17125 Infective Endocarditis Surgery

Overview

Infective endocarditis (say: in-FEK-tiv en-doh-kar-DY-tis) is an infection of the inner lining of the heart, most often the heart valves. Heart valves are the one-way flaps that keep blood flowing in the right direction. When germs — usually bacteria — get into the bloodstream and settle on a valve, they can grow into small clumps and damage the valve. Most people are treated with antibiotics in hospital. Surgery is needed when the infection is too severe for medicines alone, or when the valve has been badly damaged. This article explains what that surgery involves, why it may be suggested, and what recovery can look like.

It is uncommon — roughly a few cases per 100,000 people each year in countries like the UK. But it is a serious infection that always needs hospital care. Somewhere between about 1 in 5 and 1 in 2 people with endocarditis end up having surgery, depending on which valve is affected and how unwell they are.

It can affect anyone at any age. It is more common in people who already have a heart valve problem, an artificial (prosthetic) heart valve, or certain heart conditions they were born with. It is also more common in people who inject drugs, people with long-term lines or tubes in their veins, and people having dialysis. Risk rises with age.

Symptoms

Common symptoms

• Fever, often with chills or shaking
• Sweating, especially at night
• Feeling very tired or lacking energy
• Shortness of breath, especially with activity
• Weight loss you did not intend
• A new heart murmur — an unusual sound your doctor hears through a stethoscope
• Aching joints or muscles
• Small red or purple spots on the skin, or tiny marks under the fingernails
• Swelling in the legs or ankles
• A cough that does not settle

Symptoms in children

• Endocarditis is rare in children. When it happens, it is usually in a child with a heart condition they were born with, or a long-term line in a vein.
• A fever that keeps coming back or does not settle
• Poor feeding or poor weight gain
• Unusual sleepiness or irritability
• Fast breathing or getting out of breath easily
• Sweating during feeds

Symptoms in older adults

• A high fever may be missing — the temperature can be only mildly raised or even normal
• Confusion, drowsiness, or a general decline in how someone usually is
• Tiredness, poor appetite and weight loss
• Breathlessness or swelling in the legs
• Falls or reduced mobility
• Because the signs can be vague, endocarditis in older adults can take longer to spot

Causes

Main causes

• Germs, usually bacteria, getting into the bloodstream and settling on a heart valve or the heart lining
• A damaged or artificial valve gives germs an easier place to stick and grow
• Common entry points include infected teeth or gums, skin infections and wounds, infected drips or lines in a vein, and some gut or urine infections
• Sometimes no clear entry point is ever found
• Fungi can cause it too, though this is much rarer

Risk factors

• An artificial (prosthetic) heart valve
• Having had endocarditis before
• A heart condition you were born with
• Damaged valves, for example after rheumatic fever
• Older age
• Injecting drugs
• Long-term tubes or lines in a vein, or dialysis treatment
• Poor dental health or gum disease
• A weakened immune system
• Conditions affecting the heart lining, such as certain heart muscle problems

When to see a doctor

See a doctor urgently if:

• You have a heart valve problem or an artificial valve and you develop a fever — get medical advice the same day
• Fever with breathlessness, chest pain, confusion or feeling very unwell
• A fever that lasts more than a few days without a clear reason
• You feel feverish and generally unwell after dental treatment or another procedure and you are in a higher-risk group

Book a routine appointment if:

• Tiredness, weight loss or night sweats that you cannot explain
• A heart murmur or a change in your usual heartbeat
• Before dental work or a procedure, if you have had valve surgery — ask whether you need any extra protection
• Any concerns after heart surgery, such as a wound that looks red or leaks, or a fever

Diagnosis

There is no single test for endocarditis. Doctors put together several clues: your symptoms, a physical examination, blood tests, blood cultures (samples of blood used to grow and identify any germs), and an echocardiogram — an ultrasound scan that shows the valves and heart lining. You will usually be seen in hospital, and a cardiologist (heart specialist) and sometimes a heart surgeon will be involved.

Tests that may be done

• Blood tests to look for signs of infection and inflammation
• Blood cultures — several blood samples taken at different times to try to grow the germ
• An echocardiogram done through the chest, using sound waves to picture the heart
• Sometimes a transoesophageal echocardiogram — a small probe passed gently down the throat for clearer pictures
• An ECG (heart tracing) and sometimes a chest X-ray
• Scans such as CT or MRI if doctors want to check for infection spreading or complications

What to expect at your appointment

You will usually be admitted to hospital. Expect a number of blood samples over a day or two, a heart scan, and questions about recent dental work, skin infections, procedures, and any drugs you use. If surgery is being considered, the heart surgeon will explain the risks and benefits, what the operation involves, and what recovery will look like. It is fine to bring someone with you and to write down your questions.

Treatment

Treatment has two parts. First, antibiotics given into a vein in hospital for several weeks to fight the infection. Second, if the infection or the valve damage is too serious, heart surgery to clean out the infection and repair or replace the valve. Surgery is usually done as an urgent operation, but a planned operation may be possible if you are stable.

