Table 4. Surgical indications: prevention of embolism.
| Guidelines | Recommendation | Level/class of evidence |
|---|---|---|
| ESC guidelines | Aortic or mitral NVE or PVE with persistent vegetations >10 mm after one or more embolic episode despite appropriate antibiotic therapy—timing of surgery: urgent | I/B |
| Aortic or mitral NVE with vegetations >10 mm, associated with severe valve stenosis or regurgitation, and low operative risk—timing of surgery: urgent | IIa/B | |
| Aortic or mitral NVE or PVE with isolated very large vegetations (>30 mm)—timing of surgery: urgent | IIa/B | |
| Aortic or mitral NVE or PVE with isolated large vegetations (>15 mm) and no other indication for surgery. Surgery may be preferred if a procedure preserving the native valve is feasible—timing of surgery: urgent | IIb/B | |
| Right-sided IE: Persistent tricuspid valve vegetations >20 mm after recurrent pulmonary emboli with or without concomitant right heart failure | IIa/C | |
| AHA/ACC guidelines | Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) may be considered in patients with native valve endocarditis who exhibit mobile vegetations greater than 10 mm in length (with or without clinical evidence of embolic phenomenon | IIb/B |
| Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is reasonable in patients with IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy | IIa/B |
ESC guidelines show greater stratification in choosing the correct intervention timing, in assessing the size of the vegetation and the functioning of the valve on which it is positioned. The ESC guidelines also highlight a different indication in relation to the occurrence of embolic events. The AHA/ACC guidelines give greater importance to the possibility of reducing the size of vegetation with antibiotic therapy. IE, Infective endocarditis; ESC, European Society of Cardiology; AHA, American Heart Association; ACC, American College of Cardiology; NVE, native valve endocarditis; PVE, prosthetic valve endocarditis.