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Cited by 299Infective Endocarditis Diagnosis and ManagementCardiac Valve Diseases and TreatmentsInfectious Diseases and Tuberculosis

Surgical management of infective endocarditis associated with cerebral complications

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Eishi, Kiyoyuki, Kawazoe, Kouhei, Kuriyama, Yoshihiro, Kitoh, Yoshitsugu, Kawashima, Yasunaru, Omae, Teruo·1995·The Journal of Thoracic and Cardiovascular Surgery
DOI 10.1016/s0022-5223(95)70038-2
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Abstract

To establish guidelines for the surgical treatment of patients with infective endocarditis who have cerebrovascular complications, we conducted a detailed retrospective study of 181 of 244 patients with cerebral complications among 2523 surgical cases of infective endocarditis of the Japanese Association of Thoracic Surgery. The results showed that 9.7% of all patients with infective endocarditis had associated cerebral complications: 108 (44.3%) had active native valve endocarditis, 96 (39.3%) had healed native valve endocarditis, and 40 (16.4%) had prosthetic valve endocarditis. The hospital mortality of the patients with cerebral complications was 11.0% in the group as a whole: 13.9% in active native valve endocarditis, 3.1% in healed native valve endocarditis, and 37.5% in prosthetic valve endocarditis. Diseased valves included the following aortic valve in 55.5%, mitral valve 49.8%, tricuspid valve in 1.3%, and pulmonary valve in 1.3%. In 181 patients with cerebral complications, organisms were detected as follows: gram-positive cocci in 133 (73.5% [Streptococcus in 85, Staphylococcus in 32]), gram-negative in 18 (9.9%), fungus in 11 (6.1%), and unknown in 64.6%, cerebral bleeding in 31.5%, cerebral abscess in 2.8%, and meningitis in 1.1%. Hospital mortality rate and an exacerbation rate of cerebral complications, including related death, according to the interval from onset of cerebral infarction to cardiac surgery, were as follows: 66.3% and 45.5% within 24 hours, 31.3% and 43.8% between 2 and 7 days, 16.7% and 16.7% between 8 and 14 days, 10.0% and 10.0% between 15 and 21 days, 26.3% and 10.5% between 22 and 28 days, and 7.0% and 2.3% over 4 weeks later, respectively. A significant correlation existed between the interval and the exacerbation of cerebral complications (tied p = 0.008). Preoperative risk factors affecting exacerbation of cerebral complications were as follows: (1) severity of cerebral complications (p = 0.006), (2) intervals (p = 0.012), and (3) uncontrolled congestive heart failure as indications for cardiac surgery (p = 0.014). One patient underwent a cardiac operation within 24 hours of the onset of cerebral hemorrhage and died of cerebral damage. No exacerbations occurred in 10 patients who underwent their operation between 2 and 28 days. Nevertheless, exacerbations occurred in 19.0% of patients whose operation was done more than 4 weeks later. These data suggest that cardiac operations can be done safely 4 weeks after cerebral infarction, and if the delay is more than 2 weeks, the exacerbation rate will be around 10%. The risk of progression of cerebral damage is still significant 15 days and even 4 weeks after cerebral hemorrhage.

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  • These initial studies included a limited number of patients, and risk adjustments were not performed.

    “However, these initial studies included a limited number of patients, and risk adjustments were not performed.”

    From Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association (2015) · cites this paper as [267]

    The Discussion (page unavailable) says earlier studies had limited numbers of cases but describes this study’s 181 analyzed patients as sufficient for examining surgical timing. Patients and methods (page unavailable) also reports stepwise regression analysis of risk factors, contrary to the unqualified claim that risk adjustments were not performed. (LLM, conf=0.83)

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  • The high rates of postoperative morbidity and mortality seen in earlier studies have resulted in a reluctance to refer patients with infective endocarditis and acute stroke for immediate valve surgery.

    “The high rates of postoperative morbidity and mortality seen in earlier studies [265][266][267] have resulted in a reluctance to refer patients with IE and acute stroke for immediate valve surgery.”

    From Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association (2015) · cites this paper as [267]

    The section on mortality of cardiac surgery reports earlier operative mortality of 10%–37% for early valve replacement. The introduction also describes concern about operating after a cerebrovascular event because bypass could worsen brain injury. The paper does not establish that those earlier rates caused clinicians to be reluctant to refer patients for immediate surgery. Page numbers are unavailable in our copy. (LLM, conf=0.83)

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  • The largest early series of operated patients with cerebral complications included 181 patients; hospital mortality rates were 66.3% when surgery was performed within 24 hours of stroke and gradually decreased every week to 7.0% with surgery more than 4 weeks after stroke.

    “The largest early series of operated patients with cerebral complications included 181 patients.267 Hospital mortality rates as a function of the interval between evidence of cerebral infarction to cardiac surgery were 66.3% when surgery was performed within 24 hours of stroke and gradually decreased every week to 7.0% with surgery >4 weeks after stroke.”

    From Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association (2015) · cites this paper as [267]

    The Conclusion reports 181 patients with infective endocarditis and cerebral complications. The ‘Influence of cardiac surgery on preoperative cerebral infarction’ section gives the claimed 66.3% mortality within 24 hours and 7.0% after more than four weeks, but mortality did not decrease every week: it rose from 10.0% at 15–21 days to 26.3% at 22–28 days. The supplied passages have no page numbers. (LLM, conf=0.91)

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Cites

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Research works printed but not linked: 2

  1. [2]2. Boyd AD, Spencer FC, Isom OW, et al. Infective endocarditis: an analysis of 54 surgically treated pa- tients. J Thorac Cardiovasc Surg 197;73:23-30.
  2. [27]27. Roach MR, Drake CG. Ruptured cerebral aneurysms caused by microorganisms. 1965;273:240-4.

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Authors
Eishi, K., Kawazoe, K., Kuriyama, Y., Kitoh, Y., Kawashima, Y., & Omae, T.
Affiliations
National Cerebral and Cardiovascular Center (JP)
ORCID
Eishi, Kiyoyuki
Venue
The Journal of Thoracic and Cardiovascular Surgery
Publisher
Elsevier BV
Published
1995-12
Volume
110
Issue
6
Pages
1745-1755
ISSN
0022-5223 (ISSN-L)
DOI
10.1016/s0022-5223(95)70038-2
OpenAlex
W2090277811
Cited by
299
References
29
Citations by year
2026: 3 · 2025: 2 · 2024: 9 · 2023: 5 · 2022: 6 · 2021: 6 · 2020: 14 · 2019: 9 · 2018: 8 · 2017: 13 · 2016: 22 · 2015: 13 · 2014: 13 · 2013: 21 · 2012: 10
FWCI
3.45
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Thoracic and Cardiovascular Surgery (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Epidemiology › Infective Endocarditis Diagnosis and Management
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Valve Diseases and Treatments
  • Health Sciences › Medicine › Surgery › Infectious Diseases and Tuberculosis
Keywords
infective endocarditis, cerebral complications, cardiac surgery, native valve endocarditis, prosthetic valve endocarditis, in-hospital mortality, cerebral infarction, cerebral hemorrhage, time to surgery, Streptococcus, Staphylococcus, fungal endocarditis, aortic valve, mitral valve, risk factors for poor outcome
MeSH terms
Adult, Cerebrovascular Disorders, Endocarditis, Endocarditis, Bacterial, Female, Humans, Japan, Male, Retrospective Studies, Risk Factors, Time Factors, Prosthesis-Related Infections, Hospital Mortality, Guidelines as Topic

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