Impact of Preoperative Neurological Events on Outcome and Timing of Surgery in Patients with Infective Valve Endocarditis

Objectives: Infective valve endocarditis with presence of preoperative strokes poses a particular surgical challenge. The best possible timing for valve surgery is still discussed controversially due to the risk of intracerebral bleeding (ICB). Here, we investigated the impact of preoperative stroke on overall survival and analyzed timing of surgery with regard to survival status and postoperative change in neurological morbidity.

Methods: Between 2009 and 2016, 534 patients underwent surgery due to infective valve endocarditis at our institution and were analyzed retrospectively. Patients were initially grouped into native valve (NVE) (n = 356; 66.7%) and prosthetic valve endocarditis (PVE) (n = 178; 33.3%) and further divided into subgroups according to status of preoperative stroke. Statistical analysis was performed using SPSS Statistics 24.

Results: Prevalence of preoperative stroke was 24.7% (n = 88/356) in the NVE group. Patients who suffered a preoperative stroke showed significantly lower overall survival (OS) according to Kaplan-Meier estimates (mean ± SEM, 68.6 ± 2.8 versus 47.1 ± 5.0 months; p < 0.001). In the PVE group, prevalence of preoperative stroke was 15.2% (n = 27/178). Interestingly, OS did not differ significantly among preoperative stroke status (mean ± SEM, 51.9 ± 4.2 vs. 37.7 ± 7.5 months). We were further able to show, that an early surgery within 7 days of the stroke did not have a significantly higher incidence of postoperative ICB in both, the NVE (3/54 patients, 5.6%) and PVE group (1/13 patients, 7.7%). Finally, we analyzed the impact of surgery within 7 days of diagnosis on postoperative neurological outcome. Our results show that postoperative neurological symptoms classified as improvement, steady state or deterioration, are independent from timing of surgery in both groups, NVE and PVE.

Conclusion: Our results demonstrate that an early surgery in patients with infective valve endocarditis complicated by preoperative stroke is not associated with a higher incidence of postoperative ICB. Nevertheless, we call for careful selection of patients and individual multidisciplinary approach. Further studies are needed to confirm these results and help to determine an optimal time frame for surgical intervention in patients with infective valve endocarditis.