Not All Strokes Are Equal: Phenotype-Dependent Surgical Timing in Infective Endocarditis

We evaluated postoperative neurologic and mortality outcomes by stroke-to-surgery timing and stroke phenotype in patients with left-sided infective endocarditis.

Adult patients undergoing surgery for infective endocarditis complicated by preoperative stroke between 2004 and 2024 at 2 institutions were stratified by stroke-to-surgery interval (<1 week, 1-4 weeks, 4-6 weeks). The primary outcome was a composite postoperative cerebrovascular event: new stroke, enlarging stroke, or hemorrhagic conversion. Secondary outcomes were operative death and major morbidity events.

Among 2265 patients with left-sided infective endocarditis, 322 met inclusion criteria, of whom 122 (38%) underwent surgery within 1 week, 168 (52%) between 1 and 4 weeks, and 32 (10%) between 4 and 6 weeks. Operative death was similar across groups (P=0.09). Postoperative cerebrovascular events declined with time (<1 week, 21.3%; 1-4 weeks, 11.9%; 4-6 weeks, 9.4%; P=0.015). On multivariable analysis, longer stroke-to-surgery interval was associated with reduced odds of postoperative cerebrovascular events (odds ratio, 0.92/d [95% CI, 0.85-0.98]; P=0.015), driven by early events among patients with intraparenchymal hemorrhage, subarachnoid hemorrhage, and septic emboli. Among ischemic strokes, operative death was lowest with surgery within 1 week (5.8% versus 11.2% at 1-4 weeks; P=0.24). Interval embolization occurred in 10.6% of patients awaiting surgery, most commonly affecting the spleen and kidneys.

Excess postoperative neurologic risk was concentrated within the first 7 to 10 days and driven by intraparenchymal hemorrhage, subarachnoid hemorrhage, and septic emboli; ischemic stroke showed no appreciable temporal association. Routine delay after ischemic stroke may not be necessary, while a short delay (≈7 days) for hemorrhagic and septic embolic subtypes may be reasonable when hemodynamically feasible.