Self-care at home

• Take any medicines exactly as prescribed and finish the full course
• Keep all follow-up appointments, including blood tests and heart scans
• Care for your wound as your care team shows you, and keep it clean and dry
• Build activity back up slowly, a little more each day
• Attend cardiac rehabilitation if it is offered — it helps you get fitter and feel more confident
• Look after your teeth and gums, and tell your dentist about your heart valve history
• Carry any medical alert card or wear any alert jewellery your team gives you
• Stop smoking and keep alcohol within recommended limits
• Ask your team before starting any new medicine, including over-the-counter ones or supplements

Medical treatments

The main medical treatment is a course of antibiotics given through a drip in hospital, usually for several weeks, sometimes longer. Your team will keep checking your temperature, blood tests and heart scans to see whether the infection is clearing. They will also treat the source of the infection — for example, a dental or skin problem — and manage problems like heart failure or an irregular heartbeat with appropriate medicines. If you have a mechanical valve after surgery, you will need long-term blood-thinning medicine, and your team will talk you through this carefully.

When is surgery considered?

Surgery is considered when antibiotics alone are not enough. Common reasons include: heart failure caused by a badly leaking valve; an infection that keeps going despite the right antibiotics; large clumps of infection (called vegetations) that could break off and travel to the brain or other organs; an abscess or a hole forming near a valve; an infected artificial valve; or certain hard-to-treat germs such as fungi. The decision is made together by your medical and surgical teams, taking your overall health and wishes into account. The operation usually involves removing infected tissue and either repairing the valve or replacing it with a new valve — your surgeon will explain which type is suitable for you.

Living with this condition

The first few weeks after surgery are for resting and healing, with gentle activity and short walks. Tiredness is normal and improves gradually over weeks to months. Many people return to work after about 6 to 12 weeks, depending on the job and how the operation went. You will have regular check-ups, blood tests and heart scans at first, then less often. If you have a mechanical valve, you will need regular blood tests to check your blood-thinning medicine is at the right level.

Lifestyle tips

• Keep up with dental check-ups and tell your dentist about your valve surgery
• Wash your hands well and clean and cover cuts and grazes
• Avoid tattoos, piercings and cosmetic injections if your doctor advises against them
• Stop smoking — ask for support, as it is easier with help
• Keep alcohol within recommended limits
• Wear a medical alert bracelet or carry a card saying you have a heart valve replacement
• Ask your team about any travel, sport or work plans before you restart them

Diet and exercise

Eat a balanced, varied diet with plenty of vegetables, fruit, wholegrains and lean protein, and go easy on salt if your team advises it. After the wound has healed and your team says it is safe, aim for regular gentle activity such as walking, building up over weeks. Cardiac rehabilitation programmes are a safe, supervised way to get fitter — they are well worth joining. Avoid heavy lifting and strenuous exercise until you are told it is fine.

Mental health and emotional wellbeing

It is very common to feel anxious, low or shaken after a serious infection and heart surgery. Sleep can be disturbed, and some people find themselves worrying about every twinge. These feelings usually ease, but they deserve attention rather than being brushed aside. Talking to family, friends, your GP or a counsellor helps. If you ever have thoughts of harming yourself, please contact your local emergency number or a crisis support line in your country straight away — you deserve immediate help.

Prevention

You cannot fully prevent endocarditis, but you can lower the risk. The most important steps are looking after your teeth and gums, treating skin infections and wounds promptly, and avoiding unnecessary lines or drips into your veins. If you are in a higher-risk group — for example you have an artificial valve or have had endocarditis before — your doctor or dentist may recommend a short course of antibiotics before certain dental or medical procedures. Never arrange this yourself; ask your own clinical team, as guidance only applies to specific people and procedures.

Vaccines

There is no vaccine against infective endocarditis itself. Keeping up to date with routine vaccinations — including flu and pneumonia vaccines if your doctor recommends them — helps prevent other infections that can sometimes spread.

Screening programmes

There is no routine screening test for endocarditis. Regular dental check-ups do act as a form of prevention, because healthy teeth and gums are one of the best ways to keep germs out of your bloodstream.

Complications

If left untreated

• Heart failure, when a damaged valve stops the heart pumping blood properly
• Stroke or other organ damage if clumps of infection break off and travel in the blood
• An abscess (a pocket of pus) around the valve, or a hole forming in the heart
• An irregular heartbeat
• Kidney problems
• A body-wide infection (sepsis), which is life-threatening
• In the most serious cases, death — which is why prompt treatment matters so much

Long-term outlook

The outlook is good for many people, especially when the infection is found early and treated promptly. Surgery for endocarditis is a big operation, and recovery takes time, but most people who have it go back to a normal or near-normal life. You will be followed up by your heart team, and any lasting effects will be managed. It is reasonable to feel hopeful.

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