Considerations in timing of surgical intervention for infective endocarditis with cerebrovascular complications

The timing of the surgical intervention for active infective endocarditis (IE) is particularly difficult when there is a cerebrovascular complication. The study aim was to investigate the results of surgical treatment for active IE in patients with recent cerebrovascular events, and to evaluate the relationship between the size of cerebral infarction and timing of the surgical intervention.

Between January 1991 and April 2009, the details of 21 patients with cerebrovascular complications before surgery were analyzed retrospectively. Types of complication included cerebral infarction (n = 13), hemorrhagic infarction (n = 4), and cerebral hemorrhage (n = 4). The surgical treatment was single valve surgery (n = 14), multiple valve surgery (n = 3), and modified Bentall surgery (n = 4). The mean interval between onset of the cerebrovascular event and surgical intervention was 27.0 +/- 18.8 days.

Eight patients underwent surgery within two weeks; among these patient, seven had a small cerebral infarction (< or = 15 mm diameter) and one patient had a cerebral hemorrhage. Postoperative exacerbation of cerebral complications was not observed among the eight patients treated within two weeks. The interval between onset of the cerebral event and cardiac surgery was significantly shorter in patients with a small infarction (18 days) than with a large infarction (38 days) (p < 0.05). None of the patients with a small infarction had postoperative exacerbation of their cerebral complication, even with a significantly shorter interval. However, postoperative hemorrhage into the infarction area was observed in one patient with a large infarction.

The study results showed that IE patients with a small non-hemorrhagic cerebral infarction may safely undergo cardiac surgery, even within two weeks of the onset of a cerebrovascular event.