Going all in: left ventricular outflow tract, aortic root and intervalvular fibrous body reconstruction for extensive infective endocarditis

The most fundamental principle of emergency surgery is to perform the safe operation, the one that brings the patient out of the operating room alive. Specific to infective endocarditis (IE), the most important surgical goal is for radical resection of all infected structures, including any pre-existing prosthetic material, to enable a reconstruction without residual nidi of infection [1, 2]. There is an innate tension between these 2 principles; a more complete resection necessitates a more complex and higher-risk operation. Infective endocarditis is an infection of the endocardium, the innermost lining of the heart and heart valves. Its incidence seems to be increasing, from 9.3 cases per 100 000 in 1998 to 15 cases per 100 000 as of 2011 [3]. Over time, the presentation of IE has evolved; the incidence of prosthetic valve endocarditis (PVE) has increased [2, 4, 5], while Staphyloccocus aureus invasion [2, 5, 6] has become the most common identifiable aetiology. Mortality is higher in cases of PVE compared to native valve endocarditis [7–9]. Both PVE [10] and S.aureus-associated IE [7] typically result in more extensive infection, thereby necessitating more aggressive resection and repair [1]. Overall, IE is the cardiac valve disease with the highest operative mortality. Despite advancing surgical techniques and perioperative care, mortality remains high, even in experienced IE repair centres [1–3, 6, 8, 9, 11, 12]. However, extensive IE is usually fatal in the absence of any invasive treatment [1].