Influence of the Timing of Cardiac Surgery on the Outcome of Patients With Infective Endocarditis and Stroke

Bruno Barsic () 7 Stuart Dickerman 6 Vladimir Krajinovic 7 Paul Pappas 5 Javier Altclas 12 Giampiero Carosi 11 Jos H. Casab 10 Vivian H. Chu 5 Francois Delahaye 9 Jameela Edathodu 14 Claudio Querido Fortes 13 Lars Olaison 8 Ana Pangercic 3 Mukesh Patel 4 Igor Rudez 1 Syahidah Syed Tamin 2 Josip Vincelj 1 Arnold S. Bayer 0 Andrew Wang 5 for the International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators 0 Geffen School of Medicine at the University of California , Los Angeles 1 Dubrava University Hospital , Zagreb, Croatia 2 Institut Jantung Negara , Kuala Lumpur, Malaysia 3 University Hospital Centre Sestre Milosrdnice , Zagreb, Croatia 4 University of Alabama at Birmingham, Birmingham Veterans Affairs Medical Center 5 Duke University Medical Center, Duke Clinical Research Institute , Durham, North Carolina 6 New York University School of Medicine , New York 7 Hospital for Infectious Diseases, School of Medicine , Zagreb, Croatia 8 Sahlgrenska University Hospital , Gteborg, Sweden 9 Hopital Louis Pradel, Lyon, France 10 Fundacin Favaloro, Buenos Aires, Argentina 11 University of Brescia , Italy 12 Barcelona Centre for International Health Research , Spain 13 Clementino Fraga Filho Hospital , Rio de Janeiro, Brazil 14 Faisal Hospital and Research Centre , Riyadh, Saudi Arabia Background. The timing of cardiac surgery after stroke in infective endocarditis (IE) remains controversial. We examined the relationship between the timing of surgery after stroke and the incidence of in-hospital and 1-year mortalities. Methods. Data were obtained from the International Collaboration on Endocarditis-Prospective Cohort Study of 4794 patients with definite IE who were admitted to 64 centers from June 2000 through December 2006. Multivariate logistic regression and Cox regression analyses were performed to estimate the impact of early surgery on hospital and 1-year mortality after adjustments for other significant covariates. Results. Of the 857 patients with IE complicated by ischemic stroke syndromes, 198 who underwent valve replacement surgery poststroke were available for analysis. Overall, 58 (29.3%) patients underwent early surgical treatment vs 140 (70.7%) patients who underwent late surgical treatment. After adjustment for other risk factors, early surgery was not significantly associated with increased in-hospital mortality rates (odds ratio, 2.308; 95% confidence interval [CI], .942-5.652). Overall, probability of death after 1-year follow-up did not differ between 2 treatment groups (27.1% in early surgery and 19.2% in late surgery group, P = .328; adjusted hazard ratio, 1.138; 95% CI, .802-1.650). Conclusions. There is no apparent survival benefit in delaying surgery when indicated in IE patients after ischemic stroke. Further observational analyses that include detailed pre- and postoperative clinical neurologic findings and advanced imaging data (eg, ischemic stroke size), may allow for more refined recommendations on the optimal timing of valvular surgery in patients with IE and recent stroke syndromes. - Stroke syndromes remain one of the most common and often devastating complications of infective endocarditis (IE). The published incidence of stroke in IE varies from 10% to 50% [18], with an associated mortality that ranges from 20% to 58% [911]. The timing of valvular surgery in such patients remains controversial. The high rates of postoperative morbidity and mortality reported in earlier studies [1214] have resulted in great hesitation in referring patients with IE and recent stroke for immediate valvular surgery. More recent investigations have suggested better outcomes of IE patients with stroke who underwent cardiac valvular surgery, particularly in the presence of ischemic rather than hemorrhagic stroke [1518]. Current recommendations are somewhat ambiguous, but generally favor deferral of surgical intervention for 24 weeks after a significant ischemic infarct and at least 4 weeks after intracerebral hemorrhage, unless a delay in surgery puts the patient at immediate risk of death [1922]. There have been no large, prospective studies to date that definitively guide decision making in terms of the timing of cardiac surgery in IE following acute stroke syndromes. In the present investigation, we utilized a large, prospectively enrolled, multicenter database registry of IE patients to specifically address the outcomes of cardiac surgical intervention following recent stroke. A recent study from The International Collaboration on EndocarditisProspective Cohort Study (ICE-PCS), established in 2000, suggested a survival benefit of cardiac surgery at any time during hospitalization after stroke complicating IE [23]. The objective of the current study was to further evaluate the influence of the timing of cardiac surgical interventions on in-hospital and longer-term mortality of patients with IE and recent ischemic stroke. Patient Population Data from the ICE-PCS were used for this study. From June 2000 to December 2006, 4794 patients with definite IE were enrolled into ICE-PCS from 64 centers in 28 countries. Full details on site criteria for participation and data collection have been presented previously [24]. Patient Selection/Data Collection Patients were identified prospectively using site-specific procedures to ensure consecutive enrollment. Patients were enrolled in ICE-PCS if they met criteria for possible or definite IE based upon the modified Duke criteria [25]. A standard case report form was used at all sites to collect data. Analysis included patients with definite IE, ischemic stroke, and known timing of cardiac surgery regarding the onset of stroke. Patients with hemorrhagic stroke were excluded from the study. Study flow is presented in Figure 1. Definitions Stroke was defined as an acute neurological deficit of vascular etiology lasting >24 hours, and was further characterized as ischemic or hemorrhagic using neuroimaging results. Patients with other neurologic manifestations associated with IE (eg, meningitis, brain abscess, septic encephalopathy, intracranial mycotic aneurysm, transient ischemic attack) were excluded. On the basis of the time between stroke and cardiac surgery, patients were divided into 2 groups: early (surgery performed 17 days after ischemic stroke) and late (surgery >7 days after ischemic stroke). Survival duration was defined Figure 1. Flow diagram of the International Collaboration on EndocarditisProspective Cohort Study study. as the time of admission into referral center to time of death or last contact. Statistical Analyses Categorical variables are reported as frequency and percentage. Continuous variables are reported as median and 25th and 75th percentiles. Simple comparisons were done for categorical variables using the 2 test or Fisher exact test as appropriate. If the number of patients within the cell was <10 patients, we used Freeman-Halton extension of the Fisher exact (...truncated)