Impact of Operative Timing in Infective Endocarditis with Cerebral Embolism—The Risk of Intermediate Deterioration
Abstract
:1. Introduction
2. Materials and Methods
Definitions and Statistical Analysis
3. Results
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Conflicts of Interest
References
- Habib, G.; Erba, P.A.; Iung, B.; Donal, E.; Cosyns, B.; Laroche, C.; Popescu, B.A.; Prendergast, B.; Tornos, P.; Sadeghpour, A.; et al. Clinical presentation, aetiology and outcome of infective endocarditis. Results of the ESC-EORP EURO-ENDO (European infective endocarditis) registry: A prospective cohort study. Eur. Heart J. 2019, 40, 3222–3232. [Google Scholar] [CrossRef] [Green Version]
- Salaun, E.; Touil, A.; Hubert, S.; Casalta, J.-P.; Gouriet, F.; Robinet-Borgomano, E.; Doche, E.; Laksiri, N.; Rey, C.; Lavoute, C.; et al. Intracranial haemorrhage in infective endocarditis. Arch. Cardiovasc. Dis. 2018, 111, 712–721. [Google Scholar] [CrossRef] [PubMed]
- Hubert, S.; Thuny, F.; Resseguier, N.; Giorgi, R.; Tribouilloy, C.; Le Dolley, Y.; Casalta, J.-P.; Riberi, A.; Chevalier, F.; Rusinaru, D.; et al. Prediction of Symptomatic Embolism in Infective Endocarditis. J. Am. Coll. Cardiol. 2013, 62, 1384–1392. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Habib, G.; Lancellotti, P.; Antunes, M.J.; Bongiorni, M.G.; Casalta, J.-P.; Del Zotti, F.; Dulgheru, R.; El Khoury, G.; Erba, P.A.; Iung, B.; et al. 2015 ESC Guidelines for the manage-ment of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC)Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear 284 Medicine (EANM). Eur. Heart J. 2015, 36, 3075–3128. [Google Scholar] [PubMed]
- García-Cabrera, E.; Fernández-Hidalgo, N.; Almirante, B.; Ivanova-Georgieva, R.; Noureddine, M.; Plata, A.; Lomas, J.M.; Galvez-Acebal, J.; Hidalgo-Tenorio, C.; Ruiz-Morales, J.; et al. Neurologi-cal Complications of Infective Endocarditis: Risk Factors, Outcome, and Impact of Cardiac Surgery: A Multicenter Ob-servational Study. Circulation 2013, 127, 2272–2284. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Baddour, L.M.; Wilson, W.R.; Bayer, A.S.; Fowler, V.G.; Tleyjeh, I.M.; Rybak, M.J.; Barsic, B.; Lockhart, P.B.; Gewitz, M.H.; Levison, M.E.; et al. Infective Endocarditis in Adults: Diagno-sis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2015, 132, 1435–1486. [Google Scholar] [CrossRef] [PubMed]
- Byrne, J.G.; Rezai, K.; Sanchez, J.A.; Bernstein, R.A.; Okum, E.; Leacche, M.; Balaguer, J.M.; Prabhakaran, S.; Bridges, C.R.; Higgins, R.S.D. Surgical Management of Endocarditis: The Soci-ety of Thoracic Surgeons Clinical Practice Guideline. Ann. Thorac. Surg. 2011, 91, 2012–2019. [Google Scholar] [CrossRef] [PubMed]
