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Emergency Surgery for IE with Heart Failure — EECC MCQ

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ModerateValvular Heart DiseaseEmergency Surgery for IE with Heart FailureEECC

A 40-year-old man presents with fever, new MR murmur, and splinter haemorrhages. Blood cultures grow Staphylococcus aureus. TOE shows a 14 mm vegetation on the anterior mitral leaflet with a ruptured chordae and flail segment. He has acute pulmonary oedema. According to ESC guidelines, what is the indication for urgent surgery?

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Correct answer: C — Acute severe valvular regurgitation causing refractory heart failure (pulmonary oedema) despite medical therapy — this is a Class I indication for emergency/urgent surgery in IE

The 2023 ESC IE Guidelines define three main categories of surgical indication in active IE: (1) Heart failure: acute severe AR or MR causing refractory pulmonary oedema or cardiogenic shock is a Class I emergency surgical indication — surgery should not be delayed for antibiotic 'sterilisation'; (2) Uncontrolled infection: persistent bacteraemia >7 days, perivalvular abscess, fistula, mycotic/fungal IE; (3) Prevention of embolism: vegetation >10 mm with embolic event, or >15-30 mm (depending on location/morphology). This patient has acute severe MR (flail leaflet) with pulmonary oedema — the most urgent surgical indication. S. aureus native valve IE also has a high early mortality (30-40%) and surgery should be performed within days.

Reference: ESC (2023): Guidelines on Infective Endocarditis