Timing of surgical intervention following acute stroke from infective endocarditis

Introduction

Neurologic sequelae are among the most common and devastating complications of infective endocarditis (IE) with an incidence varying between 10% and 75% [ ] and mortality ranging between 20% and 58% [ ]. In particular, mortality is higher in those with neurological complications than in those without [ , ], prompting careful attention to the management of patients with cerebral injuries. The spectrum of neurological sequelae with their approximate proportions includes ischemic stroke (70%) and intracerebral hemorrhage (10%). Less prevalent complications such as subarachnoid hemorrhage, meningoencephalitis, and intracerebral abscess each represent approximately 5% of cases. Currently, surgery is indicated in IE patients with uncontrolled sepsis despite antibiotics (such as those with aortic root abscess, ongoing fever, recurrent embolization events while on antibiotics) and those with severe valve regurgitation causing heart failure [ , ]. Based on these indications, approximately 50% of patients suffering from IE undergo cardiac surgery in combination with antibiotics therapy [ ]. However, in patients whose presentation was complicated by a stroke related to IE, a careful assessment of the risks and benefits is required.

The decision on surgery requires a balance between the urgency of the operation for cardiac indications and the perceived risk of exacerbating the neurological injury with intracerebral hemorrhage that complicates existing hemorrhagic stroke or hemorrhagic conversion of an ischemic stroke, hypotension, or further embolization related to cardiopulmonary bypass. Few large prospective studies have provided guidelines regarding the optimal timing for surgical intervention after stroke in IE. This chapter will cover the evolution of data assessing outcomes of cardiac surgery after a neurological event related to IE and provide current societies guidelines on the subject.

Ischemic stroke and timing of surgery

Looking closely at ischemic stroke, the most common neurological complication after IE, it is worth noting that earlier studies reported higher mortality with surgery performed in the acute phase after presentation. A multicenter retrospective study of 181 Japanese patients with IE who suffered a stroke showed decreased rate of neurological deterioration with delayed surgical intervention: 45.5% if surgery happened within 24 h, 43.8% if performed within a week, 16.7% if performed between 1 and 2 weeks after initial insult, and 2.3% if more than 4 weeks after an ischemic stroke [ ]. The authors concluded that cardiac operations can be safely conducted around 4 weeks after the initial infarction. Garcia-Cabrera et al. also reported that the risk of further cerebral injury was inversely correlated with time of surgical intervention: the risk of intracranial bleeding was 50%, 33%, and 20% if surgery was completed at <2, 2–3, and >3 weeks, respectively [ ]. Similar conclusions were reached by Angstwurm et al. who reported a 20% risk of neurological exacerbation with surgery performed within 3 days of presentation, 20%–50% risk if surgery between 4 and 14 days, and <10% if when surgery was done >14 days, and <1% if surgery was done >4 weeks after initial embolic event [ ].

However, data are conflicting as recent reports of early surgery following IE with stroke show no adverse outcomes, leading to a paradigm shift toward early surgery with special consideration for patients suffering for intracranial hemorrhage (ICH). In 2015, Sorabella et al. determined that in a cohort of patients who underwent early surgery defined at ≤14 days, there was no difference in rate of new postoperative stroke between patients with and without prior embolic stroke (9.3% vs. 7.1%, P = .57) [ ].

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