- Okita, Y.; Minakata, K.; Yasuno, S.; Uozumi, R.; Sato, T.; Ueshima, K.; Konishi, H.; Morita, N.; Harada, M.; Kobayashi, J.; et al. Optimal timing of surgery for active infective en-docarditis with cerebral complications: A Japanese multicentre study. Eur. J. Cardiothorac. Surg. 2016, 50, 374–382. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Angstwurm, K.; Borges, A.C.; Halle, E.; Schielke, E.; Weber, J.R. Timing the valve replacement in infective endocarditis involving the brain. J. Neurol. 2004, 251, 1220–1226. [Google Scholar] [CrossRef] [PubMed]
- Thuny, F.; Avierinos, J.-F.; Tribouilloy, C.; Giorgi, R.; Casalta, J.-P.; Milandre, L.; Brahim, A.; Nadji, G.; Riberi, A.; Collart, F.; et al. Impact of cerebrovascular complications on mortality and neurologic outcome during infective endocarditis: A prospective multicentre study. Eur. Heart J. 2007, 28, 1155–1161. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Snygg-Martin, U.; Gustafsson, L.; Rosengren, L.; Alsiö, Å.; Ackerholm, P.; Andersson, R.; Olaison, L. Cerebrovascular Complications in Patients with Left-Sided Infective Endocarditis Are Common: A Prospective Study Using Magnetic Resonance Imag-ing and Neurochemical Brain Damage Markers. Clin. Infect. Dis. 2008, 47, 23–30. [Google Scholar] [CrossRef] [PubMed]
- Wilbring, M.; Irmscher, L.; Alexiou, K.; Matschke, K.; Tugtekin, S.-M. The impact of preoperative neurological events in pa-tients suffering from native infective valve endocarditis. Interact Cardiovasc. Thorac. Surg. 2014, 18, 740–747. [Google Scholar] [CrossRef] [PubMed]
- Cahill, T.J.; Baddour, L.M.; Habib, G.; Hoen, B.; Salaun, E.; Pettersson, G.B.; Schäfers, H.J.; Prendergast, B.D. Challenges in Infective Endocarditis. J. Am. Coll. Cardiol. 2017, 69, 325–344. [Google Scholar] [CrossRef]
- Hickey, G.L.; Dunning, J.; Seifert, B.; Sodeck, G.; Carr, M.J.; Burger, H.U.; Beyersdorf, F. Statistical and data reporting guidelines for theEuropean Journal of Cardio-Thoracic Surgeryand theInteractive CardioVascular and Thoracic Surgery. Eur. J. Cardio-Thoracic Surg. 2015, 48, 180–193. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Ruttmann, E.; Willeit, J.; Ulmer, H.; Chevtchik, O.; Höfer, D.; Poewe, W.; Laufer, G.; Müller, L.C. Neurological Outcome of Septic Cardioembolic Stroke After Infective Endocarditis. Stroke 2006, 37, 2094–2099. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Yoshioka, D.; Sakaguchi, T.; Yamauchi, T.; Okazaki, S.; Miyagawa, S.; Nishi, H.; Yoshikawa, Y.; Fukushima, S.; Saito, S.; Sawa, Y. Impact of Early Surgical Treatment on Postoperative Neurologic Outcome for Active Infective Endocarditis Complicated by Cerebral Infarction. Ann. Thorac. Surg. 2012, 94, 489–496. [Google Scholar] [CrossRef] [PubMed]
