VALVE-REPLACEMENT IN PATIENTS WITH ENDOCARDITIS AND ACUTE NEUROLOGIC DEFICIT

Background. Acute neurologic deficits occur in up to 40% of patients w ith left heart endocarditis. Appropriate evaluation and management of patients with acute neurologic dysfunction who require valve operation s for endocarditis remain controversial. This retrospective review was undertaken to develop recommendations for the evaluation and treatmen t of these challenging patients. Methods. From 1983 to 1995, 247 patie nts underwent operations for left heart native valve endocarditis at t he Johns Hopkins Hospital. From a review of medical and pathology reco rds, 34 patients (14%) with preoperative neurologic deficits were iden tified. Data on these 34 patients were recorded and analyzed. Results. Causes of neurologic dysfunction included embolic cerebrovascular acc ident (n = 23, 68%), embolic cerebrovascular accident with hemorrhage (n = 4, 12%), ruptured mycotic aneurysm (n = 3, 9%), transient ischemi c attack (n = 2, 6%), and meningitis (n = 2, 6%). Preoperative diagnos tic studies included computed tomography (32 patients), magnetic reson ance imaging (11 patients), cerebral angiogram (14 patients), and lumb ar puncture (2 patients). Computed tomography demonstrated structural lesions in 29 of 32 patients; in only 1 patient did magnetic resonance imaging reveal a lesion not already seen on computed tomography. Of 1 4 patients having cerebral angiograms, 7 had a mycotic aneurysm. Three mycotic aneurysms had ruptured, and these were clipped before cardiac operations. The mean interval from onset of neurologic deficit to car diac operation was 22.2 +/- 2.8 days for all patients and 22.1 +/- 3.0 days for those with embolic cerebrovascular accident. The hospital mo rtality rate was 6%. New or worse neurologic deficits occurred in 2 pa tients (6%). Conclusions. Neurologic deficits are common in patients w ith endocarditis referred for cardiac operations. Despite substantial preoperative morbidity, most of these patients do well if the operatio n can be delayed for 2 to 3 weeks. Computed tomography scan is the pre operative imaging technique of choice, as routine magnetic resonance i maging and cerebral angiogram are unrewarding. Cerebral angiogram is i ndicated only if computed tomography reveals hemorrhage.