Is preoperative intracranial hemorrhage a surgical contraindication in infective endocarditis with stroke?

The optimal timing for surgery in infective endocarditis (IE) with hemorrhagic stroke and neurologic deficits is difficult to decide because of the risk of exacerbating the stroke and provoking intracranial hemorrhagic conversion after surgery using cardiopulmonary bypass (CPB). This retrospective study aimed to investigate the impact of the presence or absence of preoperative intracranial hemorrhage (ICH) on surgical outcomes in IE with recent stroke.

The medical records of all patients who underwent open heart surgery for active IE from February 2009 to December 2020 were retrospectively reviewed. Among 164 patients who had surgery for left-sided IE, 71 cases in which the period from stroke onset to surgery was <4 weeks were divided into two groups for analysis.

Group A consisted of 49 patients without preoperative ICH and group B consisted of 22 patients with preoperative ICH. There was no significant difference in underlying conditions between the two groups. The two groups had similar rates of postoperative ICH (10.2%, group A vs. 13.6%, group B, P=0.696). The 30-day mortality rate was 8.2% in group A and 4.5% in group B (P=1.000), and the one-year survival was 86.8% in group A and 95.5% in group B (P=0.320). Univariate analysis was performed to identify risk factors for exacerbation of postoperative ICH in the 71 patients, but none of the factors tested showed statistically significant association with the exacerbation of ICH.

Preoperative ICH did not appear to increase the risk of exacerbation of postoperative ICH or the early mortality rate after open heart surgery in patients with infectious endocarditis accompanied by recent septic cerebral embolism.