticvalveendocarditis.
Modifiedfromreferences3,6,and7.
Therecommendationof10mmasthesizeofthevegetationabovewhich
thereisincreasedriskofembolizationhasshownvalidityinpediatricIE,118but
thereisageneralimpressionthatthismightneedtobeadjustedinincreasingly
youngerandsmallerpediatricpatients.
Surgerytopreventaprimaryemboliceventintheabsenceofriskfactors
hasnotbeenrecommendedgiventhelackofprovenbenefitandlong-termrisks


ofvalvereplacementinchildhood.3However,thereisagrowingunderstanding

thattheremightbeneedofwideningofindications.Recentstudiesinadults
havesuggestedthatsurgeryinpatientswithleft-sidedIE,evenwhennot
consideredurgent,mayproducebetteroutcomesandlowermortalitythan
medicaltherapyalone.119,120
SurgeryforthefirsteventofPVEwithblockedmotionofleafletsor
dehiscencewithnewparavalvarleakwarrantsearlyoperation.Itismoredifficult
todecideontheindicationandtimingofsurgeryforprostheticvalveswith
preservedfunctionandwithoutcomplications,andithastobeindividualized.If
theannulusispreservedafterthedebridementandresection,itisacceptableto
implantanewmechanicalprosthesis.Ifthereisintracranialbleeding,biologic
prosthesisshouldbeimplanted.
SurgeryforrelapsingPVEisrecommendedevenifvalvarfunctionremains
intactafterprolongedmedicaltherapy.Thedecisiononwhentoreplacean
infectedprostheticvalveisindividualandprobablyshouldbeearlyforleftheart
prostheticvalveIE.
SurgeryforIEontricuspidvalveindicationsarenotwelldelineated,butthis
shouldcertainlybeperformedearlyincasesofacuterightventricular
dysfunctionbecauseofsevereregurgitation,largevegetationsgreaterthan20
mm,andlackofresponsetoantibiotictherapyformorethan7daysforresistant
organismslikefungi,S.aureus,andPseudomonasaeruginosa.Themajorityof
tricuspidvalveIEsurgeriesremainelective.
SurgeryforIEonrightventricle-to-pulmonaryartery(RV-PA)conduitis
urgentincasesofobstructionandineffectiveantibiotictherapy.Electivesurgery
evenafterresolutionofinfectioniscurrentlyconsideredofbenefitasperthe
notionofhigherratesofrecurrenceandreinfection,althoughthishasnotbeen
investigatedinlargestudies.
Surgeryforlead-associatedendocarditis(LAE)hasgivenwaytotranscatheter
interventionalproceduresforremovalofleadsandiscurrentlyrarelynecessary.
Majorcomplicationswereassociatedwithanopensurgicalapproachfordevice
removal,andtheriskwasincreasedinavegetationsizegreaterthan1cm.121

SurgeryforneonatalIEisahigherrisksurgerycomparedwitholderchildren,
andeveryattemptshouldbemadeatsuccessofmedicalmanagementand
removingtheprovokingorpredisposingfactor,namelylines.
TimingofInfectiveEndocarditisSurgery(EarlyInfective
EndocarditisSurgery).