West Virginia University Morgantown, West Virginia, United States
Disclosure(s):
Kareem Wasef: No financial relationships to disclose
Purpose: Some patients presenting with active endocarditis also suffer acute stroke, placing them at possible risk for hemorrhagic conversion at the time of valve surgery. Controversy persists over the optimal operative timing. We sought to evaluate the safety and outcomes of early or immediate surgery in this complex patient population. Methods: We combined a regional multidisciplinary infectious disease and surgical endocarditis database with our Society of Thoracic Surgeons Adult Cardiac Surgery Database to evaluate outcomes for all patients undergoing valve surgery for acute endocarditis January 1, 2016, to July 1, 2021. Clinical follow-up and regional electronic health records were reviewed to include detailed stroke information and longitudinal follow-up. Logistic regression assessed relationship between preoperative and postoperative stroke and Kaplan Meier Survival Curves evaluated longitudinal outcomes. Results: We identified 442 patients undergoing valve surgery for acute endocarditis (mitral 144, 32.6%; aortic 76, 17.2%; tricuspid 283, 64.0%). Average age was 37±13 years, 347 (78.5%) were secondary to intravenous drug abuse, with 77 (17.4%) redo valve operations. The mitral and tricuspid valve repair rates were 49.3% and 47.4%, respectively. There were 79 (17.9%) patients with acute preoperative stroke (53, 67.5% embolic without hemorrhage; 26, 32.5% with hemorrhagic conversion). The median time between preoperative stroke diagnosis and surgery was 9 days, with 23 (29.1%) undergoing surgery within 72 hours of diagnosis, 3 of whom had evidence of a hemorrhage preoperatively. The overall incidence of new/worsening postoperative stroke was 1.6% (7/442) and 3.8% (3/79) in preoperative stroke patients including 2 patients had preoperative embolic converted to hemorrhagic strokes operated on at 10 and 17 days after stroke diagnosis, and 1 patient had expansion of a hemorrhagic stroke with surgery 9 days after initial diagnosis. However, preoperative stroke (OR 3.5, p=0.103) or days between diagnosis and surgery (OR 0.99, p=0.909) were not associated with new/worsening postoperative stroke. Importantly, between patients with and without preoperative stroke, there was no difference in hospital (95.9% vs 92.4%, p= 0.19) or longitudinal survival (Figure, p=0.414). Conclusion: The decision to operate on endocarditis in the setting of an acute stroke can be challenging. These contemporary data highlight the safety of an early valve surgery strategy in the setting of acute stroke, with non-inferior postoperative stroke risk and longitudinal survival compared to patients without a preoperative stroke.
Identify the source of the funding for this research project: 1. Yanagawa B, Pettersson GB, Habib G, Ruel M, Saposnik G, Latter DA, Verma S. Surgical Management of Infective Endocarditis Complicated by Embolic Stroke: Practical Recommendations for Clinicians. Circulation. 2016 Oct 25;134(17):1280-1292 2. Yoshioka D, Sakaguchi T, Yamauchi T, Okazaki S, Miyagawa S, Nishi H, Yoshikawa Y, Fukushima S, Saito S, Sawa Y. Impact of early surgical treatment on postoperative neurologic outcome for active infective endocarditis complicated by cerebral infarction. Ann Thorac Surg. 2012 Aug;94(2):489-95; discussion 496.
