Commentary: The toll of complicated endocarditis and septic sequela: Old wives' tales and dogma

Abstract

Woldendorp and colleagues 1 present a patient with complicated bloodstream infections involving multiple components of the arterial tree. The authors were challenged by the multiplicity of septic foci in their patient but ultimately ended up with a successful short-term outcome. Their patient had evidence of brain, lung, and abdominal aortic infections that may have originated from an infected mitral valve. The authors used a combination of temporizing endovascular procedures and valve replacement to provide a successful intermediate-term outcome in a very complicated patient.The management of embolic strokes or other satellite lesions in the setting of a need for cardiac operations related to endocarditis is complex and mostly lacking evidencebased guidance. There are surprisingly few randomized trials or even systematic reviews that deal with managing multifaceted, associated lesions in patients with complex endocarditis. 2 Arguably, no part of cardiac surgery is more in need of an evidence base than the surgical treatment of complicated endocarditis. Despite optimal care for patients with endocarditis, 1-year mortality approaches 30%. 3 Treatment controversies abound, including questions about timing and sequencing of operations, control of peripheral sites of infection, and need for prolonged antibiotics.An old wives' tale was part of my training. The most senior surgeon pronounced, as if it were gospel, that 80% of things that embolize from the heart go to the brain. I have no idea where this piece of information came from, but there is probably some truth to it. The case report presented by Woldendorp and colleagues 1 supports this dogma, but it is unsettling that we may still rely on this type of unverified claim in dealing with complicated endocarditis.The peer review process gleaned a predictable range of critical comments to the article by Woldendorp and colleagues.