Early versus delayed surgery to prevent hemorrhagic transformation in patients with septic cerebral emboli from infective endocarditis

The optimal timing of cardiac surgery in patients with infective endocarditis and ischemic septic cerebral embolism remains uncertain, largely because of concern for perioperative hemorrhagic transformation. This study evaluates the association between surgical timing and outcomes in this population. Patients with infective endocarditis and preoperative septic cerebral emboli who underwent cardiac surgery were identified from an institutional database (1999-2025). After excluding those with preoperative cerebral hemorrhage, 240 patients with ischemic stroke were stratified by interval from stroke to surgery: early (≤7 days, n=109) versus delayed (8-30 days, n=131). Propensity score matching was used to balance baseline confounders. The primary outcome was postoperative hemorrhagic transformation; secondary outcomes included new postoperative stroke, intensive care unit and hospital length of stay, four-year survival assessed by Kaplan-Meier analysis, and mortality assessed by Cox proportional hazards modeling. Matching yielded 194 patients. Postoperative hemorrhagic transformation occurred in 10 of 194 (5.2%) patients and did not differ by timing (6.2% early vs. 4.1% delayed, p=0.73). New postoperative stroke occurred in 19 of 194 patients (9.8%) and was similar (10.3% early vs. 9.3% delayed, p>0.99), as was 30-day mortality (6.2% early vs. 10.3% delayed, p=0.42). Four-year survival did not differ by timing (68.0% early vs. 57.4% delayed, p=0.07), and there was no significant association between surgical timing and mortality (HR 0.67 [0.44-1.03]; p=0.07). In patients with infective endocarditis and ischemic stroke, early surgery (≤7 days) was not associated with increased rates of postoperative hemorrhagic transformation, new stroke, or 30-day or long-term mortality compared with delayed surgery.