Investigate the influence of valve replacement surgical timing on neurologic outcomes in patients with infectious endocarditis (IE) and major pre-operative neurologic complications.

IE guidelines recommend delay in valve replacement by 4 weeks after major ischemic stroke or intracranial hemorrhage. Many studies supporting these guidelines assess outcomes not clearly attributable to adverse effects of the surgery itself. We compared surgical delay by greater or less than 4 weeks in this patient population.

Of 907 IE patients with neurologic complications based on clinical course and imaging, 94 had undergone valve replacement (MVR, AVR, TVR). Major complications included mycotic aneurysms (MA), subarachnoid hemorrhages (SAH), ischemic strokes (IS), microhemorrhages, intraparenchymal hemorrhages (IPH), brain abscesses, epidural abscesses, and death attributable to neurological causes. For patients with major neurologic complications prior to valve surgery we assessed post-operative neurologic complications based on timing of surgery (<4 or >4 weeks). We considered complications potentially attributable to surgery if they occurred within 30 post-operative days. 

Of 27 patients with major neurologic complications, 63% had MVR, 48% had TVR, and 7% had AVR. Complications included IS (74%),  microhemorrhages (19%), SAH (15%), IPH (15%), seizures (15%), brain abscesses (15%), epidural abscesses (11%) and MAs (11%). 

No patient had major neurologic complications within 30 days of surgery. Twenty-one (78%) had surgery after 4 weeks, 22% had surgery <4 weeks due to respiratory complications (5) and high risk of re-embolization (1). Of 20 patients with pre-operative IS, 4 had surgery in <4 weeks, of IPH 1, of MA 1. Patients with all other complications had surgery after 4 weeks.

Patients undergoing valve surgery <4 weeks following major neurologic complications had no post-operative neurologic complications. Although small, this study suggests the need for more research on optimal timing for surgery in IE.