Neurological Complications and Surgical Outcomes in Infective Endocarditis

BACKGROUND: Neurological complications affect up to 40% of patients with infective endocarditis and pose challenges for perioperative management, with limited evidence on the safety, optimal timing, and surgical strategy, especially in intracerebral hemorrhage (ICH). METHODS: We retrospectively analyzed patients with left-sided infective endocarditis undergoing cardiac surgery at Peking Union Medical College Hospital (December 2012-December 2024). Outcomes in patients with preoperative neurological complications were assessed using multivariable logistic and Cox regression, with propensity score matching to adjust for baseline differences. Subgroup analyses evaluated the impact of complication type, surgical timing, and valve strategy on prognosis. RESULTS: Of 663 patients, 204 (30.8%) had preoperative neurological complications. Propensity score matching analysis confirmed overall comparable short- and long-term survival between patients with and without neurological complications, particularly in those with nonhemorrhagic cerebral embolism. In contrast, ICH was independently associated with higher mortality. Delayed surgery (>30 days) in nonhemorrhagic cerebral embolism and early surgery (≤7 days) in ICH were associated with poorer mortality. Competing-risk analyses showed that neurological complications were associated with a markedly higher cumulative incidence of neurological death, whereas nonneurological mortality was also increased, particularly in ICH. Effect modification analyses suggested that mitral valve repair and bioprosthetic valve implantation might confer additional survival benefits in this high-risk population. CONCLUSIONS: Cardiac surgery in patients with infective endocarditis with neurological complications could achieve favorable short- and long-term outcomes. Nonhemorrhagic cerebral embolism should not delay surgery, whereas ICH represents a high-risk condition requiring careful timing. Mitral valve repair and bioprosthetic valve implantation may be preferred when feasible.