From the Guidelines
Stroke prevention in patients with infective endocarditis (IE) and aortic valve vegetations primarily involves prompt initiation of appropriate antibiotic therapy and consideration of early surgical intervention, with a focus on minimizing the risk of embolization and cerebral hemorrhage. The management of these patients should be guided by a multidisciplinary team, including infectious disease specialists, cardiologists, cardiac surgeons, and neurologists 1. Patients should receive empiric antibiotics immediately after blood cultures are drawn, typically vancomycin 15-20 mg/kg IV every 12 hours plus ceftriaxone 2g IV daily, adjusted based on culture results and continued for 4-6 weeks.
For patients with large vegetations (>10mm), early surgical intervention should be considered, particularly if there are other risk factors such as severe valve regurgitation, heart failure, or previous embolic events 1. The timing of surgery in patients with neurological symptoms and deficits should be a balance of the severity of cardiac decompensation and pathology and the severity of neurological symptoms 1.
Some key considerations for surgical management include:
- Preoperative neurological imaging should be performed for all patients with IE 1
- Vascular imaging (CT angiography or angiography) should be performed in patients with a cerebral hemorrhage to rule out ruptured infectious aneurysm 1
- Patients with severe cardiac decompensation and severe mechanical cardiac lesions should be operated on emergently or urgently unless the neurological status precludes heparinization or when neurological recovery to reasonable quality of life is very unlikely 1
- For patients with IE and silent microembolism, transient ischemic attack, and ischemic strokes without more than minimal hemorrhagic conversion, no delay in surgery is recommended 1
Anticoagulation is generally contraindicated in infective endocarditis due to increased bleeding risk, especially cerebral hemorrhage, unless there are specific indications such as mechanical valve prostheses 1. If anticoagulation is absolutely necessary, unfractionated heparin is preferred over warfarin due to its shorter half-life. Antiplatelets like aspirin are not routinely recommended, as they do not reduce the risk of embolic events and may increase the risk of bleeding 1. Close monitoring with serial echocardiography is essential to assess vegetation size and response to therapy. The risk of embolization is highest during the first two weeks of antibiotic therapy, with the risk decreasing substantially after effective antimicrobial treatment reduces the infectious burden and stabilizes the vegetations 1.
From the Research
Strategies for Stroke Prevention in Patients with Infective Endocarditis (IE) and Aortic Valve Vegetations
- The management of patients with IE and aortic valve vegetations requires careful consideration of the risk of stroke and the potential benefits of anticoagulation therapy 2.
- The size of the vegetation is an important factor in determining the risk of embolic events, with larger vegetations (>10 mm) posing a higher risk 3.
- Antibiotic treatment can reduce the size of vegetations, but the effect of different antibiotics on vegetation size varies 4.
- In patients with mechanical heart valves, anticoagulation with Warfarin is recommended to prevent stroke, with a target INR range of 2-3 for patients with a bileaflet mechanical valve in the aortic position 5.
- The decision to initiate anticoagulation therapy in patients with IE and aortic valve vegetations must be made on a case-by-case basis, taking into account the risk of hemorrhagic transformation and the potential benefits of reducing the risk of embolic events 2.
- Close follow-up with transesophageal echocardiography is essential to monitor the size of vegetations and the development of complications such as abscess formation 6, 4.
- Surgical intervention may be necessary in patients with large vegetations or complications such as perivalvular abscess formation, valvular destruction, and persistent pyrexia 3.