30-day Stroke Research Articles

Abstract 79: Twelve-Year Trends in Ninety-Day Stroke Outcomes and Ethnic Differences From a Population-Based Study

Background: Stroke outcomes may be changing over time with improved acute stroke therapy, secondary prevention, and post-acute care. At the same time, stroke mortality has declined suggesting more people are living with stroke disability. No US population-based data exists on trends in outcomes. The objective was to investigate trends and ethnic differences in 90-day stroke outcomes in a population-based study. Methods: First-ever ischemic strokes in the population-based Brain Attack Surveillance in Corpus Christi Project (2009-2020, n=1,449) were included. 90-day outcomes included function (activities of daily living (ADL)/instrumental ADL), cognition (modified mini-mental state exam), NIHSS, and quality of life (Stroke-Specific Quality of Life (SS-QoL)). Linear regression with multiple imputation and inverse probability weighting was used to model adjusted associations between time, ethnicity, the interaction of time and ethnicity and outcomes. Results: Median age was 66; 61% Mexican American (MA). Trends in 90-day function overtime were roughly quadratic (Figure) and the change in the ethnic difference was significant among reference groups (p-value&lt0.01). Trends in NIHSS were linear with no change in the ethnic difference (p-value=0.51). Trends in cognition were approximately cubic and the change in the ethnic difference was significant within reference groups (p-value=0.03). Trends in QOL were stable with no change in the ethnic difference. Conclusion: Recent improvements in 90-day post-stroke functional and cognitive outcomes in MAs have resulted in reduced disparities. Factors contributing to favorable trends in outcomes in this group should be further studied.

30-day in-hospital stroke case fatality and significant risk factors in sub-Saharan-Africa: A systematic review and meta-analysis.

Existing studies investigating 30-day in-hospital stroke case fatality rates in sub-Saharan Africa have produced varying results, underscoring the significance of obtaining precise and reliable estimations for this indicator. Consequently, this study aimed to conduct a systematic review and update of the current scientific evidence regarding 30-day in-hospital stroke case fatality and associated risk factors in sub-Saharan Africa. Medline/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), APA PsycNet (encompassing PsycINFO and PsychArticle), Google Scholar, and Africa Journal Online (AJOL) were systematically searched to identify potentially relevant articles. Two independent assessors extracted the data from the eligible studies using a pre-tested and standardized excel spreadsheet. Outcomes were 30-day in-hospital stroke case fatality and associated risk factors. Data was pooled using random effects model. Ninety-three (93) studies involving 42,057 participants were included. The overall stroke case fatality rate was 27% [25%-29%]. Subgroup analysis revealed 24% [21%-28%], 25% [21%-28%], 29% [25%-32%] and 31% [20%-43%] stroke case fatality rates in East Africa, Southern Africa, West Africa, and Central Africa respectively. Stroke severity, stroke type, untyped stroke, and post-stroke complications were identified as risk factors. The most prevalent risk factors were low (<8) Glasgow Coma Scale score, high (≥10) National Institute Health Stroke Scale score, aspiration pneumonia, hemorrhagic stroke, brain edema/intra-cranial pressure, hyperglycemia, untyped stroke (stroke diagnosis not confirmed by neuroimaging), recurrent stroke and fever. The findings indicate that one in every four in-hospital people with stroke in sub-Saharan Africa dies within 30 days of admission. Importantly, the identified risk factors are mostly modifiable and preventable, highlighting the need for context-driven health policies, clinical guidelines, and treatments targeting these factors.

Self-expanding versus balloon expandable stent for intracranial arterial stenosis: A systematic review and meta-analysis.

