Early and Mid-Term Outcomes Following Surgical Management of Infective Endocarditis with Associated Cerebral Complications: A Single Centre Experience

Background

Surgical management of patients with infective endocarditis (IE) who have suffered preoperative cerebrovascular complications remains controversial. This study evaluates the impact of timing from stroke to valvular surgery on the early and mid-term neurological sequelae, functional status and quality of life in this high-risk group of patients with IE.

Method

Data on 13/108 (12%) patients with IE who suffered cerebrovascular complications during the period 1998–2009 was prospectively collected. Mean follow-up was 37.2 months (100% complete).

Results

Three of 13 (23%) suffered haemorrhagic stroke, 10/13 (77%) had embolic events (nine, stroke; one, TIA). The clinical diagnosis was made by a neurologist in 6/13 (46%) and confirmed in all by CT scan. Twelve of 13 had motor deficit involving MCA territory. Thirty-day mortality was 2/13 (one, cardiac; one, neurological) with no late deaths. The mean time from embolic stroke to surgery was 2.3 weeks (range 3–60 days). The reason for operating on eight patients in less than two weeks was heart failure in five, uncontrolled sepsis, AMI and TIA (one each). 2/8 (25%) suffered additional postoperative neurological events (one, brain death, one, new MCA stroke). On follow-up of the remaining eight patients with embolic events, five had improved neurology and three had stable neurology. The mean time to surgery from haemorrhagic stroke was 5.8 weeks (range 3–60 days). Deficit improved in two patients (<1 week, 1; >8 weeks, 1). On follow-up the NYHA class was I–II in 6/11 (56%). The EQ-5D questionnaire was used to assess quality of life. Mean index for the group was 0.67 using the US preference-weighted index score (SD 0.27).

Conclusions

Results regarding timing for haemorrhagic stroke cannot be defined from the small numbers. Timely surgical intervention (embolic greater than two weeks and preferably four weeks in absence of heart failure) is associated with acceptable neurological outcome, functional class and quality of life.

Keywords: Infective endocarditis, Cerebrovascular complications, Surgical management