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

Xavier Duval,Bruno Hoen,Aepei (Association Pour L'etude Et La Prévention De L'endocardite Infectieuse) ,Véronique Vernet-Garnier,François Alla,Jean-François Obadia,Sidney Chocron,Claire Federspiel,Yvette Bernard,Vincent Le Moing,Catherine Chirouze,Pierre Tattevin,Christine Selton-Suty,François Delahaye,Pierre Nazeyrollas

doi:10.1371/journal.pone.0158522

Abstract

ObjectivesSymptomatic 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.MethodsFrom 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.ResultsAmong 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.ConclusionsThe 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.

Highlights

Symptomatic cerebral neurological complications (SNC) are a major cause of morbidity and mortality in patients with infective endocarditis (IE) and may interact with the decision for surgery.[1]
The rate of valve surgery was 43% in the 100 patients with SNC, 77% in the 35 with Asymptomatic NC (AsNC), and 54% in the 148 with No NC (NoNC) (p
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

Summary

Introduction

Symptomatic cerebral neurological complications (SNC) are a major cause of morbidity and mortality in patients with infective endocarditis (IE) and may interact with the decision for surgery.[1] not recommended by previous guidelines, systematic neuroimaging procedures (NIP) such as brain MRI or CT scan to look for asymptomatic cerebral neurological complications (AsNC) are often performed in patients with IE during everyday care. The discovery of such complications may impact the surgical management of the patient. In the study by Cooper et al, on 40 patients with left-sided IE and brain MRI,[5] 70% had MRI evidence of subclinical brain embolization; 3 month-mortality was similar in the 13 patients with SNC and in the 19 patients with AsNC, but significantly higher than the mortality of the 8 patients with no cerebral lesions

Objectives

Results

Conclusion