Excess postoperative neurologic risk after surgery for left-sided infective endocarditis with preoperative stroke was concentrated within the first 7 to 10 days and driven by intraparenchymal hemorrhage, subarachnoid hemorrhage, and septic emboli, while 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.
Of 2265 patients with left-sided infective endocarditis, 322 had a preoperative stroke and met inclusion criteria, and most underwent surgery within 4 weeks of the stroke.
The rate of postoperative cerebrovascular events (new stroke, enlarging stroke, or hemorrhagic conversion) declined as the stroke-to-surgery interval lengthened.
On multivariable analysis, a longer stroke-to-surgery interval was independently associated with lower odds of postoperative cerebrovascular events.
Operative death did not differ significantly across stroke-to-surgery interval groups.
Among patients with ischemic stroke, operative death was numerically lowest with surgery within 1 week, and ischemic stroke showed no appreciable temporal association with postoperative neurologic risk.
Excess postoperative neurologic risk was concentrated in the first 7 to 10 days after stroke and tied to specific stroke phenotypes.
Interval embolization occurred in about one in ten patients awaiting surgery, most often affecting the spleen and kidneys.
The authors conclude that timing of surgery should be phenotype-dependent: routine delay after ischemic stroke may be unnecessary, while a short delay (~7 days) may be reasonable for hemorrhagic and septic embolic subtypes.
This study looked at 322 people who had heart surgery for a serious infection of the left-sided heart valves (infective endocarditis) after already having a stroke. The researchers compared outcomes depending on how long after the stroke the surgery took place: within 1 week, 1 to 4 weeks, or 4 to 6 weeks. They also looked at the type of stroke, since strokes can be caused by blocked blood vessels, bleeding in the brain, or infected clots. New or worsening brain problems after surgery were more common when surgery was done sooner (21.3% within 1 week vs. about 12% at 1-4 weeks and 9% at 4-6 weeks). This pattern was mainly seen in people whose stroke involved bleeding in the brain or infected clots (septic emboli). For people with ischemic strokes (caused by blocked vessels), timing made no clear difference to brain outcomes, and deaths around the time of surgery did not differ significantly between timing groups. About 1 in 10 patients waiting for surgery also had clots travel to organs such as the spleen and kidneys. This research suggests that waiting after an ischemic stroke may not always be needed, while a short wait of about a week may be reasonable for bleeding or septic embolic strokes if the patient is stable enough. This was an observational study from two centers, so it shows associations rather than proving cause, and treatment decisions need to be individualized by the care team.
Kubi B, Homaei A, Keshwani A, Bajaj R, Odekunle E, Walker R, et al.. (2026). Not All Strokes Are Equal: Phenotype-Dependent Surgical Timing in Infective Endocarditis.. Journal of the American Heart Association. https://doi.org/10.1161/JAHA.126.052918