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Surgical aspects of bacterial endocarditis.

T. A. H. ENGLISH and J. K. ROSS Survival in patients with bacterial endocarditis has improved greatly since the introduction of antibiotics. The nature of the disease and indications for operative treatment have also changed. Forty patients with a previous history of bacterial endocarditis were treated surgically. Thirty-five were male and five female. Their ages ranged between 12 and 68 years, with a maximal incidence in the fourth, fifth, and sixth decades. Twenty-seven patients were operated on electively at varying intervals after completion of antibiotic therapy. One patient had an isolated mitral valve replacement and 26 had aortic valve replacements. Of these 26, 10 also required either repair (4) or replacement (6) of the mitral valve, and three others had closure of a ventricular septal defect secondary to the infective process. There were four deaths (mortality 15%). Seven patients underwent emergency operation for intractable heart failure before completion of antibiotic treatment. The interval between initiation of chemotherapy and surgery varied between 6 and 42 (mean= 20) days. Six of the seven survived operation and there was one late death (mortality 29°,). Six patients had infections on pre-existing cardiac prostheses. Three required emergency surgery. One patient with a large mycotic aneurysm of the aortic root died at operation. Another died five days after replacement of an infected aortic homograft valve by a Starr-Edwards prosthesis. The other four survived (mortality 33%/0). These included one patient who had triple valve replacement of aortic, mitral, and tricuspid prostheses affected by fungal endocarditis. There were no late infections. Endocarditis on cardiac prostheses is difficult to cure and reports of successful cases are rare. Our results indicate that surgical treatment has an important role both in the management of intractable heart failure consequent on bacterial endocarditis and in the eradication of infection. The timing of operation is crucial, particularly where valve destruction occurs early, and in this event operation may be necessary before completion of antibiotic therapy.