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IE with MAIVF Abscess — EECC MCQ

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HardValvular Heart DiseaseIE with MAIVF AbscessEECC

A 48-year-old man with infective endocarditis of the native mitral valve has a paravalvular abscess extending into the mitral-aortic intervalvular fibrosa (MAIVF). He remains febrile despite 2 weeks of appropriate IV antibiotics. What is the surgical indication?

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Correct answer: C — Uncontrolled infection with perivalvular extension (abscess, pseudoaneurysm, fistula) is a Class I indication for urgent surgery — the MAIVF location is particularly concerning as it can create intracardiac fistulae and destroy the structural integrity of the cardiac skeleton

Perivalvular extension (abscess, pseudoaneurysm, fistula) complicates 10-40% of IE cases and represents uncontrolled infection — a Class I indication for urgent surgery per the 2023 ESC IE Guidelines. The mitral-aortic intervalvular fibrosa (MAIVF) — the fibrous continuity between the anterior mitral leaflet and the aortic valve — is a high-risk location because: (1) it is avascular (antibiotics penetrate poorly); (2) abscess can spread to involve both valves; (3) fistula formation can create intracardiac shunts (LV-LA or LV-aortic fistula); (4) conduction system destruction (proximity to the AV node/His bundle). Surgical indicators in IE (Class I): (1) HF from acute valvular dysfunction; (2) uncontrolled infection (perivalvular extension, persistent bacteraemia >7 days); (3) prevention of embolism (large vegetations >10 mm with embolic events).

Reference: ESC (2023): IE Guidelines