Valve replacement in patients with endocarditis and acute neurologic deficit

A. Marc Gillinov, Rinoo V. Shah, William E. Curtis, R. Scott Stuart, Duke E. Cameron, William A Baumgartner, Peter Schuyler Greene

Research output: Contribution to journalArticle

Abstract

Background. Acute neurologic deficits occur in up to 40% of patients with left heart endocarditis. Appropriate evaluation and management of patients with acute neurologic dysfunction who require valve operations for endocarditis remain controversial. This retrospective review was undertaken to develop recommendations for the evaluation and treatment of these challenging patients. Methods. From 1983 to 1995, 247 patients underwent operations for left heart native valve endocarditis at the Johns Hopkins Hospital. From a review of medical and pathology records, 34 patients (14%) with preoperative neurologic deficits were identified. Data on these 34 patients were recorded and analyzed. Results. Causes of neurologic dysfunction included embolic cerebrovascular accident (n = 23, 68%), embolic cerebrovascular accident with hemorrhage (n = 4, 12%), ruptured mycotic aneurysm (n = 3, 9%), transient ischemic attack (n = 2, 6%), and meningitis (n = 2, 6%). Preoperative diagnostic studies included computed tomography (32 patients), magnetic resonance imaging (11 patients), cerebral angiogram (14 patients), and lumbar puncture (2 patients). Computed tomography demonstrated structural lesions in 29 of 32 patients; in only 1 patient did magnetic resonance imaging reveal a lesion not already seen on computed tomography. Of 14 patients having cerebral angiograms, 7 had a mycotic aneurysm. Three mycotic aneurysms had ruptured, and these were clipped before cardiac operations. The mean interval from onset of neurologic deficit to cardiac operation was 22.2 ± 2.8 days for all patients and 22.1 ± 3.0 days for those with embolic cerebrovascular accident. The hospital mortality rate was 6%. New or worse neurologic deficits occurred in 2 patients (6%). Conclusions. Neurologic deficits are common in patients with endocarditis referred for cardiac operations. Despite substantial preoperative morbidity, most of these patients do well if the operation can be delayed for 2 to 3 weeks. Computed tomography scan is the preoperative imaging technique of choice, as routine magnetic resonance imaging and cerebral angiogram are unrewarding. Cerebral angiogram is indicated only if computed tomography reveals hemorrhage.

Original languageEnglish (US)
Pages (from-to)1125-1130
Number of pages6
JournalAnnals of Thoracic Surgery
Volume61
Issue number4
DOIs
StatePublished - Apr 1996

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Neurologic Manifestations
Endocarditis
Infected Aneurysm
Tomography
Angiography
Stroke
Magnetic Resonance Imaging
Hemorrhage
Ruptured Aneurysm
Spinal Puncture
Transient Ischemic Attack
Heart Valves
Hospital Mortality
Meningitis
Medical Records

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery

Cite this

Valve replacement in patients with endocarditis and acute neurologic deficit. / Gillinov, A. Marc; Shah, Rinoo V.; Curtis, William E.; Stuart, R. Scott; Cameron, Duke E.; Baumgartner, William A; Greene, Peter Schuyler.

In: Annals of Thoracic Surgery, Vol. 61, No. 4, 04.1996, p. 1125-1130.

