Skip to main content

Advertisement

SpringerLink
Log in

Effect of cerebral embolus size on the timing of cardiac surgery for infective endocarditis in patients with neurological complications

  • Original Article
  • Published:
European Journal of Clinical Microbiology & Infectious Diseases Aims and scope Submit manuscript

Abstract

The optimal timing of cardiac surgery remains unclear for patients with neurological complications of infective endocarditis (IE). However, neuroimaging findings may allow more refined clinical decision-making. We analyzed clinical and advanced neuroimaging data for 135 patients with IE who had preoperatively diagnosed ischemic cerebral complications (86 patients) or hemorrhagic complications (49 patients), between January 1997 and May 2013. The effect of early surgery (within 3 and 7 days of ischemic and hemorrhagic complications respectively) on in-hospital mortality and 1-year adverse outcomes (mortality, relapse, or new embolic events) was estimated. Small cerebral emboli (≤2 cm) led to early surgery (cases with ischemic complications: 57% vs 26%, p = 0.04; cases with hemorrhagic complications: 56% vs 13%, p = 0.02). Early surgery was not significantly associated with increased rates of in-hospital mortality and 1-year adverse outcomes among patients with ischemic complications (14% vs 9%, odds ratio [OR] 1.67, 95% confidence interval [CI] 0.44–6.38, p = 0.52; 17% vs 14%, OR 1.27, 95% CI 0.39–4.14, p = 0.7 respectively). Only 1 patient (4%) with hemorrhagic complications experienced in-hospital mortality in the early surgery group, and early surgery was not significantly associated with 1-year adverse outcomes (21% vs 12%, OR 1.93, 95% CI 0.41–9.16, p = 0.46). The risks of in-hospital mortality and 1-year adverse outcome were not increased, even if cardiac surgery had been carried out earlier than previously described. Our findings suggest that early surgery, when indicated, may be performed for patients with IE and neurological complications, especially if the cerebral embolus has a diameter of ≤2 cm.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Thuny F, Beurtheret S, Mancini J et al (2011) The timing of surgery influences mortality and morbidity in adults with severe complicated infective endocarditis: a propensity analysis. Eur Heart J 32:2027–2033

    Article  PubMed  Google Scholar 

  2. Chu VH, Park LP, Athan E et al (2015) Association between surgical indications, operative risk, and clinical outcome in infective endocarditis: a prospective study from the international collaboration on Endocarditis. Circulation 131:131–140

    Article  PubMed  Google Scholar 

  3. Iung B, Doco-Lecompte T, Chocron S et al (2016) Cardiac surgery during the acute phase of infective endocarditis: discrepancies between European Society of Cardiology guidelines and practices. Eur Heart J 37:840–848

    Article  PubMed  Google Scholar 

  4. Hoen B, Duval X (2013) Infective endocarditis. N Engl J Med 368:785

    Article  Google Scholar 

  5. Kang DH, Kim YJ, Kim SH et al (2012) Early surgery versus conventional treatment for infective endocarditis. N Engl J Med 366:2466–2473

    Article  CAS  PubMed  Google Scholar 

  6. Kim DH, Kang DH, Lee MZ et al (2010) Impact of early surgery on embolic events in patients with infective endocarditis. Circulation 122:S17–S22

    Article  PubMed  Google Scholar 

  7. Thuny F, Grisoli D, Collart F et al (2012) Management of infective endocarditis: challenges and perspectives. Lancet 379:965–975

    Article  PubMed  Google Scholar 

  8. Baddour LM, Wilson WR, Bayer AS et al (2015) Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications. A scientific statement for healthcare professionals from the American Heart Association. Circulation 131:1435–1486

    Article  Google Scholar 

  9. Habib G, Lancellotti P, Antunes MJ et al (2015) 2015 ESC guidelines for the management of infective endocarditis. Eur Heart J 36:3075–3128

