# New strategy of early surgery for infective endocarditis complicated by intracranial hemorrhage

## TL;DR

A new surgical strategy using nafamostat mesilate and low-dose heparin safely enables early surgery for infective endocarditis patients with intracranial hemorrhage.

## Contribution

Introduces a novel anticoagulation strategy to safely perform early surgery in high-risk patients with intracranial hemorrhage.

## Key findings

- No exacerbation of intracranial hemorrhage was observed in 23 patients using the new strategy.
- Early surgery was safely performed with a 4% early mortality rate and 90.7% 5-year survival.
- Neurologic deterioration was avoided in all patients despite intracranial hemorrhage.

## Abstract

Early surgery for infective endocarditis with intracranial hemorrhage can cause severe bleeding, which is correlated with an increased mortality. In 2005, we started using nafamostat mesilate and low-dose heparin as anticoagulants during cardiopulmonary bypass for early surgery. The outcomes of this strategy have been reviewed.

All patients who underwent cardiac surgery for active infective endocarditis with intracranial hemorrhage between 2005 and 2023 were evaluated.

There were 23 consecutive patients (median age 62 years old). Ten patients (43%) had neurologic deficits. The indication for early surgery in most patients was the presence of mobile vegetation or existing embolic events (18 of 23, 78%). No complications were associated with cardiopulmonary bypass. The median interval between the diagnosis and surgery was two days. There was 1 early death (4%) due to sepsis. There was no exacerbation of intracranial hemorrhage. One patient had new ectopic microbleeds without deterioration of neurologic findings. One patient had a new-onset cerebral infarction with neurologic deficits. None of the patients exhibited neurologic deterioration. The median follow-up duration was 26 months. overall survival was 90.7% after 5 years.

Our strategy of using nafamostat mesilate enabled us to safely perform early surgery in patients with intracranial hemorrhage without hemorrhage exacerbation.