tailieunhanh - Chapter 118. Infective Endocarditis (Part 13)

Timing of Cardiac Surgery In general, when indications for surgical treatment of infective endocarditis are identified, surgery should not be delayed simply to permit additional antibiotic therapy, since this course of action increases the risk of death (Table 118-6). Delay is justified only when infection is controlled and congestive heart failure is fully compensated with medical therapy. After 14 days of recommended antibiotic therapy, excised valves are culture-negative in 99% and 50% of patients with streptococcal and S. aureus endocarditis, respectively. Recrudescent endocarditis involving a new implanted prosthetic valve follows surgery in 2% of patients with culture-positive native valve. | Chapter 118. Infective Endocarditis Part 13 Timing of Cardiac Surgery In general when indications for surgical treatment of infective endocarditis are identified surgery should not be delayed simply to permit additional antibiotic therapy since this course of action increases the risk of death Table 118-6 . Delay is justified only when infection is controlled and congestive heart failure is fully compensated with medical therapy. After 14 days of recommended antibiotic therapy excised valves are culture-negative in 99 and 50 of patients with streptococcal and S. aureus endocarditis respectively. Recrudescent endocarditis involving a new implanted prosthetic valve follows surgery in 2 of patients with culture-positive native valve endocarditis and in 6-15 of patients with active prosthetic valve endocarditis. These risks are more acceptable than the high mortality rates that result when surgery is inappropriately delayed or not performed. Among patients who have experienced a neurologic complication of endocarditis further neurologic deterioration can occur as a consequence of cardiac surgery. The risk of significant neurologic exacerbation is related to the interval between the complication and the surgery. Whenever feasible cardiac surgery should be delayed for 2-3 weeks after a nonhemorrhagic embolic stroke and for 4 weeks after a hemorrhagic embolic stroke. A ruptured mycotic aneurysm should be clipped and cerebral edema allowed to resolve before cardiac surgery. Antibiotic Therapy after Cardiac Surgery Bacteria visible in Gram-stained preparations of excised valves do not necessarily indicate a failure of antibiotic therapy. Organisms have been detected on Gram s stain or their DNA has been detected by PCR in excised valves from 45 of patients who have successfully completed the recommended therapy for endocarditis. In only 7 of these patients are the organisms most of which are unusual and antibiotic resistant cultured from the valve. Despite the detection of

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