Endocarditis Surgery: Timing, Bleeding and Vasoplegia

Last episode we diagnosed endocarditis. This one operates — and it opens on the number that reframes the whole disease: more than half of patients with endocarditis will meet the criteria for cardiac surgery. Half of them go through one of the biggest operations a human being can have, while septic, followed by a long intensive care stay and very often a tracheostomy. And the outcomes remain poor — prosthetic valve endocarditis carries around a 27% one-year mortality, with device-related disease closer to a one in four risk of not getting home at all. As Mike puts it, we don't really tell people that when we consent them for a heart valve. Please note: the drugs and doses discussed are Wythenshawe-specific local practice. Take the principles, and check your own guidelines. We start with the endocarditis team — a couple of mornings a week, regional cases discussed, antibiotics and imaging reviewed, and surgery arranged when indicated. If you're the registrar in a district general hospital with a patient you think has endocarditis, there is a route in: ring your cardiac centre and ask for the endocarditis MDT. Don't sit on them. Then the indications for surgery — prosthetic material, severe regurgitation, uncontrolled infection and embolic risk, with the vegetation sizes worth memorising — and the argument that matters most: timing. Guidance says emergency or urgent, and some read that as "theatre now". The case made here is that there is almost always a twenty-four hour window to bring that patient to intensive care first: filter them, take fluid off, start inotropes, fix the antibiotics, correct the metabolic mess. Because if you take a grossly overloaded septic patient, put them on bypass and repair their valve, they will not come off bypass. That day isn't a delay. It's what makes the operation survivable. In theatre, the thing you must not forget: send tissue for 16S PCR. For a patient whose blood was sterilised by antibiotics before anyone took proper cultures, the valve in the surgeon's hand may be the only remaining chance to name the organism — and it decides their treatment for the next six weeks. We cover repair versus replacement (aortic valves tend to be replaced; up to 80% of mitral valves can be repaired), and then two traps. First, these patients are thrombotic rather than coagulopathic — until they bleed, when it can be catastrophic. Second, heparin resistance: many arrive on a heparin infusion having depleted their antithrombin, so the answer is antithrombin III, not more heparin. Treat the cofactor, not the drug. Then cytokine absorbers — what they are, why an endocarditis patient in particular gets one, and an honest account of the evidence, which is essentially "it probably won't harm and the rationale is strong". Vasoplegia gets the full stepwise ladder, with the warning that matters: be certain it isn't a low cardiac output state before you give methylene blue. We finish with post-operative ECMO, and a patient the team had agreed wasn't for mechanical support — until the decision was reversed on the table, and they went home. Chapters (00:00) Cold open — more than half need surgery (01:20) The outcomes nobody mentions at consent (02:30) The endocarditis team, and how to get a patient discussed (04:00) Indications for surgery, and the vegetation sizes (05:40) When not to operate (06:40) The timing argument, from both sides (08:40) Why the twenty-four hours makes the operation survivable (10:00) Send the tissue: 16S PCR (11:20) Repair or replace? (12:30) Thrombotic, not coagulopathic (13:40) Heparin resistance — treat the cofactor (15:00) Cytokine absorbers, and honest evidence (16:30) Vasoplegia, and the methylene blue warning (18:00) Post-operative ECMO, and a decision reversed (19:30) Prophylaxis for non-cardiac surgery (20:40) Wrap-up Key takeaways More than half of patients with endocarditis meet the criteria for surgery, and the outcomes remain poor Every suspected case should be discussed with an endocarditis team — there is a route in from any hospital Operate for prosthetic material, severe regurgitation, uncontrolled infection or embolic risk; vegetations over 10 mm after an embolus, or over 15 mm in isolation Surgery is contraindicated with intracranial haemorrhage or coma, but the restrictions around stroke have relaxed There is almost always a twenty-four hour window to optimise — filter, inotropes, antibiotics, fluid off — and that isn't a delay, it's what lets them come off bypass Send tissue for 16S PCR: it may be the only chance to identify the organism Aortic valves tend to be replaced; up to 80% of mitral valves can be repaired These patients are thrombotic rather than coagulopathic — but when they bleed it can be catastrophic Heparin resistance is an antithrombin problem: give antithrombin III, not more heparin Cytokine absorbers are used on rationale rather than randomised evidence — and they adsorb drugs too Two arterial lines, and climb the vasoplegia ladder — but be certain it isn't low cardiac output before giving methylene blue Needing ECMO after endocarditis surgery is a poor prognostic sign — but stay humble, because patients surprise us References / further reading Charlesworth M, Williams BG, Ray S. Infective endocarditis. BJA Education 2023 Delgado V et al. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023 Pettersson GB, Hussain ST. Current AATS guidelines on surgical treatment of infective endocarditis. Ann Cardiothorac Surg 2019 Kang DH et al. Early surgery versus conventional treatment for infective endocarditis. NEJM 2012 Boer C et al. EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. 2017 Levin RL et al. Methylene blue reduces mortality and morbidity in vasoplegic patients after cardiac surgery. Ann Thorac Surg 2004 National Institute for Health and Care Excellence. Prophylaxis against infective endocarditis (CG64) Follow the podcast Bluesky: @cardiacoutput.bsky.social X: @CardiacOutputMC If you've found this useful, a follow or a share genuinely helps other trainees find it — and do get in touch if there's a topic you'd like covered. This podcast is for medical education for healthcare professionals. It is not clinical advice. All drugs and doses discussed reflect local Wythenshawe practice at the time of recording — always follow your own centre's guidelines and current local policy.