Key result
Intermediate surgery post-stroke is linked to highest in-hospital mortality at ~26% versus earlier or later timing.
Why the study?
Cerebral embolism due to infective endocarditis carries significant morbidity and mortality, but the optimal time-interval between symptomatic stroke and cardiac surgery remains unclear.
Does the timing of cardiac surgery (early, intermediate, or late) affect in-hospital mortality in patients with infective endocarditis and cerebral embolism?
Cohort (n=119)
Single-blind
No
Does the timing of cardiac surgery (early, intermediate, or late) affect in-hospital mortality in patients with infective endocarditis and cerebral embolism?
Operative timing is not an independent risk factor for in-hospital mortality in IE patients with cerebral embolism, though early surgery is recommended for those with large vegetations (>8 mm).
Answers are grounded in this paper and cite their sources.
Intermediate timing linked to higher mortality but not independently; leaves open optimal surgical timing in IE with cerebral embolism.
Cerebral embolism due to infective endocarditis (IE) is associated with significant morbidity and mortality. The optimal time-interval between symptomatic stroke and cardiac surgery remains unclear. This study aimed to analyze the patients’ outcomes and define the potential risk factors with regard to surgical timing for IE patients with preoperative symptomatic cerebral embolism (CE). A total of 119 IE patients with CE were identified and analyzed with regard to operative timing: early (1–7 days), intermediate (8–21 days), and late (>22 days). The preoperative patient data, comorbidities and previous cardiac surgical procedures were analyzed to identify potential predictors and independent risk factors for in-hospital mortality using univariate and multivariate regression analysis. Actuarial survival was estimated by the Kaplan-Meier method. In-hospital mortality for the entire study cohort was 15.1% (n = 18), and in comparison, between groups was found to be highest in the intermediate surgical group (25.7%). Univariate analysis identified preoperative mechanical ventilation dependent respiratory insufficiency (p = 0.006), preoperative renal insufficiency (p = 0.019), age (p = 0.002), large vegetations (p = 0.018) as well as intermediate (p = 0.026), and late (p = 0.041) surgery as predictors of in-hospital mortality. The presence of large vegetations (>8 mm) (p = 0.019) and increased age (p = 0.037)—but not operative timing—were identified as independent risk factors for in-hospital mortality. In the presence of large vegetations (>8 mm), cardiac surgery should be performed early and independently from the entity of cerebral embolic stroke. Postponing surgery to achieve clinical stabilization and better postoperative outcomes of IE patients with CE is reasonable, however, worsening of the disease process with deterioration and resulting heart failure during the first 3 weeks after CE results in a significantly higher in-hospital mortality and inferior long-term survival.
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Dashkevich et al. (2021) conducted a cohort in Infective endocarditis with cerebral embolism (n=119). Intermediate operative timing (8-21 days) vs. Early (1-7 days) and late (>22 days) operative timing was evaluated on In-hospital mortality (p=0.066). Intermediate operative timing (8-21 days) was associated with the highest in-hospital mortality (25.7%, p=0.066 overall) and significantly inferior long-term survival (p=0.019) compared to early or late surgery, though only large vegetations and increased age were independent mortality predictors.
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