Valvular heart disease
Incidence, Imaging Analysis, and Early and Late Outcomes of Stroke After Cardiac Valve Operation

https://doi.org/10.1016/j.amjcard.2008.01.029Get rights and content

The aim of this study was to analyze the incidence, topography, and mechanisms of stroke, independent predictors, and late outcome after cardiac valve operations. We retrospectively analyzed prospectively collected data from 2,808 patients (mean age 63 ± 15 years, n = 1,610, 55% men) who underwent valve surgery with or without concomitant coronary artery bypass grafting from January 1998 to December 2006. Stroke was defined as any new permanent focal neurologic deficit. Overall incidence of stroke was 2.2% (n = 63) and decreased during the study period from 3.3% (1998 to 2002) to 1.3% (2003 to 2006; p = 0.001). The highest stroke rate was observed after double aortic/mitral valve replacement (5.4%) and valve/coronary artery bypass grafting procedures (3.6%). Brain imaging was positive in 74% (n = 43 of 58) and showed ischemic stroke in all patients and hemorrhagic conversion in 28%. Distribution of acute stroke was large territory embolic artery (n = 33, 77%), watershed (n = 7, 16%), and mixed pattern (n = 3, 7%). Multivariate analysis revealed calcified ascending aorta (odds ratio [OR] 2.7), female gender (OR 2.6), ejection fraction <30% (OR 2.3), diabetes (OR 2.2), age >70 years (OR 2.0), and cardiopulmonary bypass time >120 minutes (OR 3.7) as predictors of stroke. Hospital mortality was 24% and 4.6% in patients with and without stroke, respectively. Survival of stroke patients was 78% and 54% at 1 year and 5 years, respectively, and was significantly decreased compared with patients without stroke. Valve pathology including endocarditis did not influence the incidence of stroke. Intraoperative epiaortic scanning may contribute in decreasing the incidence of this complication and may be warranted in all patients undergoing valvular surgery. In conclusion, stroke after valvular surgery is associated with an increased hospital mortality and morbidity and decreased long-term survival.

Section snippets

Methods

The protocol was approved by our local institutional review board and compliant to the Health Insurance Portability and Accountability Act regulations and the ethical guidelines of the 1975 Declaration of Helsinki. Approval included a waiver of informed consent.

From January 1, 1998, to December 31, 2006, 2,808 patients underwent valve surgery with or without concomitant CABG procedures at The Mount Sinai Hospital. Clinical variables were prospectively entered into the New York State Department

Results

A total of 2,808 adult patients were included in the study. Mean age was 63 ± 15 years and 55% of patients (n = 1,610) were men. Patient demographics and preoperative risk factors are listed in Table 1. Distribution of valve procedures was aortic valve replacement (29%, n = 820), mitral valve reconstruction (30%, n = 855), mitral valve replacement (12%, n = 323), combined aortic valve replacement and mitral valve reconstruction (5%, n = 143), combined aortic and mitral valve replacement (4%, n

Discussion

Our study was designed to examine the issue of stroke in a large cohort of patients undergoing valvular surgery. In our analysis, using a precise definition of stroke based on the New York State Department of Health (any new permanent focal neurologic deficit), overall incidence of this complication was 2.2%. A notable finding was that valve pathology did not influence the incidence of stroke, which was similar between different types of single-valve operations. However, rate of stroke was

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    This is an important caveat in our study and others in which assessment by neurologists and post-operative MRI were not uniformly utilized. Our finding of the association of thoracic aortic disease with PS supports the use of Epi-Aortic US prior to cannulation to detect atheromatous plaques that could precipitate a stroke.28–31 Moderate to severe aortic atherosclerosis detected on Epi-Aortic US has been associated with a higher risk of adverse events in prior studies, including 30 day risk of stroke and death following SAVR.32

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