Surgical timing for patients with infective endocarditis complicated with intracranial hemorrhage: Controversies and consensus_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

QING Hongkun ,  JIAN Xuhua

Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510010, P. R. China;

Corresponding?author：

JIAN Xuhua, Email: jianxuhua@gdph.org.cn

Keywords：

Infective endocarditis; intracranial hemorrhage; infectious intracranial aneurysm; surgical timing; neurological complications; perioperative death

DOI：

10.7507/1007-4848.202406033

Video：

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Intracranial hemorrhage (ICH) represents a severe complication of infective endocarditis (IE) and stands as a significant contributor to the poor prognosis associated with IE. Current guidelines suggested a delay of 4 weeks for cardiac surgery in patients with ICH, but these recommendations were based on insufficient clinical evidence, and recent studies have yielded different opinions. In this paper, we thoroughly reviewed relevant guidelines and their references in conjunction with 3 typical cases with IE and ICH, discussed the recommendations, and proposed a process for the management of IE with ICH.

Citation： QING Hongkun, JIAN Xuhua. Surgical timing for patients with infective endocarditis complicated with intracranial hemorrhage: Controversies and consensus. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2026, 33(6): 840-847. doi: 10.7507/1007-4848.202406033 Copy

1.	Delgado V, Ajmone MN, de Waha S, et al. 2023 ESC guidelines for the management of endocarditis. Eur Heart J, 2023, 44(39): 3948-4042.
2.	Lee J, Lim HA, Hong SB, et al. Is preoperative intracranial hemorrhage a surgical contraindication in infective endocarditis with stroke? J Thorac Dis, 2023, 15(9): 4765-4774.
3.	García-Cabrera E, Fernández-Hidalgo N, Almirante B, et al. Neurological complications of infective endocarditis. Circulation, 2013, 127(23): 2272-2284.
4.	Nakatani S, Ohara T, Ashihara K, et al. JCS 2017 guideline on prevention and treatment of infective endocarditis. Circ J, 2019, 83(8): 1767-1809.
5.	Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease. J Thorac Cardiovasc Surg, 2021, 162(2): e183-e353.
6.	中華醫學會胸心血管外科分會瓣膜病外科學組. 感染性心內膜炎外科治療中國專家共識. 中華胸心血管外科雜志, 2022, 38(3): 146-155.Group of Valve Surgery, Chinese Society for Thoracic and Cardiovascular Surgery. Chinese expert consensus on surgical treatment of infective endocarditis. Chin J Thorac Cardiovasc Surg, 2022(3): 146-155.
7.	AATS Surgical Treatment of Infective Endocarditis Consensus Guidelines Writing Committee Chairs; Pettersson GB, Coselli JS, et al. 2016 the American Association for Thoracic Surgery (AATS) consensus guidelines: surgical treatment of infective endocarditis: executive summary. J Thorac Cardiovasc Surg, 2017, 153(6): 1241-1258.
8.	Eishi K, Kawazoe K, Kuriyama Y, et al. Surgical management of infective endocarditis associated with cerebral complications. Multi-center retrospective study in Japan. J Thorac Cardiovasc Surg, 1995, 110(6): 1745-1755.
