Relative Importance of Timing vs Size of Preoperative Stroke for Valve Operation in Infective Endocarditis

The optimal timing of operation for infective endocarditis with preoperative stroke remains unclear.

Adults undergoing an operation for acute aortic or mitral valve infective endocarditis were reviewed from our institutional database from 1991 to 2023. Large preoperative strokes were defined stroke volume ≥20 cm³ calculated from magnetic resonance imaging. Multivariable logistic regression was performed.

Preoperative stroke was present in 21% (202 of 965) of patients, of which 81% (95 of 118) were small and 76% (88 of 118) were ischemic. Preoperative stroke occurred a median of 24 days before valve operation with 42 of 202 (21%) undergoing surgery within 7 days of stroke. Overall, postoperative stroke occurred in 42 of 965 patients (4.3%). The median admission-to-operation time for patients without preoperative stroke was 3 days (interquartile range, 1-6 days) and with preoperative stroke was 6 days (interquartile range, 3-10 days) (P < .001). Postoperative stroke was twice as likely in patients with preoperative stroke (6.9% [14 of 202]) than patients without preoperative stroke (3.7% [28 of 763]; P = .04). Postoperative stroke was more likely if preoperative stroke was large (22% [5 of 23]) vs small (4% [4 of 95]; P = .005), but not hemorrhagic vs ischemic (P = .8). On multivariable regression, postoperative stroke was associated with large preoperative stroke (P = .001). There was no association between postoperative stroke and preoperative stroke-to-operation time or preoperative hemorrhagic stroke. Hemorrhagic conversion did not occur in patients with preoperative ischemic stroke.

In patients with aortic and mitral valve infective endocarditis, the size of stroke-not timing of the operation-is significantly associated with postoperative stroke. As a surgical community, we must consider early intervention in patients with left-sided infective endocarditis and small preoperative strokes.