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Heart block during bacterial endocarditis: a review of the literature and guidelines for surgical intervention
Insights
Bacterial endocarditis with atrioventricular block can sometimes be managed medically. This case study suggests specific guidelines for surgical intervention in heart block patients with endocarditis.
Area of Science:
- Cardiology
- Infectious Diseases
Background:
- Management of bacterial endocarditis with atrioventricular block relies on limited, retrospective data.
- Aortic endocarditis with heart block is often presumed to indicate myocardial abscess and necessitate early surgery.
Observation:
- A patient with aortic and mitral endocarditis developed transient first-degree heart block.
- The patient was successfully treated with antibiotics alone, without surgical intervention.
Findings:
- Heart block in bacterial endocarditis does not always mandate surgery.
- Proposed guidelines for surgical consideration include new/progressive heart block, aortic valve involvement, persistent block despite antibiotics, and exclusion of other causes.
Implications:
- These guidelines may help select endocarditis patients with heart block who can be managed non-surgically.
- Further research is needed to refine treatment strategies for this complex patient population.
Abstract:
The management of patients with bacterial endocarditis complicated by atrioventricular block is based on uncontrolled data, mostly from retrospective surgical and autopsy series. It is difficult to advance broad recommendations on the basis of such a biased population. Nevertheless, it is the firm opinion of many experienced clinicians that heart block developing as the result of aortic endocarditis signals myocardial abscess formation, and thereby is an indication for early surgery. I present a patient with aortic and mitral endocarditis in whom first degree heart block developed and then disappeared over five days; she was successfully managed with medical therapy alone. This case illustrates that some patients with endocarditis and heart block will not require surgery. In this setting, I propose the following guidelines in selecting patients for operation: 1) the observed appearance or progression of heart block; 2) the presence of aortic valve involvement; 3) the persistence of heart block, despite at least one week of optimal antibiotics; and 4) the elimination of other potential causes of conduction abnormalities.