title: Optimal timing of surgery for active infective endocarditis with cerebral complications: a Japanese multicentre study.
abstract: OBJECTIVE
  The aim of this study was to investigate the effect of the timing of valve surgery on the clinical outcomes of patients with active infective endocarditis (IE) accompanied by cerebral complications.
  
  
  METHODS
  We retrospectively analysed a cohort of 568 patients, comprising 118 with non-haemorrhagic cerebral infarction (CI), 54 with intracranial haemorrhage (ICH) and 396 without cerebral events (C; control), who underwent surgery for left-sided active IE in 15 Japanese institutes from 2000 to 2011. The mean age was 58.4 ± 16.9 years in the CI group; 54.5 ± 17.4 years in the ICH group and 56.9 ± 16.0 years in the C group. Clinical outcomes were analysed according to the timing of surgery after the diagnosis of CI or ICH was made.
  
  
  RESULTS
  In the CI group, there were 9 (7.6%) hospital deaths, 13 (11%) new cerebral events and 1 (0.8%) redo valve surgery. In the ICH group, there were 3 (5.6%) hospital deaths, 8 (14.8%) new cerebral events and 2 (3.7%) redo valve surgeries. In the C group, there were 36 (9.1%) hospital deaths, 23 (5.8%) new cerebral events and 9 (2.3%) redo valve surgeries. Risk factors for hospital death were prosthetic valve endocarditis (P = 0.045), high C-reactive protein (CRP; P < 0.001) and the elderly (P < 0.001) in the CI group. Delayed surgery (2 weeks after CI) seemed result in a higher incidence of hospital death in the CI group. Patients who had surgery between 15 and 28 days or after 29 days from the onset of CI had higher incidences of hospital death [odds ratio 5.90 (P = 0.107) and 4.92 (P = 0.137), respectively] compared with those who had surgery within 7 days. In the ICH group, risk factors for hospital death were high CRP (P = 0.002) and elderly (P < 0.001). Contrary to CI patients, patients who had surgery between 8 and 21 days or after 22 days after the onset of ICH had lower incidences of hospital death [odds ratio 0.79 (P = 0.843) and 0.12 (P = 0.200), respectively] compared with those who had surgery within 7 days.
  
  
  CONCLUSIONS
  Although statistically insignificant, early surgery in active IE patients with CI is safe, but very early surgery (within 7 days) should be avoided in patients with ICH.
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan yokita@med.kobe-u.ac.jp.
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Okita
authors.affiliation: Kyoto University Graduate School of Medicine, Kyoto, Japan.
authors.forename: Kenji
authors.initials: K
authors.lastname: Minakata
authors.affiliation: Kyoto University Hospital, Kyoto, Japan.
authors.forename: Shinji
authors.initials: S
authors.lastname: Yasuno
authors.affiliation: Kyoto University Graduate School of Medicine, Kyoto, Japan.
authors.forename: Ryuji
authors.initials: R
authors.lastname: Uozumi
authors.affiliation: Kyoto University School of Public Health, Kyoto, Japan.
authors.forename: Tosiya
authors.initials: T
authors.lastname: Sato
authors.affiliation: Kyoto University Hospital, Kyoto, Japan.
authors.forename: Kenji
authors.initials: K
authors.lastname: Ueshima
authors.affiliation: Konishi Cardio-Vascular Medical Clinic, Shimonoseki, Japan.
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Konishi
authors.affiliation: National Cerebral and Cardiovascular Center, Osaka, Japan.
authors.forename: Naomi
authors.initials: N
authors.lastname: Morita
authors.affiliation: University of Tokushima, Tokushima, Japan.
authors.forename: Masafumi
authors.initials: M
authors.lastname: Harada
authors.affiliation: National Cerebral and Cardiovascular Center, Osaka, Japan.
authors.forename: Junjiro
authors.initials: J
authors.lastname: Kobayashi
authors.affiliation: Osaka City University Graduate School of Medicine, Osaka, Japan.
authors.forename: Shigefumi
authors.initials: S
authors.lastname: Suehiro
authors.affiliation: Jichi Medical University, Shimotsuke, Japan.
authors.forename: Koji
authors.initials: K
authors.lastname: Kawahito
authors.affiliation: Iwate Medical University, Morioka, Japan.
authors.forename: Hitoshi
authors.initials: H
authors.lastname: Okabayashi
authors.affiliation: Sakakibara Heart Institute, Okayama, Japan.
authors.forename: Shuichiro
authors.initials: S
authors.lastname: Takanashi
authors.affiliation: Nara Prefecture General Medical Center, Nara, Japan.
authors.forename: Yuichi
authors.initials: Y
authors.lastname: Ueda
authors.affiliation: Nagoya University Graduate School of Medicine, Nagoya, Japan.
authors.forename: Akihiko
authors.initials: A
authors.lastname: Usui
authors.affiliation: Yokohama City University Medical Center, Yokohama, Japan.
authors.forename: Kiyotaka
authors.initials: K
authors.lastname: Imoto
authors.affiliation: Kurume University School of Medicine, Kurume, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Tanaka
authors.affiliation: Wakayama Medical University, Wakayama, Japan.
authors.forename: Yoshitaka
authors.initials: Y
authors.lastname: Okamura
authors.affiliation: Kobe City Medical Center General Hospital, Kobe, Japan.
authors.forename: Ryuzo
authors.initials: R
authors.lastname: Sakata
authors.affiliation: Kyoto Prefectural University of Medicine, Kyoto, Japan.
authors.forename: Hitoshi
authors.initials: H
authors.lastname: Yaku
authors.affiliation: Kawasaki Medical School, Kurashiki, Japan.
authors.forename: Kazuo
authors.initials: K
authors.lastname: Tanemoto
authors.affiliation: Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan.
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Imoto
authors.affiliation: Jikei University School of Medicine, Tokyo, Japan.
authors.forename: Kazuhiro
authors.initials: K
authors.lastname: Hashimoto
authors.affiliation: Jikei University School of Medicine, Tokyo, Japan.
authors.forename: Ko
authors.initials: K
authors.lastname: Bando
mesh_terms: D006348:Cardiac Surgical Procedures / Q000379:methods*; D002544:Cerebral Infarction / Q000453:epidemiology / Q000209:etiology*; D004696:Endocarditis / Q000150:complications / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015994:Incidence; D020300:Intracranial Hemorrhages / Q000453:epidemiology / Q000209:etiology*; D007564:Japan / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome
keywords: Cerebral complications; Infective endocarditis; Timing of surgery