Optimal Timing for Cardiac Surgery in Patients with Infective Endocarditis Complicated by Acute Septic Embolic Ischemic Stroke: A Systematic Review and Meta-analysis
Abyaz Asmar1, Summaiyya Waseem2, Emiliya Melkumova3
1Neurology, Houston Methodist Neurological Institute, 2Dow University of Health Sciences, 3Neurology, Tufts University School of Medicine
Objective:
To define optimal timing for cardiac surgery in infective endocarditis (IE) patients with acute ischemic stroke (AIS) and to analyze the risk of peri-operative stroke and mortality after early surgery (< 14 days) compared to delayed surgery (> 14 days)
Background:
Multiple factors come into play when deciding the timing for surgery in patients with IE who develop AIS such as the size of vegetations, persistent bacteremia, area of infarction, and presence of hemorrhagic transformation. Although current cardiothoracic surgery guidelines recommend delaying cardiac surgery for 4 weeks in patients with IE complicated by an AIS in light of the increased peri-operative risk of stroke and mortality, recent studies have shown an increasing trend toward the safety of earlier surgery
Design/Methods:
A comprehensive literature review was performed using PubMed, Embase, and Cochrane, from inception till May 2023 that included 22 observational studies analyzing the risk of mortality and peri-operative neurological complications in IE patients who underwent cardiac surgery within 7-14 days when compared to patients operated upon after 14 days. Comprehensive Meta-Analysis (CMA) version 3.0 was used
Results:
A total of 1818 patients were included in the analysis with 758 in the early surgery group and 1100 undergoing delayed surgery. There was a significantly increased risk of peri-operative mortality in the early group (RR=1.480, 95% [CI= 1.124-1.949], p=0.000), but no statistically significant difference in the risk for peri-operative neurological complications (RR=1.493, [95% CI=0.799-2.792], p=0.975). Sub-group analysis based on the timing of early surgery showed similar results.
Conclusions:
Early cardiac surgery (<14 days) in IE patients with embolic AIS increases the risk of peri-operative mortality without worsening neurological complications. Surgery performed 14 days after AIS is not associated with an increased risk of peri-operative mortality nor neurological complications, and therefore, can be considered as the optimal timing but there is a need for more supportive evidence.