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Rostagno. Vessel Plus 2020;4:7 I http://dx.doi.org/10.20517/2574-1209.2019.29 Page 3 of 7

Table 1. The endocarditis team - role
Should have meetings on a regular basis in order to discuss cases, take surgical decisions, and define the type of follow-up
Chooses the type, duration, and mode of follow up of antibiotic therapy following the current guidelines
Should participate in national or international registries, publicly report the mortality and morbidity of their center, and be involved in a
quality improvement and patient education programs
The follow-up should be organized on an outpatient visit basis at a frequency depending on the patient’s clinical status (ideally at 1, 3,6,
and 12 months after hospital discharge, since the majority of events occur during this period)
Modified from ref. [12]

Table 2. Factors related to choice of surgical strategy
Favor mitral valve repair Favor mitral valve replacement
Single scallop or leaflet valve involvement Extensive damage of anterior leaflet
Isolated vegetation Large lesion of posterior leaflet and/or commissures
Valve perforation Annular abscesses
Less extensive valve damage with enough tissue after debridement Low volume repair centers in patients with severe valve
allowing repair with patches, neo-chordae, annular ring damage
Cardiogenic shock

risk of further neurologic impairment is related more to severity of baseline neurologic damage than to
surgery timing. In the case of hemorrhagic stroke surgery should be delayed at least 30 days.

ESC guidelines suggest that patients with IE should be referred to specialist centers and managed with
a multidisciplinary specialized team (the “Endocarditis Team”) including “at least cardiac surgeons,
cardiologists, anesthesiologists, infectious disease specialists, microbiologists and, when available, specialists
in valve diseases, CHD, pacemaker extraction, echocardiography and other cardiac imaging techniques,
[11]
neurologists, and facilities for neurosurgery and interventional neuroradiology” [Table 1] . An approach by
a formalized multidisciplinary team led to a reduction in in-hospital and long-term mortality. This decrease
in mortality was even more impressive since patients were old and suffered from several comorbidities [14,15] .

Despite a clear indication, about 25% of all patients with IE still do not undergo surgery. Independent
factors associated with a decision not to proceed with surgery include liver disease [odds ratio (OR)
for surgery: 0.16; 95%CI: 0.04-0.64], stroke before surgical decision (OR = 0.54 ; 95%CI: 0.32-0.90), and
[16]
Staphylococcus aureus infection (OR = 0.50; 95%CI: 0.30-0.85) .

A comprehensive multidisciplinary evaluation in IE may be extremely useful for the individualisation of
proper surgical strategy, whose objectives are total removal of infected tissues and reconstruction of cardiac
morphology.

With mitral and tricuspid involvement, the extent of valvular destruction and of extra valvular extension
are the main determinant in the choice between valve repair and replacement. Involvement of valve leaflets,
including perforation, favors mitral valve (MV) repair. Neo-chordae may be used in the case of isolated
or multiple ruptured chordae. Extensive damage of a single leaflet or abscess formation are not necessarily
a contraindication for valve repair. Extensive damage of the anterior leaflet, large lesions involving the
posterior leaflet or the MV commissures and perivalvular extension with annular abscesses are considered
the main technical difficulties for mitral repair. Intraoperative assessment of the valve after initial
debridement allows to evaluate whether the remaining tissue is of sufficient quality to achieve a durable
result. Intraoperative transesophageal echocardiography should guide surgeons in assessing residual valve
regurgitation after valve repair [Table 2].

MV repair vs. valve replacement
No randomized trial has been conducted comparing MV repair and replacement in patients with infective
endocarditis. In light of present evidence, it may be ethically unfeasible in the future to conduct such