Management of infective endocarditis in patients with post-stroke brain damages

Abstract

This study evaluated the effectiveness of anesthesiological management in sur-gical treatment of infective endocarditis with cerebrovascular complications. The aim of the study was to decrease neurological complications and hospital mortality after surgical inter-ventions with the use of cardiopulmonary bypass in patients with infective endocarditis.
 The main preoperative risk factors of endocardit-associated cerebrovascular complications, which influenced the immediate results of cardiac surgery were: sepsis, systemic inflammatory response, disorders of systemic hemodynamics, high risk of recurrent cerebrovascular events, anemia and carbohydrate disorders. New anesthesiological management protocol was de-veloped and improved.
 Intraoperative risk factors for hospital mortality were associated with: total protein at the end of surgery less than 49 g/l; maximum blood glucose during surgery more than 10.7 mmol/l; anemia and hemodilution – hemoglobin level less than 58.8 g/l in the period of complete bypass and less than 79.4 g/l at the end of the surgery; positive water balance at the end of the operation.
 Determination of preoperative blood S100? protein level may be recommended to determine the prognosis of postoperative neurological complications, since the level above 0.13 µg/l was associated with postoperative neurological impairment.
 The implemented changes in the anesthetic management permitted to decrease neuro-logical complication rate from 22.2% to 9.6% and thirty-day mortality from 19.0% to 2.7% after surgical treatment of infective endocarditis with the use of cardiopulmonary bypass in patients with cerebrovascular complications.
 In order to achieve maximum effectiveness of anesthesiological management and to re-duce the level of postoperative neurological complications the optimal timing for surgery was 2–3 days after development of cerebrovascular impairment. In case of ischemic stroke in the most acute phase of the course (the first 72 hours), emergency cardiac surgery was advisable (except the cases of brain coma or total volume of myocardial infarction exceeding 31.5 cm3). In the case of ischemic stroke, more than 72 hours after the onset, and in the absence of progression of acute heart failure, the recommended timing for cardiac surgery was 4 weeks after the manifestation of cerebrovascular impairment. In the case of hemorrhagic or mixed type of neurological impairment, cardiac surgery was postponed for 1.4–2 months (since the development of the stroke).