Research output: Contribution to journalArticle

Gillinov, A. Marc ; Shah, Rinoo V. ; Curtis, William E. ; Stuart, R. Scott ; Cameron, Duke E. ; Baumgartner, William A ; Greene, Peter Schuyler. / Valve replacement in patients with endocarditis and acute neurologic deficit. In: Annals of Thoracic Surgery. 1996 ; Vol. 61, No. 4. pp. 1125-1130.
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title = "Valve replacement in patients with endocarditis and acute neurologic deficit",
abstract = "Background. Acute neurologic deficits occur in up to 40{\%} of patients with left heart endocarditis. Appropriate evaluation and management of patients with acute neurologic dysfunction who require valve operations for endocarditis remain controversial. This retrospective review was undertaken to develop recommendations for the evaluation and treatment of these challenging patients. Methods. From 1983 to 1995, 247 patients underwent operations for left heart native valve endocarditis at the Johns Hopkins Hospital. From a review of medical and pathology records, 34 patients (14{\%}) with preoperative neurologic deficits were identified. Data on these 34 patients were recorded and analyzed. Results. Causes of neurologic dysfunction included embolic cerebrovascular accident (n = 23, 68{\%}), embolic cerebrovascular accident with hemorrhage (n = 4, 12{\%}), ruptured mycotic aneurysm (n = 3, 9{\%}), transient ischemic attack (n = 2, 6{\%}), and meningitis (n = 2, 6{\%}). Preoperative diagnostic studies included computed tomography (32 patients), magnetic resonance imaging (11 patients), cerebral angiogram (14 patients), and lumbar puncture (2 patients). Computed tomography demonstrated structural lesions in 29 of 32 patients; in only 1 patient did magnetic resonance imaging reveal a lesion not already seen on computed tomography. Of 14 patients having cerebral angiograms, 7 had a mycotic aneurysm. Three mycotic aneurysms had ruptured, and these were clipped before cardiac operations. The mean interval from onset of neurologic deficit to cardiac operation was 22.2 ± 2.8 days for all patients and 22.1 ± 3.0 days for those with embolic cerebrovascular accident. The hospital mortality rate was 6{\%}. New or worse neurologic deficits occurred in 2 patients (6{\%}). Conclusions. Neurologic deficits are common in patients with endocarditis referred for cardiac operations. Despite substantial preoperative morbidity, most of these patients do well if the operation can be delayed for 2 to 3 weeks. Computed tomography scan is the preoperative imaging technique of choice, as routine magnetic resonance imaging and cerebral angiogram are unrewarding. Cerebral angiogram is indicated only if computed tomography reveals hemorrhage.",
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T1 - Valve replacement in patients with endocarditis and acute neurologic deficit

AU - Gillinov, A. Marc

AU - Shah, Rinoo V.

AU - Curtis, William E.

AU - Stuart, R. Scott

AU - Cameron, Duke E.

AU - Baumgartner, William A

AU - Greene, Peter Schuyler

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AB - Background. Acute neurologic deficits occur in up to 40% of patients with left heart endocarditis. Appropriate evaluation and management of patients with acute neurologic dysfunction who require valve operations for endocarditis remain controversial. This retrospective review was undertaken to develop recommendations for the evaluation and treatment of these challenging patients. Methods. From 1983 to 1995, 247 patients underwent operations for left heart native valve endocarditis at the Johns Hopkins Hospital. From a review of medical and pathology records, 34 patients (14%) with preoperative neurologic deficits were identified. Data on these 34 patients were recorded and analyzed. Results. Causes of neurologic dysfunction included embolic cerebrovascular accident (n = 23, 68%), embolic cerebrovascular accident with hemorrhage (n = 4, 12%), ruptured mycotic aneurysm (n = 3, 9%), transient ischemic attack (n = 2, 6%), and meningitis (n = 2, 6%). Preoperative diagnostic studies included computed tomography (32 patients), magnetic resonance imaging (11 patients), cerebral angiogram (14 patients), and lumbar puncture (2 patients). Computed tomography demonstrated structural lesions in 29 of 32 patients; in only 1 patient did magnetic resonance imaging reveal a lesion not already seen on computed tomography. Of 14 patients having cerebral angiograms, 7 had a mycotic aneurysm. Three mycotic aneurysms had ruptured, and these were clipped before cardiac operations. The mean interval from onset of neurologic deficit to cardiac operation was 22.2 ± 2.8 days for all patients and 22.1 ± 3.0 days for those with embolic cerebrovascular accident. The hospital mortality rate was 6%. New or worse neurologic deficits occurred in 2 patients (6%). Conclusions. Neurologic deficits are common in patients with endocarditis referred for cardiac operations. Despite substantial preoperative morbidity, most of these patients do well if the operation can be delayed for 2 to 3 weeks. Computed tomography scan is the preoperative imaging technique of choice, as routine magnetic resonance imaging and cerebral angiogram are unrewarding. Cerebral angiogram is indicated only if computed tomography reveals hemorrhage.

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