title: Valve surgery in active endocarditis patients complicated by intracranial haemorrhage: the influence of the timing of surgery on neurological outcomes.
abstract: OBJECTIVE
  The risk of neurological deterioration during valve surgery using cardiopulmonary bypass under systemic heparinization in infective endocarditis (IE) patients with intracranial haemorrhage (ICH) is unknown. The objective of this retrospective study was to investigate the stratified risk related to the timing of valve surgery on neurological outcomes in patients with active IE and preoperative ICH.
  
  
  METHODS
  From 2004 to 2012, 246 patients underwent valve surgery for IE in hospitals enrolled in the Osaka Cardiovascular Research Group. Of these, a group of 30 patients had preoperative ICH, and they included 18 patients with cerebral haemorrhage, 8 with subarachnoid haemorrhage and 4 with haemorrhagic infarction. The preoperative characteristics, neurological statuses and postoperative results of these patients were retrospectively explored to analyse the effects of the timing of surgery on neurological outcomes.
  
  
  RESULTS
  Twenty-one patients had symptomatic ICH, and the median modified Rankin score was 1.5 (95% confidence interval [CI] 1.2-2.8). Eight patients were diagnosed with mycotic aneurysms, and 7 of these patients underwent aneurysm resection or clipping before valve surgery. All 30 patients underwent valve surgery, and the median interval between ICH onset and surgery was 22.5 (95% CI 15.5-39.4) days. Four patients died of multiple organ dysfunction or heart failure. The interval between ICH onset and valve surgery was within 7 days for 5 cases, between 8 and 14 days for 6, between 15 and 28 days for 9 and >29 days for 10. Postoperative neuroimaging showed that neither neurological deterioration nor exacerbation of haemorrhagic lesions had occurred among the 30 patients, regardless of the timing of surgery. However, 2 cases who underwent valve surgery 8 and 81 days after the onset of ICH developed new ectopic asymptomatic haemorrhages postoperatively.
  
  
  CONCLUSIONS
  The risk of postoperative neurological deterioration resulting from the exacerbation of haemorrhagic lesions seemed relatively low, even in IE patients who underwent valve surgery within 2 weeks of ICH onset. However, further evaluation of the sizes and aetiologies of haemorrhagic lesions is vital to establish a safe interval between the ICH onset and surgery.
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Daisuke
authors.initials: D
authors.lastname: Yoshioka
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Koichi
authors.initials: K
authors.lastname: Toda
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Taichi
authors.initials: T
authors.lastname: Sakaguchi
authors.affiliation: Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Shuhei
authors.initials: S
authors.lastname: Okazaki
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Yamauchi
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Shigeru
authors.initials: S
authors.lastname: Miyagawa
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Nishi
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Yasushi
authors.initials: Y
authors.lastname: Yoshikawa
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Satsuki
authors.initials: S
authors.lastname: Fukushima
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Tetsuya
authors.initials: T
authors.lastname: Saito
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan sawa-sec@surg1.med.osaka-u.ac.jp.
authors.forename: Yoshiki
authors.initials: Y
authors.lastname: Sawa
mesh_terms: D000328:Adult; D000368:Aged; D004696:Endocarditis / Q000150:complications / Q000453:epidemiology / Q000601:surgery; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000379:methods*; D006801:Humans; D020300:Intracranial Hemorrhages / Q000150:complications / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome
keywords: Endocarditis; Heart valve; Intracranial haemorrhage; Stroke