Symptomatic and Asymptomatic Neurological Complications of Infective Endocarditis: Impact on Surgical Management and Prognosis

International audienceObjectives:Symptomatic neurological complications (NC) are a major cause of mortality in infective endocarditis (IE) but the impact of asymptomatic complications is unknown. We aimed to assess the impact of asymptomatic NC (AsNC) on the management and prognosis of IE.Methods: From the database of cases collected for a population-based study on IE, we selected 283 patients with definite left-sided IE who had undergone at least one neuroimaging procedure (cerebral CT scan and/or MRI) performed as part of initial evaluation.Results Among those 283 patients, 100 had symptomatic neurological complications (SNC) prior to the investigation, 35 had an asymptomatic neurological complications (AsNC), and 148 had a normal cerebral imaging (NoNC). The rate of valve surgery was 43% in the 100 patients with SNC, 77% in the 35 with AsNC, and 54% in the 148 with NoNC (p<0.001). In-hospital mortality was 42% in patients with SNC, 8.6% in patients with AsNC, and 16.9% in patients with NoNC (p<0.001). Among the 135 patients with NC, 95 had an indication for valve surgery (71%), which was performed in 70 of them (mortality 20%) and not performed in 25 (mortality 68%). In a multivariate adjusted analysis of the 135 patients with NC, age, renal failure, septic shock, and IE caused by S. aureus were independently associated with in-hospital and 1-year mortality. In addition SNC was an independent predictor of 1-year mortality.Conclusions The presence of NC was associated with a poorer prognosis when symptomatic. Patients with AsNC had the highest rate of valve surgery and the lowest mortality rate, which suggests a protective role of surgery guided by systematic neuroimaging results

Guía ESC 2015 sobre el tratamiento de la endocarditis infecciosa

[No abstract available

Cerebral complications in infective endocarditis

Infective endocarditis (IE) is a life-threatening disease. Cerebral embolization complicates the course in 10-40% of IE episodes. Aims of study were to investigate the frequency of cerebrovascular complications (CVC) in left-sided IE and the influence of protective and risk factors with focus on antiplatelet and anticoagulant therapy. CVC rate was examined by repeated magnetic resonance imaging of the brain and by assaying levels of brain damage markers in cerebrospinal fluid in 60 IE patients in paper I. The overall CVC frequency was 65%, with 35% of the patients experiencing neurological symptoms and 30% characterized as having clinically silent CVC. The risk of neurological deterioration during cardiac surgery after established cerebral embolism was low. In paper II the relationship between symptomatic CVC and established use of antiplatelet therapy was evaluated in 684 definite left-sided IE episodes. Antiplatelet agents were used by 23% of the patients. These patients were older and more often had a history of congestive heart failure. In 25% of all episodes a CVC was seen. There was no statistically significant difference in CVC rate between patients with and without previously established antiplatelet therapy (24% vs. 25%, n.s.). Twelve-month mortality was significantly higher for patients on previously established antiplatelet therapy in the univariable analysis (34% vs. 24%, OR 1.6, 95% CI 1.1-2.4), but after adjustment for covariables the use of antiplatelet therapy was no longer a risk factor. The association between ongoing warfarin therapy and CVC incidence in native valve endocarditis (NVE) was analyzed in paper III. Out of 587 NVE episodes 8% were seen in patients using warfarin on admission. Patients on warfarin suffered from CVC significantly less frequently than patients not on warfarin (6% vs. 26%, 0.2 95% CI 0.06-0.6). In a multivariable model S.aureus etiology (adjusted OR [aOR] 6.3, 95% CI 3.8-10.4) and vegetation length (aOR 1.04, 95% CI 1.01-1.07) were associated with higher CVC frequency. Warfarin use (aOR 0.26, 95% CI 0.07-0.94), history of congestive heart failure (aOR 0.22, 95% CI 0.1-0.52) and previous IE episode (aOR 0.1, 95% CI 0.01-0.79) conferred a lower risk of CVC. Cerebral hemorrhagic complications were few

Cerebral complications in

infective endocarditi