    Article  PubMed  Google Scholar 

  10. Byrne JG, Rezai K, Sanchez JA et al (2011) Surgical management of endocarditis: the Society of Thoracic Surgeons clinical practice guideline. Ann Thorac Surg 91:2012–2019

    Article  PubMed  Google Scholar 

  11. Yoshioka D, Sakaguchi T, Yamauchi T et al (2012) Impact of early surgical treatment on postoperative neurologic outcome for active infective endocarditis complicated by cerebral infarction. Ann Thorac Surg 94:489–495

    Article  PubMed  Google Scholar 

  12. Sorabella RA, Han SM, Grbic M et al (2015) Early operation for endocarditis complicated by preoperative cerebral emboli is not associated with worsened outcomes. Ann Thorac Surg 100:501–508

    Article  PubMed  PubMed Central  Google Scholar 

  13. Ruttmann E, Willeit J, Ulmer H et al (2006) Neurological outcome of septic cardioembolic stroke after infective endocarditis. Stroke 37:2094–2099

    Article  PubMed  Google Scholar 

  14. Barsic B, Dickerman S, Krajinovic V et al (2013) Influence of the timing of cardiac surgery on the outcome of patients with infective endocarditis and stroke. Clin Infect Dis 56:209–217

    Article  PubMed  Google Scholar 

  15. Kang DH (2015) Timing of surgery in infective endocarditis. Heart 101:1786–1791

    Article  CAS  PubMed  Google Scholar 

  16. Bennet JE, Dolin R, Blaser MJ (2014) Mandell, Douglas, and Bennett’s principles and practice of infectious diseases, 8th edn. Saunders, Elsevier, New York, p 1019

    Google Scholar 

  17. García-Cabrera E, Fernández-Hidalgo N, Almirante B et al (2013) Neurological complications of infective endocarditis: risk factors, outcome, and impact of cardiac surgery: a multicenter observational study. Circulation 127:2272–2284

    Article  PubMed  Google Scholar 

  18. Angstwurm K, Borges AC, Halle E et al (2004) Timing the valve replacement in infective endocarditis involving the brain. J Neurol 251:1220–1226

    Article  PubMed  Google Scholar 

  19. Thuny F, Avierinos JF, Tribouilloy C et al (2007) Impact of cerebrovascular complications on mortality and neurologic outcome during infective endocarditis: a prospective multicenter study. Eur Heart J 28:1155–1161

    Article  PubMed  Google Scholar 

  20. Snygg-Martin U, Gustafsson L, Rosengren L et al (2008) Cerebrovascular complications in patients with left-sided infective endocarditis are common: a prospective study using magnetic resonance imaging and neurochemical brain damage markers. Clin Infect Dis 47:23–30

    Article  PubMed  Google Scholar 

  21. Wilbring M, Irmscher L, Alexiou K et al (2014) The impact of preoperative neurological events in patients suffering from native infective endocarditis. Interact Cardiovasc Thorac Surg 18:740–747

    Article  PubMed  Google Scholar 

  22. Yoshioka D, Toda K, Sakaguchi T et al (2014) Valve surgery in active endocarditis patients complicated by intracranial hemorrhage: the influence of the timing of surgery on neurological outcomes. Eur J Cardiothorac Surg 45:1082–1088

    Article  PubMed  Google Scholar 

  23. Cahill TJ, Baddour LM, Habib G et al (2017) Challenges in infective endocarditis. J Am Coll Cardiol 69:325–344

    Article  PubMed  Google Scholar 

  24. Li JS, Sexton DJ, Mick N et al (2000) Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 30:633–638

    Article  CAS  PubMed  Google Scholar 

  25. Charlson ME, Pompei P, Ales KL et al (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383

    Article  CAS  PubMed  Google Scholar 

  26. Gaca JG, Sheng S, Daneshmand MA et al (2011) Outcomes for endocarditis surgery in North America: a simplified risk scoring system. J Thorac Cardiovasc Surg 141:98–106

