Does a focal neurologic deficit contraindicate operation in a patient withendocarditis?

Background. As many as 40% of patients with left-sided bacterial endocardit is will sustain a neurologic insult. The importance of a neurologic change as an indication or a contraindication for valve replacement remains contro versial. Methods. We performed a retrospective analysis of the records of 33 patient s admitted to the University of Virginia Health Sciences Center between Jan uary 1, 1978, and Tune 30, 1996, with a diagnosis of endocarditis and a neu rologic change. Results. All 33 patients had echocardiographic or pathologic evidence of le ft-sided endocarditis; 23 were seen with focal neurologic findings and had a mortality rate of 22% (5 of 23), and 10 patients were seen with nonfocal, diffuse encephalopathy and had a mortality rate of 60% (6 of 10) (p < 0.05 ). Of the 33 patients, 14 underwent operation and 19 were treated medically . The mortality rate was 21.4% (3 of 14) in the surgical group and 42.1% (8 of 19) in the medical group (p = not significant). In 71% (10 of 14) of th e surgical patients, the operation was done within 1 week of the neurologic event. Additional neurologic deterioration occurred in 18.2% (2 of II) of survivors in the surgical group and 9.1% (I of 11) in the medical group (p = not significant). Conclusions. Choosing therapy for a patient with endocarditis and a neurolo gic change remains a difficult challenge. Initial findings of nonfocal, glo bal dysfunction on examination are a predictor of a poor outcome. By compar ing surgical and medical groups derived from the same series of patients, i t is clear that patients with bacterial endocarditis and central nervous sy stem changes face substantial mortality regardless of intervention. However , these data demonstrate that when compared with a similar group of medical patients, surgical patients who require and receive operation early in the course of their illness do comparatively well. Improving outcomes by delay ing surgical intervention may serve to "select out" hardier patients but wi ll lead to the death of patients who might benefit from such intervention. (C) 1999 by The Society of Thoracic Surgeons.