There are limited data regarding the comparison of balloon expandable stents (BES) and self-expanding stents (SES) for the treatment of intracranial arterial stenosis. We conducted a systematic review to identify studies that compared SES and BES in patients with symptomaticintracranial arterial stenosis. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until from January 1, 2010 to September 28, 2023. Statistical pooling with random-effects meta-analysis was undertaken to compare the rates/severity ofpostprocedure stenosis, technical success, 30-day stroke and/or death, cumulative clinical endpoints, and restenosis rates. A total of 20 studies were included.The standardized mean difference (SMD) for postprocedure stenosis (%) was significantly lower (SMD: -0.52, 95% confidence interval [CI]: -0.79 to -0.24, p < .001, 10 studies involving 1515 patients) with BES. The odds for 30-day stroke and/or death were significantly lower (odds ratio [OR] 0.68, 95% CI: 0.50-0.94, p = .019, 15 studies involving 2431 patients), and cumulative clinical endpoints on follow-up were nonsignificantly lower (OR 0.64, 95% CI: 0.30-1.37, p = .250, 10 studies involving 947 patients) with BES. The odds for restenosis during follow-up were significantly lower (OR 0.50, 95% CI: 0.31-0.80, p = .004, 13 studies involving 1115 patients) with BES. Compared with SES, BES were associated with lower rates of postprocedure 30-day stroke and/or death with lower rates of restenosis during follow up andthe treatment of symptomatic intracranial arterial stenosis.

Effects of Concomitant CABG on Outcomes in Veterans Who Require Surgery for Endocarditis.

Infective Endocarditis (IE) is a complicated disease frequently accompanied by coronary artery disease (CAD) though no clear guidelines exist for when concomitant revascularization should be undertaken once valve surgery is indicated. Data on this topic within the United States (US) Veteran population, who have unique healthcare needs when compared to the civilian population, is sparse. We investigated the impact of concomitant coronary artery bypass grafting (CABG) on morbidity and mortality in US Veterans requiring surgical management of IE. We identified 489 patients who underwent surgical management of IE between January 1 2010 and December 31 2020 at any of 43 Veterans Affairs (VA) cardiac surgery centers in the US. Patients were stratified based on who underwent concomitant CABG at the time of operation. Primary outcomes included the occurrence of postoperative myocardial infarction (MI), stroke, or mortality. Continuous variables were compared using independent t-tests or Mann Whitney U tests, and categorical variables were compared using the Chi square test. Cox proportional-hazard models were used to calculate risk for primary outcomes based on group. 61 patients (12.5%) underwent concomitant CABG for CAD. After adjusting for significant covariates, patients who underwent CABG had a higher long-term risk of MI (adjusted hazard ratios (aHR) 2.37, 95% CI: 1.29-4.35, p = 0.005) and higher risk of MI at 30-days (aHR 2.34, 95% CI: 1.06-5.19, p = 0.035). Concomitant CABG was not associated with long-term stroke or death, 30-day stroke or death, or perioperative complications. On sub-analysis of patients with moderate to severe CAD, rates of MI were higher in the CABG group at 30 days (25.9 vs. 3.4%, p = 0.016) and 1 year (33.3 vs. 3.4%, p = 0.004), though not long-term. The mean number of grafts was 1.51 ± 0.76, with only one graft performed in 65.6% (40/61) of patients. Concomitant CABG at the time of operation for IE was associated with increased risk of MI at 30-day and long-term, though most CABGs involved a low number of grafts. It was not associated with 30-day stroke or death, long term stroke or death, or perioperative complications. The optimal treatment of CAD noted during preoperative evaluation for veterans undergoing surgery for IE remains unclear.

Outcomes of carotid endarterectomy in octogenarians compared to their younger counterparts: a retrospective observational study.

This study was performed to analyze the association between age and outcomes of carotid endarterectomy (CEA) by comparing postoperative outcomes between octogenarians and younger patients. From November 1994 to December 2022, 1,585 internal carotid arteries of 1,434 patients were enrolled. Patients were stratified into 2 groups: octogenarians (≥80 years old) and non-octogenarians (<80 years old). Primary endpoints were early (≤30 days) outcomes of ipsilateral stroke, any stroke, myocardial infarction, death, and major adverse cardiovascular events (MACE). We also compared overall any stroke and death between the 2 groups. One of 132 octogenarians (0.8%) and 17 of 1,453 non-octogenarians (1.1%) experienced ipsilateral stroke within 30 days. Thirty-day MACE occurred in 4 of 132 octogenarians (3%) and 44 of 1,453 non-octogenarians (3%). There were no significant differences in any early (≤30 days) outcomes. Symptomatic status was associated with increased 30-day MACE (odds ratio [OR], 2.610; 95% confidence interval [CI], 1.450-4.696; P = 0.003) and 30-day any stroke (OR, 3.999; 95% CI, 1.627-9.828; P = 0.003). Symptomatic status was also associated with overall any stroke (hazard ratio [HR], 2.885; 95% CI, 1.865-4.463; P < 0.001), but age of ≥80 years was not associated with 30-day MACE, 30-day any stroke, or overall stroke. Age of ≥80 years was only associated with overall survival (HR, 2.644; 95% CI, 1.967-3.555; P < 0.001). CEA would be a safe and effective treatment for octogenarians with low 30-day complications and long-term stroke rates, comparable with that of younger counterparts. Advanced age is not a contraindication for CEA.

