Surgery for infective endocarditis: who and when?

Infective endocarditis (IE) remains a dangerous condition with unchanging incidence and a mortality approaching 30% at 1 year.1,2 Surgery is potentially lifesaving3 and is required in 25% to 50% of cases during acute infection and 20% to 40% during convalescence.4–7 Operative procedures are often technically difficult and associated with high risk, not least because patients are frequently extremely sick with multisystem disease. Nevertheless, indications for surgery are clear in many patients, and international guidelines8,9 provide strong recommendations that are applicable for the majority. These guidelines are not supported by robust clinical evidence, however, and clinical decision making is often hampered by diverse considerations, including advancing age of the overall patient cohort, the presence of extracardiac complications or preexistent comorbidity, prior antibiotic therapy of varying duration, and the availability of appropriate surgical expertise. In this article, we review the evidence base that supports current clinical practice and attempt to provide recommendations in areas where doubt persists.