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IE Surgery Timing After Stroke — EECC MCQ

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HardValvular Heart DiseaseIE Surgery Timing After StrokeEECC

A 65-year-old man with native aortic valve infective endocarditis (Staphylococcus aureus) develops an embolic stroke on day 3 of appropriate antibiotic therapy. CT head shows a moderate-sized ischaemic stroke with no haemorrhagic transformation. Echocardiography shows a 15 mm vegetation with moderate AR and no abscess. What is the recommended timing of cardiac surgery?

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Correct answer: A — Urgent surgery (within days) should be considered for the large vegetation with embolic event despite stroke, provided neurology assessment confirms acceptable surgical risk

The 2023 ESC IE Guidelines recommend urgent surgery for large vegetations (>10 mm) with embolic events. Regarding timing after stroke, the guidelines acknowledge that the risk of neurological deterioration during surgery is highest in the first few days after a large stroke. However, delaying surgery for 4 weeks exposes the patient to further embolic events and haemodynamic deterioration. Current evidence (from the ENDOVAL study and systematic reviews) suggests that surgery within 2 weeks of an ischaemic stroke can be performed with acceptable neurological outcomes provided: (1) no haemorrhagic transformation, (2) the stroke is not massive (not involving >1/3 of the MCA territory), and (3) neurological assessment confirms acceptable risk. A multidisciplinary approach (cardiology, cardiac surgery, neurology, infectious diseases) is essential.

Reference: ESC (2023): Guidelines on Infective Endocarditis