Original article
Adult cardiac
Impact of Early Surgical Treatment on Postoperative Neurologic Outcome for Active Infective Endocarditis Complicated by Cerebral Infarction

Presented at the Forty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–Feb 1, 2012.
https://doi.org/10.1016/j.athoracsur.2012.04.027Get rights and content

Background

The optimal timing of surgical intervention for infective endocarditis (IE) with cerebrovascular complications remains controversial because the risk of perioperative intracranial hemorrhage is still unclear. The aim of this study was to investigate the prevalence of acute cerebral infarction (CI) in patients with IE and its hemorrhagic risk after valve operations.

Methods

We retrospectively evaluated 102 consecutive patients (35 with neurologic symptoms; 67 without neurologic symptoms) who underwent diffusion-weighted magnetic resonance imaging (DW-MRI) before valve operations for left-sided active IE between 2005 and 2010. The prevalence of acute CI and its postoperative neurologic outcome were evaluated.

Results

Acute CI was detected preoperatively in 64 of 102 (62.7%) patients. Of the 64 patients with acute CI, 34 underwent surgical treatment within 14 days after diagnosis of CI (early group), whereas the other 30 patients underwent operation after more than 14 days (delayed group). Postoperative CI deterioration was confirmed in 1 patient in each group. Furthermore, in 43 of the patients with acute CI who were followed with postoperative neuroimaging, hemorrhagic transformation was confirmed in only 1 patient in the delayed group. However new ectopic intracranial hemorrhage was confirmed in 2 patients in the early group and 3 patients in the delayed group.

Conclusions

The risk of postoperative hemorrhagic transformation of preoperative acute CI was low, even in patients who underwent early operation. Our data suggested that there is no benefit for delaying surgical treatment beyond 2 weeks to prevent hemorrhagic transformation in patients with CI. However ectopic intracranial hemorrhage sometimes occurs regardless of the timing of surgical treatment.

Section snippets

Patient Selection

This retrospective study protocol was approved by the institutional review board of each hospital as well as the Ethics Committee of Osaka University Hospital. Using the Osaka Cardiovascular Research Group database, 150 patients who underwent valve operations for active IE from 2005 to 2010 were identified. In these 150 patients, 102 patients who underwent preoperative cephalic DW-MRI evaluations before operation were enrolled in this study. The decision for MRI evaluation depended mainly on

Clinical Characteristics

Of 102 patients, 35 patients (34.3%) had preoperative CI symptoms. The relationships between preoperative CI symptoms and the prevalence of acute CI are shown in Fig 2. Nearly all patients with existing CI symptoms (34 of 35 [97.1%]) had acute CIs, whereas the 1 patient without acute CI had a subarachnoid hemorrhage. Even in patients without existing CI symptoms, 30 of 67 (44.8%) had at least 1 acute CI revealed by DW-MRI. In those patients with acute CI, the maximum length of the CIs was

Comment

Bacterial CI is a major complication of IE and about 20% to 30% of patients with IE have a neurologically symptomatic stroke [1, 6, 14, 15, 16]. However several previous studies that used MRI reported that the incidence of central nervous complications in patients with IE was much more frequent than their neurologic symptoms would suggest [9, 10, 17, 18]. In those reports, even in patients without a clinically overt stroke, MRI findings revealed that 40% to 70% had silent acute CIs. In the

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