- Eishi, K.; Kawazoe, K.; Kuriyama, Y.; Kitoh, Y.; Kawashima, Y.; Omae, T. Surgical management of infective endocarditis as-sociated with cerebral complications. J. Thorac. Cardiovasc. Surg. 1995, 110, 1745–1755. [Google Scholar] [CrossRef] [Green Version]
- Kim, Y.K.; Choi, C.G.; Jung, J.; Yu, S.N.; Lee, J.Y.; Chong, Y.P.; Kim, S.-H.; Lee, S.-O.; Choi, S.-H.; Woo, J.H.; et al. Effect of cerebral embolus size on the timing of cardiac sur-gery for infective endocarditis in patients with neurological complications. Eur. J. Clin. Microbiol. Infect Dis. 2018, 37, 545–553. [Google Scholar] [CrossRef] [PubMed]
- Okonta, K.E.; Adamu, Y.B. What size of vegetation is an indication for surgery in endocarditis? Interact Cardiovasc. Thorac. Surg. 2012, 15, 1052–1056. [Google Scholar] [CrossRef] [PubMed] [Green Version]
Parameters, n (%) | All Patients (n = 119) | Early (1–7 Days) (n = 40) | Intermediate (8–21 Days) (n = 35) | Late (>22 Days) (n = 44) | p-Value |
---|---|---|---|---|---|
Age (mean, years ± SD) | 61.0 ± 14.7 | 57.5 ± 17.3 | 62.5 ± 14.3 | 62.9 ± 12.1 | 0.358 |
Male gender | 78 (65.5%) | 24 (60.0%) | 26 (74.3%) | 28 (63.6%) | 0.407 |
AV endocarditis | 68 (57.1%) | 28 (70.0%) | 22 (62.9%) | 18 (40.9%) | 0.019 * |
MV endocarditis | 67 (56.3%) | 20 (50.0%) | 18 (51.4%) | 29 (65.9%) | 0.268 |
TV endocarditis | 2 (1.7%) | 1 (2.5%) | 1 (2.9%) | - | 0.530 |
Prev. cardiac surgery | 33 (27.7%) | 6 (15.0%) | 17 (48.6%) | 10 (22.7%) | 0.003 * |
PVE | 30 (25.2%) | 5 (12.5%) | 16 (45.7%) | 9 (20.5%) | 0.003 * |
Smoking history | 23 (19.3%) | 9 (22.5%) | 3 (8.6%) | 11 (25.0%) | 0.152 |
Coronary artery disease | 29 (24.4%) | 7 (17.5%) | 9 (25.7%) | 13 (29.6%) | 0.399 |
Arterial hypertension | 73 (61.3%) | 21 (52.5%) | 24 (68.6%) | 28 (63.6%) | 0.335 |
Pulmonal hypertension | 8 (6.7%) | 2 (5.0%) | 2 (5.7%) | 2 (4.6%) | 0.815 |
Diabetes mellitus | 25 (21.0%) | 6 (15.0%) | 9 (25.7%) | 10 (22.7%) | 0.493 |
Hyperlipoproteinemia | 36 (30.3%) | 11 (27.5%) | 12 (34.3%) | 13 (29.6%) | 0.809 |
Obesity | 23 (19.3%) | 4 (10.0%) | 8 (22.9%) | 11 (25.0%) | 0.181 |
Peripheral artery disease | 8 (6.7%) | 2 (5.0%) | 5 (14.3%) | 1 (2.3%) | 0.132 |
Splenomegaly | 13 (10.9%) | 3 (7.5%) | 4 (11.4%) | 6 (13.6%) | 0.708 |
LVEF < 35% | 10 (8.4%) | 3 (7.5%) | 4 (11.4%) | 3 (6.8%) | 0.772 |
