Infective endocarditis and neurologic events: indications and timing for surgical interventions

Nikolaos Bonaros, Martin Czerny, Bettina Pfausler, Silvana Müller, Thomas Bartel, Matthias Thielmann, Sharaf-Eldin Shehada, Thierry Folliguet, Jean-Francois Obadia, Johannes Holfeld, Roberto Lorusso, Alessandro Parolari, Ludwig Müller, Michael Grimm, Elfriede Ruttmann-Ulmer, Nikolaos Bonaros, Martin Czerny, Bettina Pfausler, Silvana Müller, Thomas Bartel, Matthias Thielmann, Sharaf-Eldin Shehada, Thierry Folliguet, Jean-Francois Obadia, Johannes Holfeld, Roberto Lorusso, Alessandro Parolari, Ludwig Müller, Michael Grimm, Elfriede Ruttmann-Ulmer

Abstract

A therapeutic dilemma arises when infective endocarditis (IE) is complicated by a neurologic event. Postponement of surgery up to 4 weeks is recommended by the guidelines, however, this negatively impacts outcomes in many patients with an urgent indication for surgery due to uncontrolled infection, disease progression, or haemodynamic deterioration. The current literature is ambiguous regarding the safety of cardiopulmonary bypass in patients with recent neurologic injury. Nevertheless, most publications demonstrate a lower risk for secondary haemorrhagic conversion of uncomplicated ischaemic lesions than the risk for recurrent embolism under antibiotic treatment. Here, we discuss the current literature regarding neurologic stroke complicating IE with an indication for surgery.

Keywords: Infective endocarditis; Stroke; Valve repair.

Published on behalf of the European Society of Cardiology. © The Author(s) 2020.

Figures

Figure 1
Figure 1
Magnetic resonance imaging: intracranial abscess at the left parietal side. The female patient received a mitral valve repair and underwent successful neuro-surgical intervention at the fourth post-operative day. She regained full neurologic recovery without sequelae.
Figure 2
Figure 2
Contrast agent magnetic resonance angiography: 3 mm × 2.5 mm large mycotic aneurysm of a M2-branch of the middle cerebral artery at the right side. The male patient suffered from severe aortic valve endocarditis with paravalvular abscess formation (Staphylococcus aureus). Neurosurgical intervention was performed 3 days before aortic root replacement therapy. He died due to septic multi-organ failure but without intracerebral haemorrhage.
Figure 3
Figure 3
The upper panel shows paravalvular abscess, fistula to the right atrium complicating severe aortic valve endocarditis with vegetations are larger than 1 cm. Lower panel shows the aortic valve to be bicuspid with two- and three-dimensional display of a vegetation characterized by distinctive tissue Doppler motion pattern. A, abscess; F, fistula; LA, left atrium; LCA, left coronary artery; PML, pacemaker lead; RA, right atrium; V, vegetation.

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Source: PubMed

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