Mortality and Disparities of Acute Myocardial Infarction and Stroke in Korea, 2008-2019.

Acute myocardial infarction (AMI) and stroke are leading global causes of death and can be used to assess acute care quality. We examined the 30-day mortality trends after emergency department admission for AMI and stroke in Korea from 2008 to 2019, focusing on regional and income disparities. The AMI and stroke patients admitted to hospitals in Korea were collected from the claims data. We analyzed age and sex-standardized 30-day mortality for AMI, as well as hemorrhagic and ischemic strokes. Disparities in mortality were analyzed using absolute differences and relative ratios between the Organization for Economic Cooperation Development (OECD) and Korea, and among income levels and regions in Korea. A 12-year joinpoint regression was used to determine the annual percent change and the average annual percent change. The trends in the 30-day AMI mortality of Korea were not significantly changed from 2008 to 2019; the gap remained at 1.2 between the OECD and Korea. Korea maintained lower mortality rates for hemorrhagic and ischemic stroke than the mean of OECD. In Korea, the 30-day hemorrhagic stroke mortality showed a constant decreasing trend for the higher-income group living in urban areas; it led to a widened gap based on income levels in urban areas. The 30-day mortality for ischemic stroke tended to decrease in the higher-income group and urban areas. National-level intervention is needed to manage regional and income-based disparities in AMI and stroke 30-day mortality. It is important to understand the variance in mortality rate by different geographical regions and income levels to establish an appropriate public health strategy.

Impact of transcatheter heart valve type on outcomes of surgical explantation after failed transcatheter aortic valve replacement: the EXPLANT-TAVR international registry.

There are limited data on the impact of transcatheter heart valve (THV) type on the outcomes of surgical explantation after THV failure. We sought to determine the outcomes of transcatheter aortic valve replacement (TAVR) explantation for failed balloon-expandable valves (BEV) versus self-expanding valves (SEV). From November 2009 to February 2022, 401 patients across 42 centres in the EXPLANT-TAVR registry underwent TAVR explantation during a separate admission from the initial TAVR. Mechanically expandable valves (N=10, 2.5%) were excluded. The outcomes of TAVR explantation were compared for 202 (51.7%) failed BEV and 189 (48.3%) failed SEV. Among 391 patients analysed (mean age: 73.0±9.8 years; 33.8% female), the median time from index TAVR to TAVR explantation was 13.3 months (interquartile range 5.1-34.8), with no differences between groups. Indications for TAVR explantation included endocarditis (36.0% failed SEV vs 55.4% failed BEV; p<0.001), paravalvular leak (21.2% vs 11.9%; p=0.014), structural valve deterioration (30.2% vs 21.8%; p=0.065) and prosthesis-patient mismatch (8.5% vs 10.4%; p=0.61). The SEV group trended fewer urgent/emergency surgeries (52.0% vs 62.3%; p=0.057) and more root replacement (15.3% vs 7.4%; p=0.016). Concomitant cardiac procedures were performed in 57.8% of patients, including coronary artery bypass graft (24.8%), and mitral (38.9%) and tricuspid (14.6%) valve surgery, with no differences between groups. In-hospital, 30-day, and 1-year mortality and stroke rates were similar between groups (allp>0.05), with no differences in cumulative mortality at 3 years (log-rank p=0.95). On multivariable analysis, concomitant mitral surgery was an independent predictor of 1-year mortality after BEV explant (hazard ratio [HR] 2.00, 95% confidence interval [CI]: 1.07-3.72) and SEV explant (HR 2.00, 95% CI: 1.08-3.69). In the EXPLANT-TAVR global registry, BEV and SEV groups had different indications for surgical explantation, with more root replacements in SEV failure, but no differences in midterm mortality and morbidities. Further refinement of TAVR explantation techniques are important to improving outcomes.

