Not All Strokes Are Equal: Phenotype‐Dependent Surgical Timing in Infective Endocarditis
- 1Massachusetts General Hospital, Harvard Medical School
- 2Harvard Medical School
Abstract
Background We evaluated postoperative neurologic and mortality outcomes by stroke‐to‐surgery timing and stroke phenotype in patients with left‐sided infective endocarditis. Methods Adult patients undergoing surgery for infective endocarditis complicated by preoperative stroke between 2004 and 2024 at 2 institutions were stratified by stroke‐to‐surgery interval (<1 week, 1–4 weeks, 4–6 weeks). The primary outcome was a composite postoperative cerebrovascular event: new stroke, enlarging stroke, or hemorrhagic conversion. Secondary outcomes were operative death and major morbidity events. Results Among 2265 patients with left‐sided infective endocarditis, 322 met inclusion criteria, of whom 122 (38%) underwent surgery within 1 week, 168 (52%) between 1 and 4 weeks, and 32 (10%) between 4 and 6 weeks. Operative death was similar across groups ( P =0.09). Postoperative cerebrovascular events declined with time (<1 week, 21.3%; 1–4 weeks, 11.9%; 4–6 weeks, 9.4%; P =0.015). On multivariable analysis, longer stroke‐to‐surgery interval was associated with reduced odds of postoperative cerebrovascular events (odds ratio, 0.92/d [95% CI, 0.85–0.98]; P =0.015), driven by early events among patients with intraparenchymal hemorrhage, subarachnoid hemorrhage, and septic emboli. Among ischemic strokes, operative death was lowest with surgery within 1 week (5.8% versus 11.2% at 1–4 weeks; P =0.24). Interval embolization occurred in 10.6% of patients awaiting surgery, most commonly affecting the spleen and kidneys. Conclusions Excess postoperative neurologic risk was concentrated within the first 7 to 10 days and driven by intraparenchymal hemorrhage, subarachnoid hemorrhage, and septic emboli; ischemic stroke showed no appreciable temporal association. Routine delay after ischemic stroke may not be necessary, while a short delay (≈7 days) for hemorrhagic and septic embolic subtypes may be reasonable when hemodynamically feasible.
Related
- A multidisciplinary approach to infective endocarditis: diagnosis, medical and surgical management
- Antibiotic Prophylaxis of Infective Endocarditis in Dentistry: An Update on the ESC, AHA, and NICE Guidelines
- Robotic tricuspid valve repair for infective endocarditis with leaflet perforation and severe tricuspid regurgitation
- Integrated Clinical, Biological, and Echocardiographic Factors Independently Associated With In-Hospital Mortality in Infective Endocarditis: A Single-Centre Cohort Study From Morocco
- Tricuspid Valve Infective Endocarditis Seen on Point-of-Care Ultrasound: A Case Report
BibTeX
@article{kubi2026strokes,
title = {{Not All Strokes Are Equal: Phenotype‐Dependent Surgical Timing in Infective Endocarditis}},
author = {Boateng Kubi and Ali Homaei and Alina Keshwani and Rohin Bajaj and Emmanuel Odekunle and Rashid Walker and Jordan P. Bloom and Asishana Osho and Eriberto Michel and Arminder Jassar and Antonia Kreso and Molly Paras and Ann Woolley and Barbara Voetsch and Evin Yucel and David A. D’Alessandro and Thoralf Sundt and Akinobu Itoh and Motahar Hosseini},
journal = {Journal of the American Heart Association},
year = {2026},
month = oct,
doi = {10.1161/jaha.126.052918},
url = {https://www.ahajournals.org/doi/10.1161/JAHA.126.052918},
note = {CC BY-NC},
}
RIS
TY - JOUR
TI - Not All Strokes Are Equal: Phenotype‐Dependent Surgical Timing in Infective Endocarditis
AU - Boateng Kubi
AU - Ali Homaei
AU - Alina Keshwani
AU - Rohin Bajaj
AU - Emmanuel Odekunle
AU - Rashid Walker
AU - Jordan P. Bloom
AU - Asishana Osho
AU - Eriberto Michel
AU - Arminder Jassar
AU - Antonia Kreso
AU - Molly Paras
AU - Ann Woolley
AU - Barbara Voetsch
AU - Evin Yucel
AU - David A. D’Alessandro
AU - Thoralf Sundt
AU - Akinobu Itoh
AU - Motahar Hosseini
PY - 2026
DA - 2026/10/23
JO - Journal of the American Heart Association
DO - 10.1161/jaha.126.052918
UR - https://www.ahajournals.org/doi/10.1161/JAHA.126.052918
AB - Background We evaluated postoperative neurologic and mortality outcomes by stroke‐to‐surgery timing and stroke phenotype in patients with left‐sided infective endocarditis. Methods Adult patients undergoing surgery for infective endocarditis complicated by preoperative stroke between 2004 and 2024 at 2 institutions were stratified by stroke‐to‐surgery interval (<1 week, 1–4 weeks, 4–6 weeks). The primary outcome was a composite postoperative cerebrovascular event: new stroke, enlarging stroke, or hemorrhagic conversion. Secondary outcomes were operative death and major morbidity events. Results Among 2265 patients with left‐sided infective endocarditis, 322 met inclusion criteria, of whom 122 (38%) underwent surgery within 1 week, 168 (52%) between 1 and 4 weeks, and 32 (10%) between 4 and 6 weeks. Operative death was similar across groups ( P =0.09). Postoperative cerebrovascular events declined with time (<1 week, 21.3%; 1–4 weeks, 11.9%; 4–6 weeks, 9.4%; P =0.015). On multivariable analysis, longer stroke‐to‐surgery interval was associated with reduced odds of postoperative cerebrovascular events (odds ratio, 0.92/d [95% CI, 0.85–0.98]; P =0.015), driven by early events among patients with intraparenchymal hemorrhage, subarachnoid hemorrhage, and septic emboli. Among ischemic strokes, operative death was lowest with surgery within 1 week (5.8% versus 11.2% at 1–4 weeks; P =0.24). Interval embolization occurred in 10.6% of patients awaiting surgery, most commonly affecting the spleen and kidneys. Conclusions Excess postoperative neurologic risk was concentrated within the first 7 to 10 days and driven by intraparenchymal hemorrhage, subarachnoid hemorrhage, and septic emboli; ischemic stroke showed no appreciable temporal association. Routine delay after ischemic stroke may not be necessary, while a short delay (≈7 days) for hemorrhagic and septic embolic subtypes may be reasonable when hemodynamically feasible.
SN - 2047-9980
ER -