Early or late surgery for endocarditis with neurological complications

The European Society of Cardiology 2015 guidelines advise urgent surgery for endocarditis complicated by cerebral embolism or transient ischemic events (1B evidence). Nevertheless, the timing of surgery remains contentious. This study aimed to review our experience of early versus delayed surgery in a selected cohort.

Our surgical database was examined for patients with a discharge diagnosis of endocarditis from 2005 to 2011. Selection was limited to patients who fulfilled the Duke criteria and underwent brain imaging for a clinically diagnosed preoperative neurological event. Patients were categorized as early surgery (≤7 days of clinical or cerebral imaging diagnosis of stroke) or delayed surgery (>7 days after diagnosis).

Thirty-nine patients were identified: 20 in the early group (mean age 52 ± 15 years, diagnosis-to-surgery time 4 ± 2 days) and 19 in the delayed group (mean age 45 ± 15 years, diagnosis-to-surgery time 17 ± 11 days). There were no statistical differences in preoperative risks, operative data (cardiopulmonary bypass and crossclamp times) or postoperative neurological and mortality outcomes between the 2 groups. The size of the cerebral lesion was not a significant predictor of postoperative hemorrhagic or neurological outcome. Multivariate analysis did not show any independent predictor of mortality during follow-up (mean 51 ± 27 months). There was no difference in long-term survival, freedom from reoperation, or recurrent endocarditis between the 2 groups.

This study showed no statistical excess of mortality or neurological outcomes after early surgical intervention, regardless of the preoperative cerebral lesion size.