Surgery for infective endocarditis complicated by cerebral embolism: a consecutive series of 375 patients.
OBJECTIVE
To determine the influence of silent and symptomatic cerebral embolism on outcome of urgent/emergent surgery after acute infective endocarditis (AIE).


METHODS
From a total of 1571 patients with AIE admitted to our institution between May 1995 and March 2012 about one-quarter (375 patients; mean age, 61.8 ± 13.6 years) presented with cerebral embolism confirmed by cranial computed tomography. Isolated aortic valve endocarditis was present in 165 patients (44%), 132 patients (36%) had isolated AIE of the mitral valve, and 64 (17%) patients had left-sided double valve endocarditis.


RESULTS
Although the majority of patients presented with neurologic symptoms, 1 out of 3 patients experienced a so-called silent asymptomatic cerebral embolism or transient ischemic attack (n = 135). The rate of silent embolism was equivalent in patients with isolated aortic valve versus isolated mitral valve endocarditis (37% vs 34%; P = .54). Comparing patients with silent embolism versus symptomatic embolism, 18 patients with silent embolism versus 12 patients with symptomatic embolism developed postoperative hemiparesis (P = .69). Three versus 4 had severe postoperative intracerebral bleeding (P = .71). Median follow-up of survivors with cerebral embolism was 4.1 years (935 cumulative patient-years). Hospital mortality was 21.4% versus 19.6% (P = .68), with a long-term survival of 45% ± 5% versus 47% ± 4% at 5 years (P = .83) and 40% ± 6% versus 32% ± 5% at 10 years (P = .86). Independent risk factors of mortality were age at surgery (P < .01), chronic obstructive pulmonary disease (P = .01), preoperative requirement of catecholamines (P = .02), dialysis (P < .01), and duration of cardiopulmonary bypass (P < .01).


CONCLUSIONS
Survival after surgery for AIE is significantly impaired once cerebral embolism has occurred; however, it does not differ in patients with symptomatic versus silent cerebral embolism. Routine computed tomography scans are therefore mandatory due to the high incidence of asymptomatic cerebrovascular embolism--which appears to be equally as dangerous as symptomatic embolism.
Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany. Electronic address: martinmisfeld@yahoo.de.
Martin
M
Misfeld
Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany.
Felix
F
Girrbach
Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany.
Christian D
CD
Etz
Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany.
Christian
C
Binner
Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany.
Konstantin V
KV
Aspern
Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany.
Pascal M
PM
Dohmen
Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany.
Piroze
P
Davierwala
Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany.
Bettina
B
Pfannmueller
Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany.
Michael A
MA
Borger
Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany.
Friedrich-Wilhelm
FW
Mohr
D000368:Aged; D058070:Asymptomatic Diseases; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D002533:Cerebral Angiography / Q000379:methods; D002543:Cerebral Hemorrhage / Q000209:etiology; D004696:Endocarditis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D020766:Intracranial Embolism / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D002546:Ischemic Attack, Transient / Q000209:etiology; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010291:Paresis / Q000209:etiology; D016016:Proportional Hazards Models; D012307:Risk Factors; D020521:Stroke / Q000209:etiology; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome