Ideal Timing for Surgical Treatment in Endocarditis Patients with Recent Cerebral Embolization

Objectives: Infective endocarditis (IE) with visible vegetations often requires urgent surgical treatment. However, in some cases due to recent cerebral infarction, patients have an increased risk of cerebral hemorrhage during extracorporal circulation. No suitable guideline exists in order to clarify the best surgical timing after cerebral embolization/hemorrhage, but neurosurgeons usually recommend to wait a couple of weeks due to heparinization during surgery. We evaluated endocarditis patients with urgent surgical indication and recent cerebral infarction directly postsurgically by CCT scan, evaluating the risk of subsequent hemorrhage due to complete heparinization.

Methods: Twenty-five patients with definite IE according to the modified DUKE criteria received urgent valve surgery. All patients had suffered from recurrent cerebral infarction and subsequent intracranial hemorrhage, which could be identified on presurgical CCT scan. Time interval between cerebral infarction and cardiac surgery ranged from 2 days postinfarction up to 2 weeks. All patients received a CCT scan directly after surgery in order to identify any enlargement or new-onset intracranial hemorrhage.

Results: One patient showed acute cerebral hemorrhage and was directly transferred to the neurosurgical operating room where he was trepanned. He recovered completely within the next week with no residual neurological symptoms. Four patients showed minor enlargements of the previously described intracranial hemorrhage with no indication for surgical intervention. All those patients showed no correlation between cerebral infarction size and short-term surgical interval, but were randomly distributed within our patients collectively. The remaining 20 patients showed no sign of new-onset ischemia or embolization.

Conclusion: The risk for cerebral hemorrhage in patients with IE and previous cerebral infarction may be lower than commonly thought. In an institution with neurosurgery on site, we believe our data support that a short time interval between infarction and cardiac surgery is supportable due to the possibility of immediate treatment in case of neurological complications. We believe, especially in patients with recurring endocarditic embolization, cardiac surgery should be performed at the earliest possible time.