Surgical Implications of the 2023 ESC Endocarditis Guidelines Endorsed by EACTS: Bridging Guidelines and Practice

Abstract

Infective endocarditis (IE) remains a challenging condition with high morbidity and mortality despite advances in diagnosis and management. The 2023 European Society of Cardiology guidelines, endorsed by the European Association of Cardio-Thoracic Surgery, introduce significant updates, including several new recommendations with regard to surgical intervention. This review synthesizes current evidence on the surgical management of IE, emphasizing indications, timing, and outcomes. The multidisciplinary Endocarditis Team approach is highlighted as a key factor in improving patient prognosis by optimizing diagnosis and treatment strategies. Advanced imaging techniques, such as positron emission tomography-CT, have enhanced diagnostic accuracy, particularly for prosthetic valve endocarditis. Despite the clear survival benefits associated with surgery, only a minority of eligible patients undergo surgical treatment, underscoring the need for better patient selection and timely intervention. Furthermore, the worse prognosis is found in patients with indications for surgery who do not undergo surgical intervention. The updated IE guidelines provide detailed timing recommendations for surgery based on the clinical scenario, including new considerations for patients with stroke. Additionally, novel recommendations regarding partial oral antibiotic therapy following surgery have been introduced. Finally, important measures for the prevention of IE recurrence are discussed. In conclusion, timely surgical intervention, based on defined recommendations guided by multidisciplinary collaboration and enhanced diagnostic tools, is crucial in improving outcomes for IE patients. Surgical essentials: key principles for clinical practiceRole of the multidisciplinary "Endocarditis Team": All patients with complicated infective endocarditis (IE) should be managed by a specialized Endocarditis Team to improve diagnosis, optimize treatment, and enhance outcomes (Figure 1).Indications for surgery: The main surgical indications for IE include heart failure, uncontrolled infection, and prevention of embolic events. Surgery is one of the most important protective factors against mortality in IE patients.Timing of surgery: The updated guidelines define surgical timing as emergency (within 24 h), urgent (within 3-5 days), and non-urgent (within the same hospital stay). Delayed intervention increases the risk of complications.Post-stroke patients: Once an indication for surgery has been identified, embolic (ischaemic) stroke should not delay surgery. In the case of haemorrhagic stroke, surgery might be delayed up to 4 weeks according to the patient's clinical condition.Positron emission CT (PET-CT) in diagnosis: PET-CT has been incorporated into the diagnostic criteria for prosthetic valve endocarditis (PVE), significantly improving detection and treatment planning.Right-sided IE management: Surgery is required in select cases of right-sided IE, particularly in the presence of large vegetations, persistent bactaeremia, or septic pulmonary embolism.PVE: Early PVE (within 6 months post-surgery) requires urgent surgical intervention. PVE caused by Staphylococcus aureus or non-HACEK Gram-negative bacteria is also an indication for surgery.Cardiac implantable electronic device (CIED) IE: Complete system extraction remains the gold standard for patients with confirmed CIED-associated IE, significantly improving survival.Partial oral antibiotic therapy: Select post-surgical IE patients treated with adequate intravenous antibiotic therapy >7 days after surgery may transition to oral antibiotic therapy, based on strict clinical criteria.Long-term follow-up and prevention: Structured post-surgical follow-up, patient education, and antibiotic prophylaxis (especially for dental procedures) are crucial for preventing IE recurrence.

Keywords: Cardiac surgery; Infective endocarditis.