EVALUATION AND MANAGEMENT OF INFECTIVE ENDOCARDITIS
CLASS I
(1) Patients at risk for infective endocarditis who have unexplained fever for more than 48 h should have at least 2 sets of blood cultures obtained from different sites.
CLASS III
(1) Patients with known valve disease or a valve prosthesis should not receive antibiotics before blood cultures are obtained for unexplained fever.
TRANSTHORACIC ECHOCARDIOGRAPHY IN ENDOCARDITIS
CLASS I
(1) Transthoracic echocardiography to detect valvular vegetations with or without positive blood cultures is recommended for the diagnosis of infective endocarditis.
(2) Transthoracic echocardiography is recommended to characterize the hemodynamic severity of valvular lesions in known infective endocarditis.
(3) Transthoracic echocardiography is recommended for assessment of complications of infective endocarditis.
(4) Transthoracic echocardiography is recommended for reassessment of high-risk patients (e.g., those with a virulent organism, clinical deterioration, persistent or recurrent fever, new murmur, or persistent bacteremia).
CLASS IIa
(1) Transthoracic echocardiography is reasonable to diagnose infective endocarditis of a prosthetic valve in the presence of persistent fever without bacteremia or a new murmur.
CLASS IIb
(1) Transthoracic echocardiography may be considered for the re- evaluation of prosthetic valve endocarditis during antibiotic therapy in the absence of clinical deterioration.
CLASS III
(1) Transthoracic echocardiography is not indicated to re-evaluate uncompli- cated (including no regurgitation on baseline echocardiogram) native valve endocarditis during antibiotic treatment in the absence of clinical deterioration, new physical findings or persistent fever.
TRANSESOPHAGEAL ECHOCARDIOGRAPHY IN ENDOCARDITIS
CLASS I
(1) Transesophageal echocardiography is recommended to assess the severity of valvular lesions in symptomatic patients with infective endocarditis, if transthoracic echocardiography is nondiagnostic.
(2) Transesophageal echocardiography is recommended to diagnose infective endocarditis in patients with valvular heart disease and positive blood cultures, if transthoracic echocardiography is nondiagnostic.
(3) Transesophageal echocardiography is recommended to diagnose complications of infective endocarditis with potential impact on prognosis and management (e.g., abscesses, perforation, and shunts).
(4) Transesophageal echocardiography is recommended as first-line diagnostic study to diagnose prosthetic valve endocarditis and assess for complications.
(5) Transesophageal echocardiography is recommended for preoperative evaluation in patients with known infective endocarditis, unless the need for surgery is evident on transthoracic imaging and unless preoperative imaging will delay surgery in urgent cases.
(6) Intraoperative transesophageal echocardiography is recommended for patients undergoing valve surgery for infective endocarditis.
CLASS IIa
(1) Transesophageal echocardiography is reasonable to diagnose pos- sible infective endocarditis in patients with persistent staphylococcal bacteremia without a known source.
CLASS IIb
(1) Transesophageal echocardiography might be considered to detect infective endocarditis in patients with nosocomial staphylococcal bacteremia.
SURGERY FOR NATIVE VALVE ENDOCARDITIS
CLASS I
(1) Surgery of the native valve is indicated in patients with acute infective endocarditis who present with valve stenosis or regurgitation resulting in heart failure.
(2) Surgery of the native valve is indicated in patients with acute infective endocarditis who present with AR or MR with hemodynamic evidence of elevated LV end-diastolic or left atrial pressures (e.g., premature closure of MV with AR, rapid decelerating MR signal by continuous-wave Doppler (v-wave cutoff sign), or moderate or severe pulmonary hypertension).
(3) Surgery of the native valve is indicated in patients with infective endocarditis caused by fungal or other highly resistant organisms. (Level of Evidence: B)
(4) Surgery of the native valve is indicated in patients with infective endocarditis complicated by heart block, annular or aortic abscess, or destructive penetrating lesions (e.g., sinus of Valsalva to right atrium, right ventricle, or left atrium fistula; mitral leaflet perforation with aortic valve endocarditis; or infection in annulus fibrosa).
CLASS IIa
(1) Surgery of the native valve is reasonable in patients with infective endocarditis who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy.
CLASS IIb
(1) Surgery of the native valve may be considered in patients with infective endocarditis who present with mobile vegetations in excess of 10 mm with or without emboli.
SURGERY FOR PROSTHETIC VALVE ENDOCARDITIS
CLASS I
(1) Consultation with a cardiac surgeon is indicated for patients with infective endocarditis of a prosthetic valve.
(2) Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with heart failure.
(3) Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with dehiscence evidenced by cine fluoroscopy or echocardiography.
(4) Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with evidence of increasing obstruc- tion or worsening regurgitation.
(5) Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with complications (e.g., abscess formation).
CLASS IIa
1. Surgery is reasonable for patients with infective endocarditis of a prosthetic valve who present with evidence of persistent bacteremia or recurrent emboli despite appropriate antibiotic treatment.
2. Surgery is reasonable for patients with infective endocarditis of a prosthetic valve who present with relapsing infection.
CLASS III
1. Routine surgery is not indicated for patients with uncomplicated infective endocarditis of a prosthetic valve caused by first infection with a sensitive organism.
JACC Vol. 52, No. 13, 2008
September 23, 2008: e1-142