Perioperative Blood Transfusion Is Associated with Worse 30-Day Mortality and Complications After Thoracic Endovascular Aortic Repair

It is not uncommon for patients requiring vascular surgery, and in particular aortic surgery, to have increased requirements for blood transfusion. However, studies examining the effects of perioperative transfusion for thoracic endovascular aortic repair (TEVAR) are limited. Using large multicenter data, we aimed to study the impact of perioperative blood transfusion on 30-day mortality and complications after TEVAR. A total of 9,263 patients who underwent TEVAR were included in this retrospective study from the multicenter Vascular Quality Initiative cohort spanning 2010-2022. We excluded patients who were post-traumatic, anemic (World Health Organization criteria: hemoglobin < 12g/dl and < 13g/dl for females and males respectively), who underwent open conversions or presented with ruptured aneurysms. Primary outcomes were 30-day mortality and stroke. Secondary outcomes were postop congestive heart failure (CHF), respiratory complications, spinal cord ischemia (SCI), myocardial infarction (MI) and any postop complications (composite variable). Poisson regression with robust variance was performed to determine the risk of post op outcomes comparing patients who received red blood cells (RBCs) to those who did not. Comparing patients without any transfusion (n=8,223), perioperative transfusion of 1-3 units (n=735) was associated with 3-fold increased risk of 30-day mortality (adjusted relative risk [aRR] 3.30, 95% confidence interval [CI] 2.39,4.57, P<0.001), almost 2-fold increased risk of stroke (aRR 1.98, 95% CI 1.24,3.15, P=0.004), 2.7-fold increased risk of SCI (aRR 2.66, 95% CI 1.87-3.77, P<0.001), 3-fold increased risk of MI (aRR 3.40, 95% CI 2.30, 5.03, P<0.001), 2-fold increased risk of CHF (aRR 2.04, 95% CI 1.09, 3.83, P=0.03), 3.5-fold increased risk of respiratory complications (aRR 3.49, 95% CI 2.67, 4.56, P<0.001), and 2-fold increased risk of any postop complication (aRR 2.36, 95% CI 2.04, 2.73, P<0.001). These effects were even higher in patients transfused 4 or more units (n=305) than seen in the effects seen in those transfused 1-3 units; comparing each group to patients who received none. In hemodynamically stable patients undergoing TEVAR for nonemergent/emergent and nontraumatic indications, transfusion of any amount perioperatively is associated with worse 30-day mortality, stroke, SCI, MI, CHF, and respiratory complications. A conservative transfusion approach and multidisciplinary care to identify complications and rescue TEVAR patients who receive any amount of RBCs perioperatively might help improve outcomes. Future studies to understand the mechanisms of outcomes for transfused patients are needed.

Comparative assessment of racial disparity in 30-day outcomes for Asian Americans undergoing carotid endarterectomy

