Abstract
Infective endocarditis (IE) with neurologic complications is common in patients with
active IE. The most common and feared neurological complication of left-sided IE is
cerebrovascular, from septic emboli causing ischemic stroke, intracranial hemorrhage
(ICH), or an infectious intracranial aneurysm with or without rupture. In patients
with cerebrovascular complications, valve replacement surgery is often delayed for
concern of further neurological worsening. However, in circumstances when an indication
for valve surgery to treat IE is present, the benefits of early surgical treatment
may outweigh the potential neurologic deterioration. Furthermore, valve surgery has
been associated with lower in-hospital mortality than medical therapy with intravenous
antibiotics alone. Early valve surgery can be performed within 7 days of transient
ischemic attack or asymptomatic stroke when medically indicated. Timing of valve surgery
for IE after symptomatic medium or large symptomatic ischemic stroke or ICH remains
challenging, and current data in the literature are conflicting about the risks and
benefits. A delay of 2 to 4 weeks from the time of the cerebrovascular event is often
recommended, balancing the risks and benefits of surgery. The range of timing of valve
surgery varies depending on the clinical scenario, and is best determined by a multidisciplinary
decision between cardiothoracic surgeons, cardiologists, infectious disease experts,
and vascular neurologists in an experienced referral center.
Keywords
infective endocarditis - cerebrovascular complications - valve surgery - cerebral
microbleed - stroke
