title: The impact of preoperative neurological events in patients suffering from native infective valve endocarditis.
abstract: OBJECTIVE
  Infective native valve endocarditis (NVE) complicated by a preoperative neurological event still remains a surgical challenge. Particularly, great uncertainty exists with regard to the optimal timing of surgery. We call for a multidisciplinary team approach for individualized risk estimation and analysed our experience obtained over the past decade.
  
  
  METHODS
  Between 1997 and 2012, a total of 495 patients underwent valve surgery for the treatment of NVE. Of these, 70 (14.1%) patients suffered from NVE complicated by an acute neurological event and formed the study group. The remaining 425 (85.9%) patients served as the control group. The mean age of the predominantly male (80.0%) study population was 54 ± 14 years. EuroSCORE and EuroSCORE II predicted a high surgical risk (24.9 ± 6.8 and 10.8 ± 8.1%, respectively). The mean follow-up time was 4.0 ± 3.1 years, ranging up to 15.6 years with an interquartile range from 1.7 to 5.4 years. An interdisciplinary team consisting of a cardiac surgeon, a cardiologist and a neurologist made the decision for surgery.
  
  
  RESULTS
  Observed neurological deficits mainly consisted of ischaemic stroke (75.7%), meningoencephalitis (12.9%) and intracerebral haemorrhage (8.6%). The mean time interval between the neurological event and surgery was 8.7 ± 10.3 days for all patients, 8.0 ± 7.0 days for ischaemic stroke and 17 ± 24 days for intracerebral haemorrhage. Postoperatively, most of the patients experienced no change (22.9%) or even improvement (67.1%) of their neurological symptoms. Only 10.0% showed further deterioration of their neurological status. This was particularly true for patients suffering from intracerebral haemorrhage, with 33.3% experiencing further neurological impairment. The presence of a preoperative neurological event was identified as an independent risk factor for in-hospital mortality (OR 2.66; 95% CI: 1.02-6.78; P = 0.046) but not for mortality during further follow-up (P = 0.257). The hospital mortality rate was 17.2%; and the 1-, 5- and 10-year survival rates were 74.3, 68 ± 5.0 and 67.1 ± 9.0%, respectively.
  
  
  CONCLUSIONS
  NVE complicated by neurological events remains a challenging disease with high mortality and morbidity. Cardiac surgery seemed to be safe in the observed time interval, particularly for patients suffering from ischaemic stroke. A multidisciplinary approach is advocated for very individualized risk estimation.
authors.affiliation: Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany manuel.wilbring@gmail.com.
authors.forename: Manuel
authors.initials: M
authors.lastname: Wilbring
authors.affiliation: Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany.
authors.forename: Linda
authors.initials: L
authors.lastname: Irmscher
authors.affiliation: Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany.
authors.forename: Konstantin
authors.initials: K
authors.lastname: Alexiou
authors.affiliation: Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany.
authors.forename: Klaus
authors.initials: K
authors.lastname: Matschke
authors.affiliation: Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany.
authors.forename: Sems-Malte
authors.initials: SM
authors.lastname: Tugtekin
mesh_terms: D000328:Adult; D000368:Aged; D002545:Brain Ischemia / Q000175:diagnosis / Q000209:etiology; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D002543:Cerebral Hemorrhage / Q000175:diagnosis / Q000209:etiology; D002561:Cerebrovascular Disorders / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D018450:Disease Progression; D004696:Endocarditis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008590:Meningoencephalitis / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010348:Patient Care Team; D018579:Patient Selection; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000209:etiology; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome
keywords: Bleeding; Endocarditis; Stroke; Surgery; Timing