Infective endocarditis (IE) presents a significant public health challenge, with an estimated incidence of 13.8 cases per 100,000 individuals annually, leading to approximately 66,300 deaths globally due to its high morbidity and mortality rates. Septic embolic stroke is one of the most frequent and feared complications, affecting up to 50% of patients with IE and correlating with an increased mortality risk. However, the impact of preoperative septic cerebral embolism (SCE) on postoperative outcomes and long-term survival in IE patients requiring valve surgery remains underexplored.
This study aimed to evaluate the impact of preoperative SCE on both short- and long-term outcomes in IE patients undergoing valve surgery. This retrospective study utilized data from the Clinical Multicenter Project for Analysis of Infective Endocarditis in Germany (CAMPAIGN) registry, covering cases from 1994 to 2018 across six German centers, with follow-up until the first quarter of 2022.
The study analyzed demographic data, risk factors, medical history, clinical status, echocardiographic and microbiological findings, intraoperative and postoperative details, and complications. During the study period, a total of 4,917 patients underwent cardiac surgery due to IE. Among these, 3,909 patients (79.5%) did not present with preoperative SCE, while 1,008 patients (20.5%) did.
Among the patients with SCE, 71.6% were symptomatic, while 28.4% were asymptomatic. The SCE group showed a higher prevalence of cardiovascular risk factors, including smoking (21.3% vs. 17.1%; p < .005), myocardial infarction (8.8% vs. 6.7%; p < .05), hypertension (62.5% vs. 47.6%; p < .05), and peripheral artery disease (9.3% vs. 7.2%; p < .001). Additionally, EuroSCORE II was significantly elevated (11% vs. 10%; p < .007) in the SCE group.
The SCE group also demonstrated a significantly higher need for preoperative mechanical ventilation (18.1% vs. 7.2%; p< .001) and exhibited increased prevalence of mitral valve IE (44.1% vs. 33.0%; p < .001), presence of vegetations (87.8% vs. 57.9%; p < .001), large vegetations (>10 mm; 43.1% vs. 30.0%; p < .001), and Staphylococcus spp. as the causative microorganism (42.3% vs. 21.3%; p < .001).
Postoperative outcomes showed significantly longer mean durations of mechanical ventilation (25 h vs. 15 h; p < .001) and ICU stays (4 days vs. 3 days; p < .001) in the SCE group. Furthermore, the SCE group had a higher incidence of new-onset postoperative stroke (24.9% vs. 12.0%; p < .001).
Analysis of 30-day mortality (22.8% vs. 20.1%) and 5-year survival (49.1% vs. 47.8%) revealed no statistically significant differences.
The authors concluded that early mortality and 5-year survival are comparable between patients with and without preoperative SCE. However, a comprehensive evaluation of the patient’s overall condition remains essential for informed decision-making.
COMMENTARY:
Septic cerebral embolism (SCE) is recognized as a common complication in infective endocarditis (IE). This article reaffirms the prevalence outlined in the 2023 ESC guidelines on IE (35%), with a 20.5% occurrence rate in the CAMPAIGN registry cohort. The study also supports existing literature linking IE with SCE, noting an increased prevalence of left-sided heart involvement, presence and size of vegetations, and Staphylococcus spp. infections.
While SCE did not influence 30-day mortality or 5-year survival, it was associated with an elevated baseline risk profile and delayed recovery. The study did not analyze specific tomographic characteristics, the extent of SCE, neurological manifestations, or neurological status pre- or post-surgery, limiting comprehensive outcome analysis.
A holistic view of SCE’s impact is crucial, taking into account the patient’s neurological state without letting SCE alone dictate morbidity or drive clinical decisions.
REFERENCE:
Marin-Cuartas M, De La Cuesta M, Weber C, Krinke E, Lichtenberg A, Petrov A, et al. Outcomes following heart valve surgery in patients with infective endocarditis and preoperative septic cerebral embolism: insights from the CAMPAIGN study group. Eur J Cardiothorac Surg. 2024 Aug 2;66(2):ezae295. doi: 10.1093/ejcts/ezae295.
