title: A Meta-Analysis of Early Versus Delayed Surgery for Valvular Infective Endocarditis Complicated by Embolic Ischemic Stroke.
abstract: OBJECTIVE
  An embolic ischemic stroke occurs in 10% to 40% of patients with valvular infective endocarditis (IE) and confers significant morbidity. The optimal timing of valve surgery in this population is not well defined.
  
  
  METHODS
  With the use of PubMed, EMBASE, Ovid, and Cochrane databases, a systematic review identified 14 studies through October 2015 that compared early versus delayed surgery for valvular IE complicated by an ischemic stroke. Early surgery was defined as 3 days or less in one, 7 days or less in eight, and 14 days or less in five studies. Risk ratios (RRs) were calculated by the Mantel-Haenszel method under a fixed- or random-effects model, for the outcomes of perioperative stroke, operative mortality, and 1-year survival.
  
  
  RESULTS
  A total of 833 patients (early surgery, 330; delayed surgery, 503) were included. The majority of operations were for aortic and/or mitral valve IE, with prosthetic valve IE present in 0% to 60%. Infection with Staphylococcus aureus ranged from 19% to 66%, and heart failure prevalence at the time of operation was 24% to 66%. Early surgery was associated with an increased risk of operative mortality (RR, 1.72; 95% confidence interval [CI], 1.27-2.34; P = 0.0005), which was significant regardless of surgery within the first 7 days (RR, 2.19; 95% CI, 1.45-3.31; P = 0.0002) or 14 days (RR, 1.72; 95% CI, 1.12-2.64; P = 0.01) after stroke. Surgical timing did not affect the risk of perioperative ischemic or hemorrhagic stroke or 1-year survival.
  
  
  CONCLUSIONS
  In patients with valvular IE complicated by ischemic stroke, early surgery is associated with an increased risk of operative mortality, with no observed benefit in 1-year survival.
authors.affiliation: From the *Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA; and †Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL USA.
authors.forename: Christos G
authors.initials: CG
authors.lastname: Mihos
authors.forename: Andres M
authors.initials: AM
authors.lastname: Pineda
authors.forename: Orlando
authors.initials: O
authors.lastname: Santana
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004697:Endocarditis, Bacterial / Q000150:complications / Q000401:mortality / Q000601:surgery*; D005260:Female; D006333:Heart Failure / Q000453:epidemiology; D006349:Heart Valve Diseases / Q000150:complications / Q000382:microbiology* / Q000401:mortality / Q000601:surgery; D019918:Heart Valve Prosthesis Implantation / Q000401:mortality*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology* / Q000401:mortality / Q000601:surgery; D016019:Survival Analysis; D061665:Time-to-Treatment; D016896:Treatment Outcome