Surgical Management Of Endocarditis

Brain imaging is required if there is suspicion of stroke in the setting of endocarditis. Either magnetic resonance imaging (MRI) or computed tomography (CT) is an acceptable initial study. (B, Class I)

If MRI is chosen, diffusion weighted imaging, FLAIR imaging, gradient echo imaging, and a postcontrast study, should be performed. (B, Class I)

If MRI is not feasible, CT should be performed. (B, Class I)

Vascular imaging should be performed contemporaneously with brain imaging. Magnetic resonance angiography (MRA) and computed tomography angiography (CTA) are both acceptable vascular imaging modalities to screen for mycotic aneurysm in patients without evidence of intracranial hemorrhage. (C, Class I)

It is reasonable to reserve catheter angiography for patients with evidence of intracranial bleeding, or noninvasive vascular imaging suggestive of mycotic aneurysm. (C, Class IIa)

In patients who have had a major ischemic stroke or any intracranial hemorrhage, it is reasonable to delay valve replacement for at least 4 weeks from the stroke, if possible. (C, Class IIa)

If there is a decline in cardiac function, recurrent stroke or systemic embolism or uncontrolled infection despite adequate antibiotic therapy, a delay of less than 4 weeks may be reasonable, particularly in patients with small areas of brain infarction. (C, Class IIb)

Heparin is the major modifiable risk factor for brain hemorrhage in IE. It should be used cautiously in all patients, and should be withheld for 4 weeks after brain hemorrhage in the context of IE. (B, Class I)

For patients with IE and intracranial hemorrhage, catheter angiography should be performed to rule out MA with consideration of surgical or endovascular therapy. (B, Class I)

Once patients with IE but without neurologic symptoms have been screened to identify MA, it may be reasonable to follow mycotic aneurysms noninvasively to rule out aneurysmal expansion during antibiotic therapy. (C, Class IIb)

Aneurysms that expand during antibiotic therapy may be considered for surgical therapy. It may be reasonable to follow conservatively aneurysms that remain stable or decrease in size during antibiotic treatment. (C, Class IIb)