Infective endocarditis IE is a complex disease, at the crossroad of a large number of medical specialties, including cardiology, infectious diseases, internal medicine, neurology, intensive care, microbiology, and radiology 1 , 2.
The selection of patients in whom cardiac surgery must be performed during the acute phase of IE is among the most difficult medical decisions in contemporary medicine, as both the benefits and the risks are high. The guidelines performed a complex process of weighing the pros, and the cons, for cardiac surgery, in a broad range of clinical situations commonly encountered in patients with IE.
As could be expected, major indications for cardiac surgery are very similar in Europe and America guidelines, because the authors based their recommendations on the same tools, i. In brief, major indications for cardiac surgery are categorized in three groups in these guidelines: I heart failure, II uncontrolled infection, and III prevention of embolism 1 , 2. However, the selection of patients who will benefit from cardiac surgery is much more complex than merely screening whether they present, or not, one of these indications: as for any major decision in medicine, the benefits of the intervention must be weighed against the risk s.
As an example, guidelines state that early surgery should be considered in IE patients with large vegetation s , for the prevention of embolism 1 , 2. But they also outline literature data clearly demonstrating that the risk of embolism dramatically decreases following the start of appropriate antibiotics in patients with IE. As a consequence, the benefit of cardiac surgery for the prevention of embolism sharply decreases once an active anti-infective treatment is initiated, while the risk associated with cardiac surgery will remain grossly similar during the first days.
The situation is quite different when cardiac surgery is considered in patients with IE because of heart failure, or because of uncontrolled infection, as the situation will often get worse, with time, in patients who are not operated.
