A 65-year-old man with prosthetic aortic valve replacement (mechanical, 2 years ago) on warfarin presents with fever, malaise and a new regurgitant murmur. Blood cultures grow Staphylococcus aureus. TOE shows 12 mm mobile vegetation on the prosthetic valve with moderate perivalvular abscess. Which criterion determines the need for urgent surgical intervention in prosthetic valve endocarditis?

• A Perivalvular extension (abscess, fistula, pseudoaneurysm) is a Class I indication for surgery in PVE ✓
• B Vegetation size >10 mm is an absolute indication for surgery regardless of other findings
• C S. aureus bacteraemia alone mandates surgery without echocardiographic evidence of complications
• D Surgery should be deferred until 4–6 weeks of antibiotics are completed

Explanation

Per ESC 2023 and AHA guidelines, perivalvular extension of infection (abscess, pseudoaneurysm, fistula) in prosthetic valve endocarditis is a Class I indication for urgent surgical intervention, as it indicates uncontrolled infection that cannot be eradicated with antibiotics alone and risks aorto-cardiac fistula or complete heart block. Vegetation size alone (>10 mm) is a relative indication combined with risk of embolism. Surgery is best performed early (within days of diagnosis) when the patient is not in heart failure, rather than after prolonged antibiotics.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.