9.	Yoshioka D, Toda K, Sakaguchi T, et al. Valve surgery in active endocarditis patients complicated by intracranial haemorrhage: the influence of the timing of surgery on neurological outcomes. Eur J Cardiothorac Surg, 2014, 45(6): 1082-1088.
10.	Okita Y, Minakata K, Yasuno S, et al. Optimal timing of surgery for active infective endocarditis with cerebral complications: a Japanese multicentre study. Eur J Cardiothorac Surg, 2016, 50(2): 374-382.
11.	Shang E, Forrest GN, Chizmar T, et al. Mitral valve infective endocarditis: benefit of early operation and aggressive use of repair. Ann Thorac Surg, 2009, 87(6): 1728-1734.
12.	Wilbring M, Irmscher L, Alexiou K, et al. The impact of preoperative neurological events in patients suffering from native infective valve endocarditis. Interact Cardiovasc Thorac Surg, 2014, 18(6): 740-747.
13.	Suzuki M, Takanashi S, Ohshima Y, et al. Critical potential of early cardiac surgery for infective endocarditis with cardio-embolic strokes. Int J Cardiol, 2017, 227: 222-224.
14.	Klug D, Lacroix D, Savoye C, et al. Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management. Circulation, 1997, 95(8): 2098-2107.
15.	Tam DY, Yanagawa B, Verma S, et al. Early vs. late surgery for patients with endocarditis and neurological injury: a systematic review and meta-analysis. Can J Cardiol, 2018, 34(9): 1185-1199.
16.	Kume Y, Fujita T, Fukushima S, et al. Intracranial mycotic aneurysm is associated with cerebral bleeding post-valve surgery for infective endocarditis. Interact Cardiovasc Thorac Surg, 2018, 27(5): 635-641.
17.	Salaun E, Touil A, Hubert S, et al. Intracranial haemorrhage in infective endocarditis. Arch Cardiovasc Dis, 2018, 111(12): 712-721.
18.	Musleh R, Schlattmann P, Caldonazo T, et al. Surgical timing in patients with infective endocarditis and with intracranial hemorrhage: a systematic review and meta‐analysis. J Am Heart Assoc, 2022, 11(10): e024401.
19.	Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC guidelines for the management of infective endocarditis. Eur Heart J, 2015, 36(44): 3075-3128.
20.	Diab M, Musleh R, Lehmann T, et al. Risk of postoperative neurological exacerbation in patients with infective endocarditis and intracranial haemorrhage. Eur J Cardiothorac Surg, 2021, 59(2): 426-433.
21.	Arregle F, Martel H, Philip M, et al. Infective endocarditis with neurological complications: delaying cardiac surgery is associated with worse outcome. Arch Cardiovasc Dis, 2021, 114(8-9): 527-536.
22.	álvarez-Zaballos S, Vazquez-Alen P, Mu?oz P, et al. Prevalence and prognostic impact of stroke in a national cohort of infective endocarditis. Int J Stroke, 2024, 19(9): 989-998.
23.	de Miguel M, López J, Vilacosta I, et al. Clinical profile and prognosis of patients with left-sided infective endocarditis with surgical indication who are not operated. Microorganisms, 2024, 12(3): 607.
24.	Rost NS, Smith EE, Chang Y, et al. Prediction of functional outcome in patients with primary intracerebral hemorrhage: the FUNC score. Stroke, 2008, 39(8): 2304-2309.
