What to do with patients with active infective endocarditis complicated by intracranial bleeding

Abstract

Cerebral complications, especially intracranial hemorrhage (ICH), are critical determinants of the early outcomes of cardiac surgery for active infective endocarditis (AIE). Relevant society guidelines still recommend delaying cardiac surgery for AIE complicated by ICH for 4 weeks. Some early studies indicated that the mortality decreases when cardiac surgery for ICH is delayed. In contrast, some reported that surgical intervention should not be delayed if an early operation is indicated, even in patients with ICH. The current literature on early versus late surgery for AIE with ICH is conflicting. ICH is classified by its mechanism which includes primary intraparenchymal hemorrhage, hemorrhagic transformation of ischemic infarcts, and rupture of intracranial infectious aneurysms. Some reported that for AIE with a mycotic cerebral aneurysm, early cardiac surgery should be done after repair of the aneurysm, either surgically or endovascularly. Except for the rupture of mycotic aneurysm, primary intraparenchymal hemorrhage and hemorrhagic transformation of ischemic infarcts remain a critical and challenging dilemma. Modifying the cardiopulmonary bypass (CPB) strategy might be necessary to improve the surgical outcomes of AIE with ICH. Some studies reported that cardiac surgery using nafamostat mesylate as an alternative anticoagulant during CPB (NM-CPB) was performed successfully. The NM-CPB can be a useful option as an anticoagulant in critical situations of cardiac surgery with ICH. The timing of surgery should be decided on a case-by-case basis with multidisciplinary specialties including cardiac and neurological teams.

Keywords

Intracranial hemorrhage / early cardiac surgery / primary intraparenchymal hemorrhage / hemorrhagic transformation of ischemic infarcts / rupture of intracranial infectious aneurysms / low-dose heparin / nafamostat mesylate

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