Impact of stroke on therapeutic decision making in infective endocarditis

The diagnosis of infective endocarditis (IE) must be made as soon as possible to initiate antimicrobial therapy and identify patients at high risk for complications who may be best managed by early surgery. Cerebral complications make the timing of cardiac surgery difficult. The safety of cardiopulmonary bypass (CPB) surgery in stroke patients remains controversial. Stroke complicates the outcome of left-sided IE in 20-40% of cases and is associated with poor outcome. The risk of stroke in IE falls rapidly after the initiation of effective antimicrobial therapy. The risk of embolization is highest during the first week of therapy, and in patients with mobile vegetations or vegetations > 10 mm in diameter occurring on the anterior mitral leaflet. Indications for valvular surgery are significant congestive heart failure or valvular regurgitation, myocardial abscess, persistent bacteremia and large-size vegetations with high risk of embolism. Decisions regarding surgical intervention in patients with IE should be individualized. In the absence of large prospective studies, optimal timing of surgery is still discussed when stroke complicates IE. A multidisciplinary assessment of the situation, involving cardiologists, cardiac surgeons, infectiologists and neurologists, is recommended. Estimating the risk of recurrence after a first embolic event and careful evaluation of the indication for valve replacement are essential steps in making the therapeutic decision. Surgery should be delayed if possible in the event of large cerebral infarction or ICH in order to prevent neurological deterioration. It has been suggested that valve replacement should be considered within the first 72 h if the patients with brain infarction have severe heart failure, otherwise after 4 weeks. Early surgery appears safe in patients presenting transient ischemic attacks or silent cerebral embolism.