25.	Venn RA, Ning M, Vlahakes GJ, et al. Surgical timing in infective endocarditis complicated by intracranial hemorrhage. Am Heart J, 2019, 216: 102-112.
26.	Runde D. Calculated decisions: NIH Stroke Scale/Score (NIHSS). Emerg Med Pract, 2021, 23(Suppl 6): CD3-CD5.
27.	Hui FK, Bain M, Obuchowski NA, et al. Mycotic aneurysm detection rates with cerebral angiography in patients with infective endocarditis. J Neurointerv Surg, 2015, 7(6): 449-452.
28.	Peters PJ, Harrison T, Lennox JL. A dangerous dilemma: Management of infectious intracranial aneurysms complicating endocarditis. Lancet Infect Dis, 2006, 6(11): 742-748.
29.	Alawieh AM, Dimisko L, Newman S, et al. Management and long-term outcomes of patients with infectious intracranial aneurysms. Neurosurgery, 2023, 92(3): 515-523.
30.	Ragulojan R, Grupke S, Fraser JF. Systematic review of endovascular, surgical, and conservative options for infectious intracranial aneurysms and cardiac considerations. J Stroke Cerebrovasc Dis, 2019, 28(3): 838-844.
31.	Ducruet AF, Hickman ZL, Zacharia BE, et al. Intracranial infectious aneurysms: a comprehensive review. Neurosurg Rev, 2010, 33(1): 37-46.
32.	Petr O, Brinjikji W, Burrows AM, et al. Safety and efficacy of endovascular treatment for intracranial infectious aneurysms: a systematic review and meta-analysis. J Neuroradiol, 2016, 43(5): 309-316.
33.	Cheng-Ching E, John S, Bain M, et al. Endovascular embolization of intracranial infectious aneurysms in patients undergoing open heart surgery using n-butyl cyanoacrylate. Interv Neurol, 2017, 6(1-2): 82-89.
34.	Serrano F, Guédon A, Saint-Maurice J, et al. Endovascular treatment of infectious intracranial aneurysms complicating infective endocarditis: a series of 31 patients with 55 aneurysms. Neuroradiology, 2022, 64(2): 353-360.
35.	卿洪琨, 王維騰, 陳帆宇, 等. 感染性心內膜炎相關顱內動脈瘤的特征與治療. 中國胸心血管外科臨床雜志, 2025, 32(5): 670-676.Qing HK, Wang WT, Chen FY, et al. Clinical characteristics and treatment of infectious intracranial aneurysm related to infective endocarditis. Chin J Clin Thorac Cardiovasc Surg, 2025, 32(5): 670-676.
36.	Klein I, Iung B, Labreuche J, et al. Cerebral microbleeds are frequent in infective endocarditis. Stroke, 2009, 40(11): 3461-3465.
37.	Okazaki S, Sakaguchi M, Hyun B, et al. Cerebral microbleeds predict impending intracranial hemorrhage in infective endocarditis. Cerebrovasc Dis, 2011, 32(5): 483-488.
38.	Murai R, Kaji S, Kitai T, et al. The clinical significance of cerebral microbleeds in infective endocarditis patients. Semin Thorac Cardiovasc Surg, 2019, 31(1): 51-58.
39.	Goulenok T, Klein I, Mazighi M, et al. Infective endocarditis with symptomatic cerebral complications: contribution of cerebral magnetic resonance imaging. Cerebrovasc Dis, 2013, 35(4): 327-336.
40.	Sorabella RA, Han SM, Grbic M, et al. Early operation for endocarditis complicated by preoperative cerebral emboli is not associated with worsened outcomes. Ann Thorac Surg, 2015, 100(2): 501-508.
41.	Yamazato T, Oyama N, Fujii T, et al. Aggressive early surgical strategy in patients with intracranial hemorrhage: a new cardiopulmonary bypass option. Gen Thorac Cardiovasc Surg, 2022, 70(7): 602-610.

