URGENT VALVE SURGERY AFTER ACUTE CEREBRAL EMBOLISM DURING INFECTIVE ENDOCARDITIS

Background: The indication for urgent cardiac surgical interventions i n patients with active infective endocarditis has to be considered car efully following thromboembolic events, because of the high recurrence rate of such complications. In the case of brain embolisms the progno stic benefit of urgent surgery has been discussed controversially as e ffective anticoagulation during open heart surgery may result in secon dary cerebral hemorrhages. Patients and Methods: Between 1978 and 1993 infective endocarditis (IE) was proven in 288 consecutive and prospec tively followed patients (131 females, 157 males;mean age 53.6 +/- 8.7 [9 to 81] years). To analyze potential benefits and risks I of an urg ent surgical intervention early after embolic cerebral infarction, cum ulated survival rates were calculated for patients with and without su rgical intervention with special reference to incremental risk factors and the timing of surgery. Results: In 50 patients (17.4%) the clinic al course was complicated by one, and in 58 patients (20.2%) by recurr ent embolic events. In 80% the first embolism occurred within 33 days following the first manifestation of typical signs and symptoms of IE. 80% of recurrent events were observed within 32 days follow following the initial embolism. 71% of all embolic events were cerebral. Inpati ents with cerebral embolism corroborated by computed tomography (CCT), the clinical course was complicated by intracranial hemorrhage in 12. 5% while it ,was only 1.5% for patients without cerebral embolism. Bec ause of a lack of therapeutic alternatives, 22 of 49 patients with rec urrent embolic events, of which at least one was cerebral, underwent u rgent cardiac surgery within 4 to 366 hours after the first cerebral m anifestation. The cumulated survival rate of patients operated within 72 hours after the initial cerebral embolism was significantly more fa vorable (p less than or equal to 0.000) than for unoperated patients o r those who were : operated after more than 8 days. Conclusion: An emb olic event during IE carries a more than 50% risk of recurrence. In pa tients with short duration of signs and symptoms of IE and postembolic echocardiographic demonstration of persistent vegetations the probabi lity is > 80%. At least for those patients urgent surgical interventio n to remove the source of infection and embolic hazard seems to be ben eficial. Surgical intervention using the heart-lung-machine should be performed within 72 hours. Such early timing results in a significant lower fate of secondary cerebral hemorrhages (p less than or equal to 0.000) than a postponed operation. To exclude early reperfusion fusion hemorrhage due to spontaneous thrombus fragmentation, CCT should be r epeated directly preoperatively.