Utility of Brain Magnetic Resonance Imaging in the Surgical Management of Infective Endocarditis
Introduction
Infective endocarditis (IE) is associated with in-hospital mortality rates as high as 26%.1 Neurologic complications of IE include stroke, mycotic aneurysm, brain abscess, intracerebral hemorrhage (ICH), and meningitis. Once found, a stroke may delay the timing of cardiac valve replacement surgery, potentially leading to a worse prognosis.2, 3 Guidelines by the Society of Thoracic Surgeons advise to wait at least 4 weeks following an embolic ischemic or hemorrhagic stroke to replace an infected valve, owing to the presumed increased risk of perioperative ICH in the setting of procedural anticoagulation and cardiopulmonary bypass.4, 5, 6
The optimal timing of valve repair in IE is one of the most complex decisions in cardiovascular surgery, and neurologists are often involved. Moreover, brain imaging, particularly magnetic resonance imaging (MRI), as it is commonly known to be more sensitive than computed tomography in detecting embolic phenomena, is frequently obtained in patients with IE to detect or predict complications, yet its ability to impact decisions that may alter clinical outcomes is unknown. The existing literature assessing the utility of brain MRI in endocarditis consists primarily of descriptive neuroimaging studies of small cohorts. These studies have not assessed the value of brain MRI in guiding clinical decisions and have not examined whether obtaining a preoperative MRI is associated with better postoperative outcomes.5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 In this study, we evaluated the impact of brain MRI findings on the clinical management and functional outcomes in patients with right- or left-sided IE. We hypothesized that there were no significant differences in clinical outcomes between patients who received MRI preoperatively and those who did not, thus questioning the value of obtaining an MRI and the consequent effects imaging findings may have on valve replacement.
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Patient Population and Study Design
The Mayo Clinic Institutional Review Board approved this study. We identified 2123 patients with suspected or confirmed IE who received care at Mayo Clinic in Rochester, Minnesota, between January 1, 2007 and December 31, 2014. Patients excluded were those without definite or possible IE, lack of a neurologic assessment, lost to follow-up, or with incomplete data. This resulted in 364 patients with IE who were included in the study. Patients were divided into 2 groups: those who received
Results
Cardiac valve replacement surgery was performed in 195 of 364 (53.6%) patients, including 95 of 195 (48.7%) patients who had preoperative MRI (Fig 1). Patient characteristics and subgroup analyses between preoperative MRI and no preoperative MRI groups are displayed in Table 1. Patients who received preoperative MRI were less likely to have congestive heart failure (OR = .47; 95% CI, .24-0.94; P = .03) and more likely to have preoperative neurologic symptoms (OR = 12.92; 95% CI, 5.98-27.93; P <
Discussion
Neurologic complications of IE have been well described as sequelae of cardioembolic events with resultant arterial thrombus, hemorrhage, and arterial or meningeal infection.23, 24 Such events are commonly associated with worse prognosis. Previous studies have not addressed the impact of imaging findings on functional outcomes. The key finding of our study is that preoperative MRI findings were not linked to clinical outcomes. This emphasizes the debate of whether to obtain brain MRI in
Conclusions
In hospitalized patients with IE, preoperative brain MRI findings did not affect outcomes of valve replacement surgery. In particular, microhemorrhages on preoperative MRI were not associated with the development of postoperative ICH. Although the clinical utility of brain MRI in patients with IE deserves further investigation, our results suggest that brain MRI findings—particularly in those obtained in the absence of neurologic symptoms—may not be useful in defining the optimal timing for
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Cited by (0)
Author contributions: Tia Chakraborty, MD, authored, conceptualized, analyzed and acquired data, drafted, and revised the manuscript. She had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Eugene Scharf, MD, authored, conceptualized, acquired data, drafted, and revised the manuscript. Alejandro A. Rabinstein, MD, authored, conceptualized, drafted, and revised the manuscript. Daniel DeSimone, MD, authored, designed, conceptualized, acquired data, drafted, and revised the manuscript. Abdelghani El Rafei, MD, acquired data and revised the manuscript. Waleed Brinjikji, MD, authored and revised the manuscript. Larry M. Baddour, MD authored, conceptualized, drafted, and revised the manuscript. Eelco Wijdicks, MD, PhD, authored, conceptualized, drafted, and revised the manuscript. Walter Wilson, MD, authored and revised the manuscript. James M. Steckelberg, MD, authored and revised the manuscript. Jennifer E. Fugate, DO, authored, designed, conceptualized, drafted, and revised the manuscript.
All authors report no disclosures.