1. Delgado V, Ajmone MN, de Waha S, et al. 2023 ESC guidelines for the management of endocarditis. Eur Heart J, 2023, 44(39): 3948-4042.
2. Lee J, Lim HA, Hong SB, et al. Is preoperative intracranial hemorrhage a surgical contraindication in infective endocarditis with stroke? J Thorac Dis, 2023, 15(9): 4765-4774.
3. García-Cabrera E, Fernández-Hidalgo N, Almirante B, et al. Neurological complications of infective endocarditis. Circulation, 2013, 127(23): 2272-2284.
4. Nakatani S, Ohara T, Ashihara K, et al. JCS 2017 guideline on prevention and treatment of infective endocarditis. Circ J, 2019, 83(8): 1767-1809.
5. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease. J Thorac Cardiovasc Surg, 2021, 162(2): e183-e353.
6. 中華醫學會胸心血管外科分會瓣膜病外科學組. 感染性心內膜炎外科治療中國專家共識. 中華胸心血管外科雜志, 2022, 38(3): 146-155.Group of Valve Surgery, Chinese Society for Thoracic and Cardiovascular Surgery. Chinese expert consensus on surgical treatment of infective endocarditis. Chin J Thorac Cardiovasc Surg, 2022(3): 146-155.
7. AATS Surgical Treatment of Infective Endocarditis Consensus Guidelines Writing Committee Chairs; Pettersson GB, Coselli JS, et al. 2016 the American Association for Thoracic Surgery (AATS) consensus guidelines: surgical treatment of infective endocarditis: executive summary. J Thorac Cardiovasc Surg, 2017, 153(6): 1241-1258.
8. Eishi K, Kawazoe K, Kuriyama Y, et al. Surgical management of infective endocarditis associated with cerebral complications. Multi-center retrospective study in Japan. J Thorac Cardiovasc Surg, 1995, 110(6): 1745-1755.
9. Yoshioka D, Toda K, Sakaguchi T, et al. Valve surgery in active endocarditis patients complicated by intracranial haemorrhage: the influence of the timing of surgery on neurological outcomes. Eur J Cardiothorac Surg, 2014, 45(6): 1082-1088.
10. Okita Y, Minakata K, Yasuno S, et al. Optimal timing of surgery for active infective endocarditis with cerebral complications: a Japanese multicentre study. Eur J Cardiothorac Surg, 2016, 50(2): 374-382.
11. Shang E, Forrest GN, Chizmar T, et al. Mitral valve infective endocarditis: benefit of early operation and aggressive use of repair. Ann Thorac Surg, 2009, 87(6): 1728-1734.
12. Wilbring M, Irmscher L, Alexiou K, et al. The impact of preoperative neurological events in patients suffering from native infective valve endocarditis. Interact Cardiovasc Thorac Surg, 2014, 18(6): 740-747.
13. Suzuki M, Takanashi S, Ohshima Y, et al. Critical potential of early cardiac surgery for infective endocarditis with cardio-embolic strokes. Int J Cardiol, 2017, 227: 222-224.
14. Klug D, Lacroix D, Savoye C, et al. Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management. Circulation, 1997, 95(8): 2098-2107.
15. Tam DY, Yanagawa B, Verma S, et al. Early vs. late surgery for patients with endocarditis and neurological injury: a systematic review and meta-analysis. Can J Cardiol, 2018, 34(9): 1185-1199.
16. Kume Y, Fujita T, Fukushima S, et al. Intracranial mycotic aneurysm is associated with cerebral bleeding post-valve surgery for infective endocarditis. Interact Cardiovasc Thorac Surg, 2018, 27(5): 635-641.
17. Salaun E, Touil A, Hubert S, et al. Intracranial haemorrhage in infective endocarditis. Arch Cardiovasc Dis, 2018, 111(12): 712-721.
18. Musleh R, Schlattmann P, Caldonazo T, et al. Surgical timing in patients with infective endocarditis and with intracranial hemorrhage: a systematic review and meta‐analysis. J Am Heart Assoc, 2022, 11(10): e024401.
19. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC guidelines for the management of infective endocarditis. Eur Heart J, 2015, 36(44): 3075-3128.
20. Diab M, Musleh R, Lehmann T, et al. Risk of postoperative neurological exacerbation in patients with infective endocarditis and intracranial haemorrhage. Eur J Cardiothorac Surg, 2021, 59(2): 426-433.
21. Arregle F, Martel H, Philip M, et al. Infective endocarditis with neurological complications: delaying cardiac surgery is associated with worse outcome. Arch Cardiovasc Dis, 2021, 114(8-9): 527-536.
