Preoperative stroke in infective endocarditis neither independently affects mortality nor should it affect timing of surgery

Background: Infective endocarditis (IE) requiring surgery is associated with high mortality (10-36%) and the frequent occurrence of stroke is considered a significant preoperative risk factor. When the need for surgery is established, current recommendations suggest operating early rather than wait. When cerebrovascular complications (CVC) occur, a 72-hour window has been suggested for surgery timing. We aimed to analyze the impact of preoperative CVC in our patient population and the related timing of surgery on outcome.

Methods: We retrospectively reviewed all charts from patients operated for left-sided endocarditis in our center between January 2010 and April 2013. We performed Chi-Square and multivariable analyses to assess the impact of preoperative stroke and the timing of surgery on outcome.

Results: A total of 174 patients underwent surgery for IE during this period. The group was characterized by the preoperative presence of abscess in 32%, septic shock in 24%, heart failure in 19%, prosthetic endocarditis in 21% and mechanical ventilation in 17%. The most common organisms identified were staph. aureus (20.7%), enterococcus (15.5%), and strept. viridans (13.2). 21% were culture-negative. Total mortality was 22.4%. One third of all patients had a preoperative CVC (n = 57). Surgery was performed within 72 h after the diagnosis of CVC in 26 patients and thereafter in 31 patients. The incidence of postoperative CVC was 19% in the entire population. The presence of preoperative CVC was an independent risk factor for postoperative CVC. However, early surgery did not reduce the incidence of perioperative CVC ( < 72 h: 26.9%; >72 h: 29.1%, n.s.) or mortality. Although mortality was higher in patients with (28%) than without (22.4%) preoperative CVC, the difference was not statistically significant and preoperative CVC was not an independent predictor of mortality.

Conclusions: Our data suggest 1) that preoperative cerebrovascular complications do not significantly increase peri-operative mortality in patients with infective endocarditis and 2) that adhering to the 72-hour window does not reduce postoperative cerebrovascular complications or mortality.