Deciding on When and How To Operate

The role of timing in the surgical management of IE cannot be overemphasized. Operating too soon carries a higher risk due to the unstable condition of the patient, excessive cardiac tissue friability (resulting in early postoperative peri-prosthetic leakage), and greater possibility for recurrence (due to residual, minimally diseased foci that might go unnoticed during surgery). An undue delay in operation, on the other hand, may result in life-threatening sepsis or extensive structural destruction with irreversible damage to cardiac function. Timing in active IE can often be no less challenging than determining the type of the operation.

The choice of whether to repair the native valve or to replace it with a prosthetic valve— and in cases of replacement, whether to implant a bioprosthetic or mechanical valve—is ultimately verified intra-operatively. In multiple valve involvement, a proper combination of repair and replacement procedures may be used as appropriate for the individual case. Surgical techniques can vary along a wide spectrum of complexity, from the simple stitching repair of a well-defined leaflet perforation to an extensive aortic root replacement, and from an isolated mitral valve replacement to a complex valve and annulus reconstruction, including the correction of septal defects, fistula, aneurysm/ pseudoaneurysm, or atrioventricular discontinuity. Plans will occasionally require modification or refinement based on the findings in the operating room or due to technical issues encountered intraoperatively.

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