Prognostic impact of cerebral embolism in patients with active infective endocarditis and therapeutic strategies. A retrospective real world study in a surgical centre

Purpose: Infective endocarditis still has high mortality and invalidating complications, such as cerebral embolism. The best strategies to prevent and to manage neurologic complications remain uncertain. This study aimed to identify predictors of septic cerebral embolism and to evaluate the role of surgery in these patients, in a real-world surgical center. Methods: We retrospectively analyzed 551 consecutive patients admitted to our department with a definite diagnosis of non-device-related infective endocarditis; of these, 126 (23%) presented a neurologic complication. Results: Cerebral embolism was significantly more frequent in patients with large vegetations (p=0.001), mitral valve infection (p=0.001), and Staphylococcus aureus infection (p=0.025). At multivariable analysis, only vegetation length was an independent predictor of cerebral embolism (HR 1.057, 95% CI 1.025-1.091, p 0.001), with a best predictive threshold of 10 mm at ROC curve analysis (AUC 0.54, p=0.001). Patients with neurologic complications were more often excluded from surgery despite an indication to it (16% vs 8%, p=0.001). If eligible, they were treated within two weeks from diagnosis in similar proportion as patients without cerebral embolism with similar survival rate. Predictors of mortality were hemorrhagic lesions (p=0.018), a GCS<14 (p=0.001) or a severe degree of disability (p=0.001) at presentation. The latter was the only independent predictor of mortality at multivariable analysis (HR 2.3, 95% CI 1.43-3.80, p=0.001). Conclusions: The present study highlights the prognostic value of clinical functional presentation and the safety of cardiac surgery, when feasible, in patients with septic cerebral embolism.