Renal insufficiency | 42 (35.3%) | 16 (40.0%) | 13 (37.1%) | 13 (29.6%) | 0.584 |
Dialysis dependent | 6 (5.0%) | 2 (5.0%) | 3 (8.6%) | 1 (2.3%) | 0.438 |
COPD | 13 (10.9%) | 4 (10.0%) | 3 (8.6%) | 6 (13.6%) | 0.814 |
Cerebral embolism | |||||
Ischemic stroke | 79 (66.4%) | 31 (77.5%) | 22 (62.9%) | 26 (59.1%) | 0.177 |
Haemorrhagic stroke | 29 (24.4%) | 4 (10.0%) | 8 (22.9%) | 17 (38.6%) | 0.009 * |
Non-isch./-haemorrhagic | 11 (9.2%) | 5 (12.5%) | 5 (14.3%) | 1 (2.3%) | 0.103 |
Prev. mechanical vent. | 20 (16.8%) | 7 (17.5%) | 7 (20.0%) | 6 (13.6%) | 0.746 |
Preop. acute neurology | 85 (71.4%) | 23 (57.5%) | 27 (77.1%) | 35 (79.6%) | 0.055 |
Causative pathogens | |||||
Staphylococcus spp. | 50 (42.0%) | 19 (47.5%) | 15 (42.9%) | 16 (36.4%) | 0.582 |
Streptococccus spp. | 22 (18.5%) | 8 (20.0%) | 5 (14.3%) | 9 (20.5%) | 0.747 |
Enterococcus spp. | 16 (13.5%) | 4 (10.0%) | 7 (20.0%) | 5 (11.4%) | 0.439 |
Other | 5 (4.2%) | - | - | 5 (11.4%) | 0.011 * |
Parameters, n (%) | All Patients (n = 119) | Early (Group 1) (n = 40) | Intermediate (Group 2) (n = 35) | Late (Group 3) (n = 44) | p-Value |
---|---|---|---|---|---|
Aortic regurgitation | 64 (53.8%) | 25 (62.5%) | 23 (65.7%) | 16 (36.4%) | 0.014 * |
I | 22 (18.5%) | 5 (12.5%) | 10 (28.6%) | 7 (15.9%) | 0.173 |
II | 16 (13.5%) | 8 (20.0%) | 6 (17.1%) | 2 (4.6%) | 0.074 |
III | 24 (20.2%) | 12 (30.0%) | 6 (17.1%) | 6 (13.6%) | 0.165 |
IV | 1 (0.8%) | - | 1 (2.9%) | 0.297 | |
Mitral regurgitation | 89 (74.8%) | 32 (80.0%) | 22 (62.9%) | 35(79.6%) | 0.154 |
I | 36 (30.3%) | 13 (32.5%) | 11 (31.4%) | 12 (27.3%) | 0.859 |
II | 27 (22.7%) | 11 (27.5%) | 6 (17.1%) | 10 (22.7%) | 0.565 |
III | 16 (13.5%) | 5 (12.5%) | 3 (8.6%) | 8 (18.2%) | 0.465 |
IV | 8 (6.7%) | 3 (7.5%) | 1 (2.9%) | 4 (9.1%) | 0.590 |
Tricuspid regurgitation | 32 (26.9%) | 10 (25.0%) | 11 (31.4%) | 11 (25.0%) | 0.771 |
I | 25 (1.7%) | 8 (20.0%) | 9 (25.7%) | 8 (18.2%) | 0.703 |
II | 3 (2.5%) | - | - | 3 (6.8%) | 0.108 |
III | 4 (3.4%) | 2 (5.0%) | 2 (5.7%) | - | 0.320 |
Low cardiac output | 6 (5.0%) | 1 (2.5%) | 5 (14.3%) | - | 0.007 * |
Abscess formation (echo) | 31 (26.0%) | 11 (27.5%) | 10 (28.6%) | 10 (22.7%) | 0.814 |
Valve vegetations (echo) | |||||
<5 mm | 22 (18.5%) | 5(12.5%) | 8(22.9%) | 9(20.5%) | 0.432 |
5–8 mm | 17 (14.3%) | 9(22.5%) | 4(11.4%) | 4(9.1%) | 0.216 |
>8 mm | 57 (47.9%) | 19(47.5%) | 17(48.6%) | 21(47.7%) | 0.956 |
Peripheral septic embolism | 55 (46.2%) | 19 (47.5%) | 19 (54.3%) | 17 (38.6%) | 0.183 |
