Not All Strokes Are Equal: Phenotype‐Dependent Surgical Timing in Infective Endocarditis

Background We evaluated postoperative neurologic and mortality outcomes by stroke‐to‐surgery timing and stroke phenotype in patients with left‐sided infective endocarditis. Methods Adult patients undergoing surgery for infective endocarditis complicated by preoperative stroke between 2004 and 2024 at 2 institutions were stratified by stroke‐to‐surgery interval (<1 week, 1–4 weeks, 4–6 weeks). The primary outcome was a composite postoperative cerebrovascular event: new stroke, enlarging stroke, or hemorrhagic conversion. Secondary outcomes were operative death and major morbidity events. Results Among 2265 patients with left‐sided infective endocarditis, 322 met inclusion criteria, of whom 122 (38%) underwent surgery within 1 week, 168 (52%) between 1 and 4 weeks, and 32 (10%) between 4 and 6 weeks. Operative death was similar across groups ( P =0.09). Postoperative cerebrovascular events declined with time (<1 week, 21.3%; 1–4 weeks, 11.9%; 4–6 weeks, 9.4%; P =0.015). On multivariable analysis, longer stroke‐to‐surgery interval was associated with reduced odds of postoperative cerebrovascular events (odds ratio, 0.92/d [95% CI, 0.85–0.98]; P =0.015), driven by early events among patients with intraparenchymal hemorrhage, subarachnoid hemorrhage, and septic emboli. Among ischemic strokes, operative death was lowest with surgery within 1 week (5.8% versus 11.2% at 1–4 weeks; P =0.24). Interval embolization occurred in 10.6% of patients awaiting surgery, most commonly affecting the spleen and kidneys. Conclusions Excess postoperative neurologic risk was concentrated within the first 7 to 10 days and driven by intraparenchymal hemorrhage, subarachnoid hemorrhage, and septic emboli; ischemic stroke showed no appreciable temporal association. Routine delay after ischemic stroke may not be necessary, while a short delay (≈7 days) for hemorrhagic and septic embolic subtypes may be reasonable when hemodynamically feasible.