Introduction
Infective endocarditis (IE) is the most serious and debilitating consequence of heart valve disease, nearly usually deadly if left untreated. 1 It has a tendency to aggravate cardiac and extra-cardiac locations. 2 Around half of individuals experience serious problems that necessitate surgery.1 Between 1969 and 2000, the rate of surgery for IE climbed by 7% every decade, and by 1.7 fold between 2011 and 2018, paralleling a decline in mortality. 2 Heart failure (HF), which is most frequently caused by left valvular regurgitation, complicates 30%–40% of patients with IE and is the major rationale for early surgery in at least 50%–60% of IE patients.2 There is no advantage to waiting for the development of heart failure symptoms in individuals with native valve endocarditis (NVE) and severe valve regurgitation. 1 Acute stroke, the most prevalent embolic consequence of IE, occurs in 10-23 percent of patients and is a poor predictor of prognosis and survival.1,2
According to current American Association for Thoracic Surgery (AATS) recommendations, surgery should be considered in the presence of (1) HF, (2) features suggestive of a high risk of embolization, and (3) uncontrolled infection, and surgery should not be postponed if a surgical rationale is obvious.1,2 The development of large, mobile vegetations (>10 mm), particularly on the mitral valve and during antibiotic treatment, is symptomatic of a high-risk embolization state.1Even in the absence of embolization, the presence of HF, significant valvular dysfunction, chronic infection despite proper antibiotic treatment, or perivalvular abscess with considerable vegetation (>10 mm) are grounds for early surgery.1,2 A special difficulty is surgical scheduling in individuals who have previously suffered a stroke.2
AATS guidelines advocate postponing surgery for 1 to 2 weeks in patients who have suffered an ischemic stroke and for 3 to 4 weeks in patients who have suffered a hemorrhagic stroke. Additionally, these recommendations state that the timing of surgery should be determined by evaluating the necessity of surgery and the danger of new emboli during the waiting time against the risk of developing stroke expansion, brain edema, or intracranial hemorrhage (ICH) during the procedure.3 According to the 2006 American Heart Association (AHA) recommendations, it is permissible to postpone surgery for at least four weeks in patients who have suffered a significant stroke or ICH (Class IIa, Level of evidence C). 2,4Cardiovascular surgery is not contraindicated following an ischemic stroke, however the data about the ideal timing is contradictory due to the absence of randomized controlled trials to guide current practice.1
IE accompanied with septic emboli is a challenging medical issue. In 40% of patients, splenic embolism results in splenic infarction, whereas 5% develop splenic abscess. 4,12 Ideally, splenectomy is performed prior to valve replacement (VR) to minimize infection of the implanted valve. 4