Parameters, n (%) | All Patients (n = 119) | Early (Group 1) (n = 40) | Intermediate (Group 2) (n = 35) | Late (Group 3) (n = 44) | p-Value |
---|---|---|---|---|---|
Priority | |||||
Elective | 57 (47.9%) | 11 (27.5%) | 21 (60.0%) | 25 (56.8%) | 0.006 * |
Urgent | 29 (24.4%) | 9 (22.5%) | 8 (22.9%) | 12 (27.3%) | 0.852 |
Emergent | 33 (27.7%) | 20 (50.0%) | 6 (17.1%) | 7 (15.9%) | 0.001 * |
Surgical procedures | |||||
Aortic valve | |||||
Replacement | 49 (41.2%) | 21 (52.5%) | 12 (34.3%) | 16 (36.4%) | 0.199 |
Homograft | 3 (2.5%) | 1 (2.5%) | 2 (5.7%) | - | 0.195 |
Mitral valve | |||||
Replacement | 41 (34.5%) | 11 (27.5%) | 5 (14.3%) | 21 (47.7%) | 0.022 * |
Repair | 8 (6.7%) | 3 (7.5%) | 2 (5.7%) | 3 (6.8%) | 1.000 |
Tricuspid valve | |||||
Replacement | 2 (1.7%) | 1 (2.5%) | 1 (2.7%) | - | 0.530 |
Repair | 2 (1.7%) | - | 2 (5.7%) | - | 0.085 |
Aortic surgery | |||||
Asc. replacement | 5 (4.2%) | - | 1 (2.7%) | 4 (9.1%) | 0.261 |
Hemiarch | 1 (0.8%) | - | - | 1 (2.3%) | 1.000 |
CABG | 12 (10.1%) | 2 (5.0%) | 5 (14.3%) | 5 (11.4%) | 0.375 |
Pericardial patch plasty | 22 (18.5%) | 11 (27.5%) | 3 (8.6%) | 8 (18.2%) | 0.108 |
VSD closure | 3 (2.5%) | - | 1 (2.7%) | 2 (4.6%) | 0.512 |
PM explantation | 4 (3.4%) | 1 (2.5%) | 1 (2.7%) | 2 (4.6%) | 1.000 |
Other procedures | 6 (5.0%) | - | 1 (2.7%) | 5 (11.4%) | 0.101 |
Intraoperative data, mean (±SD) | |||||
HLM time (min) | 138.2 ± 61.1 | 137.0 ± 63.8 | 146.6 ± 58.6 | 132.5 ± 61.1 | 0.398 |
Cross-clamp time (min) | 94.8 ± 41.9 | 93.5 ± 40.6 | 98.7 ± 38.0 | 92.9 ± 46.6 | 0.584 |
Reperfusion time (min) | 36.0 ± 20.6 | 35.8 ± 22.7 | 37.6 ± 20.1 | 35.0 ± 19.2 | 0.833 |
Lowest temperature (°C) | 33.0 ± 3.5 | 33.0 ± 3.6 | 32.0 ± 3.3 | 33.0 ± 3.5 | 0.670 |
Parameters, n (%) | All Patients (n = 119) | Early (Group 1) (n = 40) | Intermediate (Group 2) (n = 35) | Late (Group 3) (n = 44) | p-Value |
---|---|---|---|---|---|
Mortality, n (%) | |||||
In-hospital | 18 (15.1%) | 6 (15.0%) | 9 (25.7%) | 3 (6.8%) | 0.066 |
During Follow-up | 12 (10.1%) | 3 (7.5%) | 4 (11.4%) | 5 (11.4%) | 0.801 |
Postoperative complications, n (%) | |||||
Reintubation | 11 (9.2%) | 4 (10.0%) | 5 (14.3%) | 2 (4.6%) | 0.322 |
Tracheostomy | 6 (5.0%) | 3 (7.5%) | 2 (5.7%) | 1 (2.3%) | 0.581 |
Renal failure (temp.) | 7 (5.9%) | 3 (7.5%) | 3 (8.6%) | 1 (2.3%) | 0.384 |
Renal failure (perm.) | 26 (21.9%) | 10 (25.0%) | 11 (31.4%) | 5 (11.4%) | 0.080 |
New stroke (perm.) | 7 (5.9%) | 4 (10.0%) | 2 (5.7%) | 1 (2.3%) | 0.331 |
LCO syndrome | 10 (8.4%) | 3 (7.5%) | 5 (14.3%) | 2 (4.6%) | 0.288 |
Sepsis/SIRS | 28 (23.5%) | 8 (20.0%) | 13 (37.1%) | 7 (15.9%) | 0.049 * |