ObjectiveCarotid endarterectomy (CEA) is an effective treatment for carotid stenosis. All previous studies on racial disparity of CEA outcomes omitted Asian Americans. This study aimed to address this gap by investigating racial disparities in 30-day outcomes following CEA among Asian Americans. MethodsAsian American and Caucasian patients who underwent CEA were identified in the American College of Surgeons National Surgical Quality Improvement Program targeted database from 2011 to 2021. Patients with age less than 18 years old were excluded. Patients with symptomatic and asymptomatic carotid stenosis were examined separately. A 1:5 propensity-score matching was used to address preoperative differences. Thirty perioperative outcomes were assessed. ResultsThere were 380 Asian Americans (2.27%) and 13,250 Caucasians (79.18%) with symptomatic carotid stenosis who underwent CEA. Also, 289 Asian Americans (1.40%) and 18,257 Caucasians (88.14%) with asymptomatic carotid stenosis had CEA. Asian Americans undergoing CEA presented with higher comorbid burdens and more severe symptomology. Also, asymptomatic Asian Americans were more likely to undergo surgeries for mild stenosis (<50%), which is not in line with practice guidelines. After 1:5 propensity-matching, all symptomatic Asian Americans were matched to 1550 Caucasian patients, and all asymptomatic Asian Americans were matched to 1445 Caucasians; preoperative differences were addressed. Asian Americans exhibited low overall 30-day mortality (symptomatic, 1.61%; asymptomatic, 0.35%) and stroke (symptomatic, 2.26%; asymptomatic, 0.69%). All perioperative outcomes were comparable to Caucasians, with the exception that Asian Americans experienced longer operation times. ConclusionsEvidence suggested that Asian Americans with asymptomatic stenosis were underrepresented in CEA. After propensity-score matching, Asian Americans demonstrated comparable 30-day outcomes to Caucasians. These suggest that, when afforded equal access to quality health care, CEA serves as an effective treatment for carotid stenosis among Asian Americans. Therefore, efforts may be aimed at addressing health care access, potentially in the screening for asymptomatic carotid stenosis in Asian Americans. This would ensure they have equitable benefits from CEA. Nevertheless, the exact preoperative differences and long-term CEA outcomes in Asian Americans should warrant further examination in future studies.

Blood Pressure Fluctuation Pattern Associated with 90-Day Ischemic Stroke and Transient Ischemic Attack After Total Knee Arthroplasty-A Retrospective Study.

Blood pressure (BP) fluctuation has been demonstrated to be closely associated with stroke. However, at present, no attention is paid to the BP fluctuation following total knee arthroplasty (TKA). The aim of this study is to investigate what is BP fluctuation patterns in stroke and transient ischemic attack (TIA) patients after primary TKA, compare clinical characteristics among different BP fluctuation patterns and determine whether it could predict the occurrence of a 90-day stroke. A retrospective study was conducted from February 1, 2011 to February 15, 2021. Stroke or TIA patients within 90 days after TKA were included. Data from a hospitalization management system were analyzed, including demographics, smoking status, comorbidities, medications, surgical variables, and 90-day stroke, mortality, and readmission rates. BP fluctuation patterns were defined based on the average BP in the first 3 days after TKA. A logistic regression analysis model was used to identify risk factors for 90-day stroke or TIA following TKA. Of the 1687 patients who underwent primary TKA, 4.0% (68/1687) experienced a 90-day stroke or TIA. A total of 63 patients met the inclusion criteria, with an average age of 67.5 years and 55.6% (35/63) female. The number of stroke or TIA patients in each BP fluctuation pattern (T1-T5) was 6 (9.5%), 5 (7.9%), 4 (6.3%), 13 (20.6%), and 35 (55.6%) respectively. Patients with a T5 pattern tended to be older and had a greater reduction in average systolic blood pressure (SBP) 3 days after surgery compared to other patterns. The T5 pattern was associated with a higher occurrence of stroke and a lower occurrence of TIA. Patients with a T5 pattern also had a longer length of stay within 90 days following TKA. After adjusting for confounding factors, average SBP fluctuation ≥40 mmHg and the T5 pattern of BP fluctuation remained risk factors for 90-day stroke or TIA after TKA. BP fluctuation patterns in the early postoperative period are associated with 90-day stroke and TIA following primary TKA.

