Introduction: Ischemic and hemorrhagic stroke often complicate infective endocarditis (IE). Optimal timing of surgical intervention for IE with stroke remains controversial. We compared neurological outcomes of early and delayed valve surgery for IE complicated by stroke.
Methods: We reviewed 73 patients with acute IE by Duke Criteria who underwent brain imaging (CT, MRI, or cerebral angiogram) before valve operations between December 2014 and August 2016. Date of IE diagnosis was defined as date of antibiotic initiation. Early surgery was defined as valve replacement ≤14 days from date of IE diagnosis and delayed surgery as >14 days. Neurological complication is defined as delirium >72 hours after extubation and cessation of sedation, new ischemic or hemorrhagic stroke.
Results: Among 73 patients who underwent valve replacement surgery, 71 had evidence of stroke on imaging: 54 patients with acute or subacute ischemic infarct, 9 patients with evidence of intracerebral hemorrhage, and 8 patients with subarachnoid hemorrhage. The median time from IE diagnosis to surgery was 9 days. Forty patients had early surgery, and 33 patients had late surgery. Early surgery group had fewer patients with history of ischemic stroke (55% vs 79%, p=0.033), fewer acute or subacute infarcts on imaging (63% vs 88% p=0.016), but more native valve infections (73% vs 45%, p=0.018). The incidence of post-operative stroke was similar between both groups (2.5% vs 9%, p=0.32). In the delayed group, ischemic strokes occurred in 4 patients awaiting surgery. Hypertension and diabetes mellitus were associated with post-operative neurological complications (p<0.05), but pre-operative stroke on imaging was not.
Conclusion: In IE patients with acute stroke, early surgery does not appear to increase post-operative neurological complications.