Indications for Surgery for Elderly Patients with Infective Endocarditis

Sir—In his review of infective endocarditis (IE) in elderly patients, Dhawan [1] proposed a list of 8 situations that he considers to be “accepted indications” for surgery for patients with IE. We agree that age must not be a factor in determining whether a patient should undergo valvular surgery. Some situations are considered to be de facto indications for valvular surgery for patients with IE—namely, acute heart failure that is unresponsive to medical treatment, continuing bacteremia despite optimal antibacterial treatment, myocardial abscess, nonstreptococcal prosthetic valve endocarditis, and endocarditis due to an organism for which no curative treatment is available [2]. However, some of the situations included in Dhawan’s list are more arbitrary. For example, the traditional indications for valvular surgery for patients with IE, to avoid embolization, are not supported by evidence-based medicine, including the size of the vegetation (110 mm) and its location (anterior mitral leaflet) and the number of embolic events (11). Steckelberg et al. [3] showed that the effect of vegetation size on embolic potential was specific to the infecting organism, with large vegetations independently predicting embolic events only in streptococcal IE. The same group showed that the rate of embolic events drops dramatically during the first 2 weeks of treatment [3]. Thus, the size of the vegetation is not sufficient per se to drive the patient to the operating room. Likewise, 11 systemic embolic event is a surgical indication only if the embolisms occurred after the start of therapy and if large vegetations remained. Recent recommendations based on an extensive review of the data in the literature suggested that the strategy for surgical intervention to avoid systemic embolization in patients with IE remains specific to the individual patient, with the benefit being greatest during the early phase of IE, when embolic rates are higher [2]. Given that age is by far the most predictive factor for complications after cardiac surgery [4], we suggest that, to avoid high-risk surgery for selected patients for whom medical treatment may be sufficient, some of the indications proposed by Dhawan as “accepted indications” for surgery for patients with IE should instead be qualified as “situations in which surgery must be considered.”