    Article  PubMed  Google Scholar 

  27. Ben-Ami R, Giladi M, Carmeli Y et al (2004) Hospital-acquired infective endocarditis. Should the definition be broadened? Clin Infect Dis 38:843–850

    Article  PubMed  Google Scholar 

  28. Tatu L, Moulin T, Bogousslavsky J et al (1996) Arterial territories of the human brain: brainstem and cerebellum. Neurology 47:1125–1135

    Article  CAS  PubMed  Google Scholar 

  29. Tatu L, Moulin T, Bogousslavsky J et al (1998) Arterial territories of the human brain: cerebral hemisphere. Neurology 50:1699–1708

    Article  CAS  PubMed  Google Scholar 

  30. Wong KS, Gao S, Chan YL et al (2002) Mechanisms of acute cerebral infarctions in patients with middle cerebral artery stenosis: a diffusion-weighted imaging and microemboli monitoring study. Ann Neurol 52:74–81

    Article  PubMed  Google Scholar 

  31. Prendergast BD, Tornos P (2010) Surgery for infective endocarditis: who and when? Circulation 121:1141–1152

    Article  PubMed  Google Scholar 

  32. San Román JA, Vilacosta I, López J et al (2015) Critical questions about left-sided infective endocarditis. J Am Coll Cardiol 66:1068–1076

    Article  PubMed  Google Scholar 

  33. Derex L, Bonnefoy E, Delahaye F (2010) Impact of stroke on therapeutic decision making in infective endocarditis. J Neurol 257:315–321

    Article  PubMed  Google Scholar 

  34. Piper C, Wiemer M, Schulte HD et al (2001) Stroke is not a contraindication for urgent valve replacement in acute infective endocarditis. J Heart Valve Dis 10:703–711

    CAS  PubMed  Google Scholar 

  35. Okita Y, Minakata K, Yasuno S et al (2016) Optimal timing of surgery for active infective endocarditis with cerebral complications: a Japanese multicenter study. Eur J Cardiothorac Surg 50:374–382

    Article  PubMed  Google Scholar 

  36. Lee SJ, SS O, Lim DS et al (2014) Clinical significance of cerebrovascular complications in patients with acute infective endocarditis: a retrospective analysis of a 12-year single-center experience. BMC Neurol 14:30

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Funding

No funding was received for this study.

Author information

Author notes

  1. Y.K.K and C.G.C contributed equally to this manuscript

Authors and Affiliations

  1. Division of Infectious Diseases, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea

    Yong Kyun Kim

  2. Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea

    Choong Gon Choi

  3. Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea

    Jiwon Jung, Shi Nae Yu, Ju Young Lee, Yong Pil Chong, Sung-Han Kim, Sang-Oh Lee, Sang-Ho Choi, Jun Hee Woo & Yang Soo Kim

  4. Division of Infectious Diseases, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea

    Jiwon Jung

  5. Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea

    Shi Nae Yu

  6. Department of Internal Medicine, San Anyang Hospital, Anyang, Republic of Korea

    Ju Young Lee

Authors
  1. Yong Kyun Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Choong Gon Choi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jiwon Jung
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Shi Nae Yu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ju Young Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Yong Pil Chong
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sung-Han Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Sang-Oh Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Sang-Ho Choi
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Jun Hee Woo
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Yang Soo Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yang Soo Kim.

Ethics declarations

Conflicts of interest

None of the authors has any potential conflicts of interest.

Ethical approval

The study was approved by the Asan Medical Center Institutional Review Board (IRB).

Informed consent

Informed consent was not required because of the retrospective nature of the present study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kim, Y.K., Choi, C.G., Jung, J. et al. Effect of cerebral embolus size on the timing of cardiac surgery for infective endocarditis in patients with neurological complications. Eur J Clin Microbiol Infect Dis 37, 545–553 (2018). https://doi.org/10.1007/s10096-017-3148-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10096-017-3148-8

Keywords

Search

Navigation