22. álvarez-Zaballos S, Vazquez-Alen P, Mu?oz P, et al. Prevalence and prognostic impact of stroke in a national cohort of infective endocarditis. Int J Stroke, 2024, 19(9): 989-998.
23. de Miguel M, López J, Vilacosta I, et al. Clinical profile and prognosis of patients with left-sided infective endocarditis with surgical indication who are not operated. Microorganisms, 2024, 12(3): 607.
24. Rost NS, Smith EE, Chang Y, et al. Prediction of functional outcome in patients with primary intracerebral hemorrhage: the FUNC score. Stroke, 2008, 39(8): 2304-2309.
25. Venn RA, Ning M, Vlahakes GJ, et al. Surgical timing in infective endocarditis complicated by intracranial hemorrhage. Am Heart J, 2019, 216: 102-112.
26. Runde D. Calculated decisions: NIH Stroke Scale/Score (NIHSS). Emerg Med Pract, 2021, 23(Suppl 6): CD3-CD5.
27. Hui FK, Bain M, Obuchowski NA, et al. Mycotic aneurysm detection rates with cerebral angiography in patients with infective endocarditis. J Neurointerv Surg, 2015, 7(6): 449-452.
28. Peters PJ, Harrison T, Lennox JL. A dangerous dilemma: Management of infectious intracranial aneurysms complicating endocarditis. Lancet Infect Dis, 2006, 6(11): 742-748.
29. Alawieh AM, Dimisko L, Newman S, et al. Management and long-term outcomes of patients with infectious intracranial aneurysms. Neurosurgery, 2023, 92(3): 515-523.
30. Ragulojan R, Grupke S, Fraser JF. Systematic review of endovascular, surgical, and conservative options for infectious intracranial aneurysms and cardiac considerations. J Stroke Cerebrovasc Dis, 2019, 28(3): 838-844.
31. Ducruet AF, Hickman ZL, Zacharia BE, et al. Intracranial infectious aneurysms: a comprehensive review. Neurosurg Rev, 2010, 33(1): 37-46.
32. Petr O, Brinjikji W, Burrows AM, et al. Safety and efficacy of endovascular treatment for intracranial infectious aneurysms: a systematic review and meta-analysis. J Neuroradiol, 2016, 43(5): 309-316.
33. Cheng-Ching E, John S, Bain M, et al. Endovascular embolization of intracranial infectious aneurysms in patients undergoing open heart surgery using n-butyl cyanoacrylate. Interv Neurol, 2017, 6(1-2): 82-89.
34. Serrano F, Guédon A, Saint-Maurice J, et al. Endovascular treatment of infectious intracranial aneurysms complicating infective endocarditis: a series of 31 patients with 55 aneurysms. Neuroradiology, 2022, 64(2): 353-360.
35. 卿洪琨, 王維騰, 陳帆宇, 等. 感染性心內膜炎相關顱內動脈瘤的特征與治療. 中國胸心血管外科臨床雜志, 2025, 32(5): 670-676.Qing HK, Wang WT, Chen FY, et al. Clinical characteristics and treatment of infectious intracranial aneurysm related to infective endocarditis. Chin J Clin Thorac Cardiovasc Surg, 2025, 32(5): 670-676.
36. Klein I, Iung B, Labreuche J, et al. Cerebral microbleeds are frequent in infective endocarditis. Stroke, 2009, 40(11): 3461-3465.
37. Okazaki S, Sakaguchi M, Hyun B, et al. Cerebral microbleeds predict impending intracranial hemorrhage in infective endocarditis. Cerebrovasc Dis, 2011, 32(5): 483-488.
38. Murai R, Kaji S, Kitai T, et al. The clinical significance of cerebral microbleeds in infective endocarditis patients. Semin Thorac Cardiovasc Surg, 2019, 31(1): 51-58.
39. Goulenok T, Klein I, Mazighi M, et al. Infective endocarditis with symptomatic cerebral complications: contribution of cerebral magnetic resonance imaging. Cerebrovasc Dis, 2013, 35(4): 327-336.
40. Sorabella RA, Han SM, Grbic M, et al. Early operation for endocarditis complicated by preoperative cerebral emboli is not associated with worsened outcomes. Ann Thorac Surg, 2015, 100(2): 501-508.
41. Yamazato T, Oyama N, Fujii T, et al. Aggressive early surgical strategy in patients with intracranial hemorrhage: a new cardiopulmonary bypass option. Gen Thorac Cardiovasc Surg, 2022, 70(7): 602-610.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Surgical timing for patients with infective endocarditis complicated with intracranial hemorrhage: Controversies and consensus

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