Surgery for infective endocarditis complicated by cerebral embolism: A consecutive series of 375 patients

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 147; no. 6; pp. 1837 - 1846
• Main Authors: Misfeld, Martin, MD, PhD, Girrbach, Felix, MD, Etz, Christian D., MD, PhD, Binner, Christian, MD, Aspern, Konstantin V., MD, Dohmen, Pascal M., MD, PhD, Davierwala, Piroze, MD, Pfannmueller, Bettina, MD, PhD, Borger, Michael A., MD, PhD, Mohr, Friedrich-Wilhelm, MD, PhD
• Format: Journal Article
• Language: English
• Published: United States Mosby, Inc 01.06.2014
• Subjects: Aged; Asymptomatic Diseases; Cardiac Surgical Procedures - adverse effects; Cardiac Surgical Procedures - mortality; Cardiothoracic Surgery; Cerebral Angiography - methods; Cerebral Hemorrhage - etiology; Endocarditis - complications; Endocarditis - diagnosis; Endocarditis - mortality; Endocarditis - surgery; Female; Hospital Mortality; Humans; Intracranial Embolism - diagnosis; Intracranial Embolism - etiology; Intracranial Embolism - mortality; Ischemic Attack, Transient - etiology; Kaplan-Meier Estimate; Male; Middle Aged; Paresis - etiology; Proportional Hazards Models; Risk Factors; Stroke - etiology; Tomography, X-Ray Computed; Treatment Outcome; computed tomography; 35.2; CT; acute infective endocarditis; 26.1.3; 26.1.4; AIE
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2013.10.076

Objective To determine the influence of silent and symptomatic cerebral embolism on outcome of urgent/emergent surgery after acute infective endocarditis (AIE). Methods From a total of 1571 patients with AIE admitted to our institution between May 1995 and March 2012 about one-quarter (375 patients; mean age, 61.8 ± 13.6 years) presented with cerebral embolism confirmed by cranial computed tomography. Isolated aortic valve endocarditis was present in 165 patients (44%), 132 patients (36%) had isolated AIE of the mitral valve, and 64 (17%) patients had left-sided double valve endocarditis. Results Although the majority of patients presented with neurologic symptoms, 1 out of 3 patients experienced a so-called silent asymptomatic cerebral embolism or transient ischemic attack (n = 135). The rate of silent embolism was equivalent in patients with isolated aortic valve versus isolated mitral valve endocarditis (37% vs 34%; P  = .54). Comparing patients with silent embolism versus symptomatic embolism, 18 patients with silent embolism versus 12 patients with symptomatic embolism developed postoperative hemiparesis ( P  = .69). Three versus 4 had severe postoperative intracerebral bleeding ( P  = .71). Median follow-up of survivors with cerebral embolism was 4.1 years (935 cumulative patient-years). Hospital mortality was 21.4% versus 19.6% ( P  = .68), with a long-term survival of 45% ± 5% versus 47% ± 4% at 5 years ( P  = .83) and 40% ± 6% versus 32% ± 5% at 10 years ( P  = .86). Independent risk factors of mortality were age at surgery ( P  < .01), chronic obstructive pulmonary disease ( P  = .01), preoperative requirement of catecholamines ( P  = .02), dialysis ( P  < .01), and duration of cardiopulmonary bypass ( P  < .01). Conclusions Survival after surgery for AIE is significantly impaired once cerebral embolism has occurred; however, it does not differ in patients with symptomatic versus silent cerebral embolism. Routine computed tomography scans are therefore mandatory due to the high incidence of asymptomatic cerebrovascular embolism—which appears to be equally as dangerous as symptomatic embolism.