Impact of valve surgery in patients with infective endocarditis and neurological complications

Abstract

Neurologic complications (NC) are a major cause of morbidity and mortality in patients (pts) with infective endocarditis (IE) and may prevent pts from receiving valve surgery. Methods:Among399cases of Li definite left-sidedIE collectedduring a one-year prospective population-based survey, 100 had at least one symptomatic neurological complication (SNC). NC included transient ischemic attack, ischemic stroke, cerebral hemorrhage, meningitis, brain abscess and intracranial mycotic aneurysm. A neuroimaging procedure was performed in 183 of the remaining pts, which diagnosed 35 asymptomatic (As) NC and was considered normal (NoNC) in 148 pts. Results: Among pts with SNC, 40 episodes occurred after the beginning of IE antibiotic therapy (21 during the first 48 hours). Mechanical prosthetic IE (OR 3.4, p = 0.007), S. aureus IE (OR 1.8, p = 0.03) and mitral IE (OR 2.0, p = 0.008) were predictive of the occurrence of NC. Among the 135 NC pts, age, renal failure, septic shock and S. aureus as responsible micro-organism were predictive of in-hospital (33%) and 1-year mortality (38%). Furthermore, a symptomatic NC was also predictive of 1-year mortality. Rate of surgery was not different between pts with and without NC (52% vs 57%) but was significantly higher in AsNC than in SNC (77% vs 43%). In-hospital mortality was higher in pts with NC than in NoNC pts (33% vs 17%, p = 0.001) and in SNC than in AsNC (42% vs 9%, p = 0.0003). Among the 135 NC pts, 95 had a surgical indication (71%) which was performed in 70 (mortality 20%) and not performed in 25 (mortality 68%). Conclusion: The presence of NC is associated with a poor prognosis when it is symptomatic. However, when NC is discovered on systematic neuroimaging, it is associated with a very high rate of surgery and a better prognosis than that of pts with SNC and even without NC, suggesting a protective role of surgery.