Prolonged Systemic Inflammatory Response Syndrome After Cardiac Surgery

Cardiac surgery induces systemic inflammatory response syndrome (SIRS), leading to higher morbidity and mortality. There are no individualized predictors for worse outcomes or biomarkers for the multifactorial, excessive inflammatory response. The interest of this study was to evaluate whether a systematic use of the SIRS criteria could be used to predict postoperative outcomes beyond infection and sepsis, and if the development of an exaggerated inflammation response could be observed preoperatively. The study was observational, with prospectively enrolled patients. This was a single institution study in a hospital setting combined with laboratory findings. The study included a cohort of 261 volunteer patients. Patients underwent cardiac surgery with cardiopulmonary bypass, and were followed up to 90 days. Biomarker profiling was run preoperatively. Altogether, 17 of 261 (6.4%) patients had prolonged SIRS, defined as fulfilling at least 2 criteria on 4 consecutive postoperative days. During hospitalization, postoperative atrial fibrillation (POAF) was found in 42.2% of patients, and stroke and transient ischemic attack in 3.8% of patients. Prolonged SIRS was a significant predictor of POAF (odds ratio [OR] 4.5, 95% CI 1.2-17.3), 90-day stroke (OR 4.5, 95% CI 1.1-18.0), and mortality (OR 10.7, 95% CI 1.7-68.8). Biomarker assays showed that preoperative nerve growth factor and interleukin 5 levels were associated with prolonged SIRS (OR 5.6, 95%, CI 1.4-23.2 and OR 0.7, 95%, CI 0.4-1.0, respectively). Nerve growth factor and interleukin 5 can be used to predict prolonged systemic inflammatory response, which is associated with POAF, stroke, and mortality.

Previous external beam radiation therapy for pelvic malignancy increases complications of total hip arthroplasty.

External beam radiation therapy (EBRT) has known effects on bone health. No large database studies have looked at the effects of pelvic EBRT on total hip arthroplasty (THA) outcomes. The purpose of this study was to evaluate 90-day and long-term (>2 years) complication rates following THA in patients with a history of pelvic malignancy and EBRT. Patients were retrospectively identified using a national insurance claims database. Subjects who underwent THA for osteoarthritis or avascular necrosis were included if they had at least 2-year follow-up and were stratified into 3 cohorts: (1) prior pelvic malignancy diagnosis (prostate, cervical, uterine, ovarian, or rectal) and EBRT (Group A); (2) prior malignancy diagnosis but no EBRT (Group B); and (3) neither prior malignancy diagnosis nor EBRT (Group C). Univariate and multivariate analyses were conducted to evaluate for an association between prior EBRT and the incidence of 90-day and 2-year complication rates using chi-square, student t-tests, and logistic regression analyses where appropriate. 671,554 patients met the inclusion criteria. Group A had higher odds of all-cause revision, septic revision, and loosening with revision after 2 years when compared to Group C and Group B (p < 0.001). Group A subjects had higher rates of 90-day deep vein thrombosis, sepsis, and stroke (p < 0.001) than groups B and C. Prior EBRT for pelvic malignancy was associated with significantly increased rates of all-cause revision, septic revision, and loosening as well as 90-day medical complications.

Spectrum of cardiac arrythmias and its influence on 30-day stroke mortality in Dar es Salaam

Spectrum of cardiac arrythmias and its influence on 30-day stroke mortality in Dar es Salaam

Ivabradine in the Prevention, and Reduction in Size, of Perioperative Myocardial Injury in Patients Undergoing Orthopedic Surgery for Acute Fracture.

Perioperative myocardial injury is common after major noncardiac surgery and is associated with adverse outcomes. This study investigated the use of ivabradine in patients undergoing urgent surgery for fracture. This was a prospective, double-blind, placebo-controlled, randomized clinical trial. Participants were enrolled 1:1 into ivabradine or placebo arm, and study drug was commenced before operation and continued for 7 days or until discharge. High-sensitivity troponin I was measured daily using Abbott Alinity analyzer and assay, and heart rate data were obtained using continuous Holter monitoring. A total of 199 patients underwent acute orthopedic surgery, 98 in the ivabradine group and 101 in the placebo group. The mean age was 78.7 years (range, 77.5-79.9 years), with 68% women. The average heart rate was 5 to 11 beats per minute lower in the ivabradine group compared with the placebo group at all time points (P<0.001 for all). There was no statistically significant difference between the ivabradine and placebo groups in the number of patients who had perioperative myocardial injury: 28.6% versus 31.6% (P=0.71). In patients with perioperative myocardial injury, average peak troponin was 168.8 ng/L (±431.2 ng/L) in the ivabradine group and 2094.5 ng/L (±7201.9 ng/L) in the placebo group (P=0.16). There was no statistically significant difference between groups in 30-day mortality, blood pressure, stroke, or major adverse cardiovascular event. Starting ivabradine preoperatively in elderly patients requiring acute surgery for fracture did not result in a statistically significant difference in the incidence of perioperative myocardial injury. There was no statistically significant difference in morbidity, mortality, or adverse events between treatment groups. URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12616001634460p.

