Safety and efficacy of mechanical thrombectomy in infective endocarditis: A matched case–control analysis from the German Stroke Registry–Endovascular Treatment

Abstract

Background and purpose Up to 30% of infective endocarditis (IE) patients have ischemic stroke as a complication. Standard treatment with mechanical thrombectomy (MT) with or without intravenous thrombolysis for large vessel occlusion (LVO) has not been evaluated formally in these patients. Methods Patients enrolled in the German Stroke Registry–Endovascular Treatment (GSR‐ET) between June 2015 and December 2019 were analyzed. Patients with stroke due to IE and patients with cardioembolic stroke and atrial fibrillation (AF) were compared using propensity score matching. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction score = 2b–3. Modified Rankin Scale (mRS) = 0–2 at 3 months indicated good outcome. Results Of 6635 patients, 55 patients (age = 69.0 ± 13.3 years, 43.6% female, median premorbid mRS (pmRS) = 1, interquartile range [IQR] = 0–1, National Institutes of Health Stroke Scale [NIHSS] = 15, IQR = 10–21) presented with septic embolic stroke due to IE and were compared to 104 patients (age = 66.5 ± 13.4 years, 39.4% female, pmRS = 0, IQR = 0–2, NIHSS = 16, IQR = 10–20) with cardioembolic stroke due to AF. Successful recanalization was achieved in 74.5% of endocarditis patients compared to 87.5% of controls (p = 0.039). Intracranial hemorrhage rates were comparable (30.9% vs. 21.6%, p = 0.175). Good functional outcome was 20.0% in patients with IE compared to 43.3% in matched patients (p = 0.006), with a significantly higher mortality (60.0% vs. 28.8%, p < 0.001). IE was strongly associated with poor outcome (odds ratio [OR] = 0.32, 95% confidence interval [CI] = 0.11–0.87, p = 0.03 for good outcome) and mortality (OR = 4.49, 95% CI = 1.80–10.68, p = 0.001). Conclusions Although MT results in high successful recanalization rates with acceptable safety profile, patients with LVO stroke due to IE have poor outcome.

Acute Ischaemic Stroke in Infective Endocarditis: Pathophysiology and Clinical Outcomes in Patients Treated with Reperfusion Therapy

“…However, comparable results were reported in a separate similar comparative analysis, with 20% of patients experiencing AIS secondary to IE achieving a good functional outcome (mRS 0-2) compared to 43.3% of the AF cohort experiencing AIS [54]. Furthermore, this multicentre study had the largest sample size of IE patients experiencing AIS receiving EVT to date [54].…”

“…Previous studies have found higher mortality rates in IE patients experiencing AIS than other AIS patients [54]. A retrospective study on patients experiencing AIS secondary to either IE or AF found no significant difference in mortality rate [55].…”

“…IE patients experiencing AIS were less likely to achieve good functional outcomes post-IVT and/or EVT than AIS patients without IE [51,54]. The retrospective analysis of a nationwide inpatient database found 10% of IE patients experiencing AIS achieved a good functional outcome compared to 37% of AIS patients without IE.…”

“…The following outcome results along with other studies' results are summarised in Table 1. 11/18 (61%) [7] 0/22 (0%) [7] 3/17 (18%) [50] 0/6 (0%) [52] 4/10 (40%) [53] 4/10 (40%) [7] * 12/19 (63%) [50] * 44/222 (20%) [51] * 17/55 (31%) [54] * 10/25 (40%) [55] 2/2 (100%) [53] 17/267 (6%) (sICH) [56] 2/35 (6%) (sICH) [57] 4/150 (3%) (sICH) [58] 53/1110 (5%) (sICH) [61] No studies [7] 15/22 (68%) [7] 13/21 (62%) [50] 3/6 (50%) [52] 3/10 (30%) [ [56][57][58][59][60]: These trials compared EVT ± IVT against the control of usual care (e.g., IVT) in AIS patients. However, a minority of patients in the control group in all five studies did not receive IVT.…”

“…In the following subsections, the majority of outcomes are obtained from Feil et al [54] and Marnat et al's [55] retrospective observational studies. These are the two largest studies investigating outcomes of AIS in IE post-thrombectomy, which is the first-line treatment method due to IVT being contraindicated (if IE diagnosis is known).…”