Management of cardiopulmonary bypass in patients with ischemic and hemorrhagic strokes in surgery for active infective endocarditis

Abstract

Stroke and intracranial hemorrhage (ICH) are serious complications that are difficult to manage during surgery for active infectious endocarditis (AIE). Relevant society guidelines still recommend delaying the cardiac surgery for AIE with ICH for 4 weeks. Some early studies indicated that the mortality rate decreases when cardiac surgery for ICH is delayed. In contrast, some reported that surgical intervention should not be delayed if an early operation is demanded, even in patients with ICH. The current literature on early vs. late surgery for infectious endocarditis (IE) with ICH is conflicting. Changing the cardiopulmonary bypass (CPB) strategy might be necessary to improve the surgical outcomes of IE with ICH. Some studies reported that cardiac surgery using nafamostat mesylate (NM) as an alternative anticoagulant during CPB was performed successfully. The combination of NM and low-dose heparin was beneficial for early surgery in patients with AIE complicated by cerebral infarction and ICH, without worsening cerebral lesions. In this report, we review and discuss the management of CPB in patients with ischemic and hemorrhagic stroke during surgery for AIE.

Keywords: Cardiopulmonary bypass; Intracranial hemorrhage; Low-dose heparin; Nafamostat mesylate; Neurological complication.

Fig. 1

Methods of cardiopulmonary bypass using nafamostat mesylate (NM-CPB). The cardiopulmonary bypass method using nafamostat mesylate (NM-CPB) is shown. The pump circuit of the NM-CPB is shown in the figure. Nafamostat mesylate was infused continuously to the cardiotomy reservoir and venous reservoir at 0.5 mg/kg/h and 1.0 mg/kg/h, respectively. The injection rate varied according to the activated clotting time

Fig. 2

A case of redo for root abscess with intracranial hemorrhage. The lower (colored) bars indicate the nafamostat mesilate dose in the venous and cardiotomy reservoirs. ICH, intracranial hemorrhage; ACT, activated clotting time; NM-CPB, cardiopulmonary bypass using nafamostat mesylate; NM, nafamostat mesylate; CTR, cardiotomy reservoir; VR, venous reservoir

Fig. 3

Relationships between the size of acute cerebral infarction and the interval from onset to operation. Relationships between the size of the acute cerebral infarction and the interval from onset to operation are shown (total n = 46, NM-CPB n = 32, normal CPB n = 14). There were two patients with exacerbation in whom cardiac surgery was performed with cardiopulmonary bypass using a normal dose of heparin

Fig. 4

Relationships between the size of intracranial hemorrhage and the interval from onset to operation. The relationships between the size of the intracranial hemorrhage and the interval from onset to operation are shown (total n = 20, NM-CPB n = 13, normal CPB n = 7). There were four patients with hospital death related to brain complications, of which two underwent NM-CPB, whereas the other two underwent CPB using normal heparin. Early surgery within 7 days from onset was performed in 12 cases of NM-CPB and three cases of normal heparinized CPB. The mean size of the intracranial hemorrhage was 723 ± 1069 mm