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Optimal Timing for Cardiac Surgery in Infective Endocarditis with Neurological Complications: A Narrative Review
Joan Siquier-Padilla1, Guillermo Cuervo2,3, Xabier Urra4
1Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, 07120 Palma de Mallorca, Spain.
Insights
For infective endocarditis patients with neurological issues, cardiac surgery timing varies. Early surgery is safe for ischemic, infectious, or asymptomatic complications, but delayed surgery is often best for intracranial hemorrhage.
Area of Science:
- Cardiology
- Neurology
- Infectious Diseases
Background:
- Optimal timing for cardiac surgery in infective endocarditis (IE) patients with neurological complications remains unclear.
- Early surgery poses varied risks of clinical deterioration.
- Evidence synthesis is needed to guide surgical timing based on neurological complication type.
Purpose of the Study:
- To review the optimal timing for cardiac surgery in IE patients with neurological complications.
- To categorize recommendations based on four types of neurological complications: ischemic, hemorrhagic, infectious, and asymptomatic.
Main Methods:
- Comprehensive literature search from June 2018 to July 2022.
- Inclusion of observational studies, clinical trials, systematic reviews, and guidelines.
- Organization of findings by neurological complication type.
Main Results:
- Cardiac surgery can proceed without delay for ischemic, infectious, or asymptomatic neurological complications.
- Mechanical thrombectomy may mitigate risks in major ischemic stroke.
- A four-week delay is generally recommended for intracranial hemorrhage, with selected cases potentially suitable for earlier intervention.
Conclusions:
- Surgical timing for IE with neurological complications should be tailored to the specific complication.
- Findings align with current European and American IE guidelines.
- Further research may refine recommendations for intracranial hemorrhage cases.
Abstract:
In patients with infective endocarditis and neurological complications, the optimal timing for cardiac surgery is unclear due to the varied risk of clinical deterioration when early surgery is performed. The aim of this review is to summarize the best evidence on the optimal timing for cardiac surgery in the presence of each type of neurological complication. An English literature search was carried out from June 2018 through July 2022. The resulting selection, comprising observational studies, clinical trials, systematic reviews and society guidelines, was organized into four sections according to the four groups of neurological complications: ischemic, hemorrhagic, infectious, and asymptomatic complications. Cardiac surgery could be performed without delay in cases of ischemic vascular neurological complication (provided the absence of severe damage, which can be avoided with the performance of mechanical thrombectomy in cases of major stroke), as well as infectious or asymptomatic complications. In the presence of intracranial hemorrhage, a delay of four weeks is recommended for most cases, although recent studies have suggested that performing cardiac surgery within four weeks could be a suitable option for selected cases. The findings of this review are mostly in line with the recommendations of the current European and American infective endocarditis guidelines.
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