Surgery for infective endocarditis complicated by cerebral embolism: a consecutive series of 375 patients

Abstract

Objective: To determine the influence of silent and symptomatic cerebral embolism on outcome of urgent/emergent surgery after acute infective endocarditis (AIE).

Methods: From a total of 1571 patients with AIE admitted to our institution between May 1995 and March 2012 about one-quarter (375 patients; mean age, 61.8 ± 13.6 years) presented with cerebral embolism confirmed by cranial computed tomography. Isolated aortic valve endocarditis was present in 165 patients (44%), 132 patients (36%) had isolated AIE of the mitral valve, and 64 (17%) patients had left-sided double valve endocarditis.

Results: Although the majority of patients presented with neurologic symptoms, 1 out of 3 patients experienced a so-called silent asymptomatic cerebral embolism or transient ischemic attack (n = 135). The rate of silent embolism was equivalent in patients with isolated aortic valve versus isolated mitral valve endocarditis (37% vs 34%; P = .54). Comparing patients with silent embolism versus symptomatic embolism, 18 patients with silent embolism versus 12 patients with symptomatic embolism developed postoperative hemiparesis (P = .69). Three versus 4 had severe postoperative intracerebral bleeding (P = .71). Median follow-up of survivors with cerebral embolism was 4.1 years (935 cumulative patient-years). Hospital mortality was 21.4% versus 19.6% (P = .68), with a long-term survival of 45% ± 5% versus 47% ± 4% at 5 years (P = .83) and 40% ± 6% versus 32% ± 5% at 10 years (P = .86). Independent risk factors of mortality were age at surgery (P < .01), chronic obstructive pulmonary disease (P = .01), preoperative requirement of catecholamines (P = .02), dialysis (P < .01), and duration of cardiopulmonary bypass (P < .01).

Conclusions: Survival after surgery for AIE is significantly impaired once cerebral embolism has occurred; however, it does not differ in patients with symptomatic versus silent cerebral embolism. Routine computed tomography scans are therefore mandatory due to the high incidence of asymptomatic cerebrovascular embolism--which appears to be equally as dangerous as symptomatic embolism.