Postop. PM | 11 (9.2%) | 2(5.0%) | 4 (11.4%) | 5 (11.4%) | 0.523 |
Rethoracotomy | 11 (9.2%) | 3 (7.5%) | 4 (11.4%) | 4 (9.1%) | 0.861 |
Inferior pericardiotomy | 9 (7.6%) | 4 (10.0%) | 1 (2.9%) | 4 (9.1%) | 0.466 |
Sternal wound infection | 3 (2.5%) | 1 (2.5%) | 2 (5.7%) | - | 0.193 |
Hospital and ICU stay, mean (±SD) | |||||
Ventilation (hours; IQR) | 18.0 (9.8 53.3) | 24.0 (12.0–72.0) | 20.1 (9.3–75.0) | 14.0 (9.0–26.0) | 0.209 |
ICU stay (days) | 5.5 ± 6.1 | 6.2 ± 6.0 | 6.2 ± 6.8 | 4.3 ± 5.4 | 0.213 |
Hospital stay (days) | 18.8 ± 14.1 | 15.6 ± 10.5 | 17.1 ± 11.1 | 23.2 ± 17.8 | 0.210 |
Univariate Analysis | p-Value | |||
---|---|---|---|---|
Increased age | 0.002 * | |||
Coronary artery disease | 0.097 | |||
Previous CABG | 0.059 | |||
Vegetations >8 mm | 0.018 * | |||
NYHA IV | 0.065 | |||
Low cardiac output | 0.060 | |||
Preoperative renal insufficiency | 0.019 * | |||
Dialysis (preoperative) | 0.059 | |||
Previous mechanical ventilation | 0.006 * | |||
Time-to-operation (after cerebral embolization) | ||||
Intermediate surgery (8–21 days) | 0.026 * | |||
Late surgery (≥22 days) | 0.041 * | |||
95%-Confidence interval | ||||
Multivariate analysis | Odds ratio | low | high | p-value |
Vegetations >8 mm | 9.408 | 1.455 | 60.821 | 0.019 * |
Increased age | 1.100 | 1.006 | 1.202 | 0.037 * |
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Dashkevich, A.; Bratkov, G.; Li, Y.; Joskowiak, D.; Peterss, S.; Juchem, G.; Hagl, C.; Luehr, M. Impact of Operative Timing in Infective Endocarditis with Cerebral Embolism—The Risk of Intermediate Deterioration. J. Clin. Med. 2021, 10, 2136. https://doi.org/10.3390/jcm10102136
Dashkevich A, Bratkov G, Li Y, Joskowiak D, Peterss S, Juchem G, Hagl C, Luehr M. Impact of Operative Timing in Infective Endocarditis with Cerebral Embolism—The Risk of Intermediate Deterioration. Journal of Clinical Medicine. 2021; 10(10):2136. https://doi.org/10.3390/jcm10102136
Chicago/Turabian StyleDashkevich, Alexey, Georg Bratkov, Yupeng Li, Dominik Joskowiak, Sven Peterss, Gerd Juchem, Christian Hagl, and Maximilian Luehr. 2021. "Impact of Operative Timing in Infective Endocarditis with Cerebral Embolism—The Risk of Intermediate Deterioration" Journal of Clinical Medicine 10, no. 10: 2136. https://doi.org/10.3390/jcm10102136
APA StyleDashkevich, A., Bratkov, G., Li, Y., Joskowiak, D., Peterss, S., Juchem, G., Hagl, C., & Luehr, M. (2021). Impact of Operative Timing in Infective Endocarditis with Cerebral Embolism—The Risk of Intermediate Deterioration. Journal of Clinical Medicine, 10(10), 2136. https://doi.org/10.3390/jcm10102136