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. 2024 Oct 15:24:170-184.
doi: 10.1016/j.xjon.2024.09.027. eCollection 2025 Apr.

Preoperative stroke predicts new postoperative clinically significant stroke in patients undergoing surgery for left-sided infective endocarditis

Nithya D Rajeev  1 , Markian M Bojko  1 , Jessica S Clothier  1 , Kamso Okonkwo  1 , Kayvan Kazerouni  1 , Serge Kobsa  1
Affiliations

Preoperative stroke predicts new postoperative clinically significant stroke in patients undergoing surgery for left-sided infective endocarditis

Nithya D Rajeev et al. JTCVS Open. .

Abstract

Objective: Operative timing remains controversial for patients with left-sided infective endocarditis (LSIE) with preoperative stroke (PREOS). Operative guidelines are determined on the basis of postoperative radiologically confirmed strokes (RCS). We evaluated the impact of PREOS on surgical outcomes.

Methods: Over 15 years, 331 patients underwent valvular surgery for LSIE at our center. PREOS (n = 71, 21%) and non-PREOS (n = 260, 79%) cohorts were identified. Propensity score matching was performed. Logistic regression identified risk factors for postoperative clinical stroke (PCS, defined as any new postoperative neurologic deficit), RCS and mortality.

Results: Among patients with PREOS, 24 of 71 (34%) had a hemorrhagic component, 34 of 71 (48%) were within 2 weeks of surgery, 46 of 71 (65%) experienced residual deficits, and 2 of 71 (3%) experienced hemorrhagic conversion postoperatively. Operative mortality was 24 of 331 (7%) and did not significantly differ between groups (P = .083). Patients with PREOS had a greater incidence of PCS (P = .001), repeat imaging of the head (P < .001), new renal failure (P = .006), and nonhome discharges (P < .001). Propensity score matching upheld these trends. Logistic regression identified PREOS as a risk factor for PCS (odds ratio [OR], 8.76; P < .001). Intraoperative abscess (OR, 4.83; P = .013), cardiogenic shock (OR 8.51; P = .023), and tricuspid procedures (OR 5.03; P = .02) were RCS risk factors. PREOS (OR 3.12; P = .025), preoperative renal failure (OR 2.67; P = .043), immunosuppression (OR 7.09; P = .022), tricuspid regurgitation (OR 4.36; P = .011), and aortic valve procedures (OR 4.38; P = .033) were risk factors for mortality.

Conclusions: Among patients with LSIE undergoing surgery, PREOS is a risk factor for PCS and new renal failure. Patients with PREOS may require greater level of care upon discharge and may benefit from more stringent preoperative evaluation.

Keywords: infective endocarditis; neurologic deficit; septic emboli; stroke; valve repair; valve replacement.

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Conflict of interest statement

The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Figures

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Graphical abstract
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Endocarditis patients with preoperative stroke risk postoperative neurological deficits.
Figure 1
Figure 1
Summary of patient selection and propensity score matching with inclusion and exclusion criteria. IE, Infective endocarditis.
Figure 2
Figure 2
Kaplan-Meier survival in entire cohort (left) and matched cohort (right) undergoing valvular intervention for infective endocarditis. 95% confidence interval.
Figure 3
Figure 3
Differences in postoperative outcomes between patients with and without preoperative stroke.
Figure E1
Figure E1
Cumulative incidence of cardiac reoperation in patients undergoing valvular intervention for infective endocarditis stratified by preoperative stroke status. 95% confidence interval.
See this image and copyright information in PMC

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