Safety of Tailored Transfemoral Carotid Artery Stenting for Symptomatic Elderly Patients: A Single Center Observational Study

Transfemoral carotid artery stenting (TFCAS) in symptomatic elderly patients (≥70 years old) may have a high periprocedural stroke rate. This study was performed to examine whether tailored TFCAS for symptomatic elderly patients is as safe as that for symptomatic nonelderly patients. The subjects were 185 patients with symptomatic internal carotid artery stenosis. Tailored TFCAS including postoperative management was performed based on preoperative examinations of vascular anatomy, plaque imaging, platelet aggregation activity, and cerebral hemodynamic impairment. The major 30-day perioperative stroke rates were examined. The patients included 51 (27.6%) <70 (group Y) and 134 (72.4%) ≥70 (group E) years old. Group E included significantly more cases with an elongated aortic arch, tortuous target lesion, and longer plaques (all P < 0.05). Among all cases, 181 (97.8%) procedures were performed as per preoperative planning. Group E had more frequent use of a proximal embolic protection device and a closed-cell or dual-layer micromesh stent (all P < 0.05). Seven patients (3.8%) had major stroke. Rates of major ischemic stroke (2.0% vs. 3.0%, P= 1.00) and intracranial hemorrhage (2.0% vs. 0.8%, P= 0.48) were low and did not differ significantly between groups Y and E. Symptomatic elderly patients have several unfavorable factors. However, tailored TFCAS for each patient based on preoperative examinations in symptomatic elderly patients may be as safe as that in symptomatic nonelderly patients.

Impact of pre-procedural bioprosthetic leaflet calcification on hemodynamic and hlinical outcomes after aortic valve-in-valve procedure

Abstract Background Transcatheter aortic valve replacement (TAVR) is a recognized option to treat patients with aortic bioprosthetic failure, but preprocedural factors associated with poor hemodynamic and clinical outcomes after valve-in-valve (ViV) TAVR remain unclear. In TAVR performed in native aortic valve, higher degrees of aortic valve calcification (AVC) have been associated with poorer outcome, but the association of bioprosthetic AVC and outcomes after ViV TAVR remains unknown. We hypothesize that a high amount of pre-procedural bioprosthetic AVC may result in a higher risk of patient-prosthesis mismatch (PPM) or post-procedural intervalvular regurgitation, and increased mid-term mortality. Purpose To assess the association of pre-procedural surgical bioprosthetic AVC and short- and mid-term hemodynamic and clinical outcomes after aortic ViV procedure. Methods All consecutive patients who underwent aortic ViV procedure for surgical aortic bioprosthetic failure at our institution between 2009-2022 with available pre-procedural CT were included, patients with TAVR-in-TAVR were excluded. We measured AVC with non-contrast CT, and this amount was divided by LVOT area (measured on echocardiography) to obtain AVC density (AVCD). Pre and post-procedural transthoracic echocardiograms were analyzed for aortic valve hemodynamics. Multivariate Cox-regression was performed to assess the determinants of mid-term all-cause mortality. Results A total of 186 patients were included. An AVCD score above the median was associated with younger age, diabetes, lower indexed aortic valve area and higher preprocedural mean gradient (figure 1). Preprocedural AVCD was not significantly different in patients with: 1) postprocedural severe PPM (n=81, 45%) vs no-moderate PPM (n=100, 55%) (207 [68-335] vs 209 [54-352] Agatston units (AU)/cm2, p=0.80); 2) ≥moderate intervalvular regurgitation (n=10, 5%) vs no-mild regurgitation (n=174, 90%) (198 [57-350] vs 251 [210-352] AU/cm2, p=0.22). Higher AVCD was not associated with 30-day mortality, stroke, or implantation of a new pacemaker (all p&amp;gt;0.05). During 38 [21-65] months of follow-up, multivariate factors associated with all-cause mortality were older age, diabetes, and chronic obstructive pulmonary disease, while AVCD was associated with a lower mortality (HR 0.77 (0.63-0.94) per 100 AU/cm2 increase, p=0.01). Conclusion High pre-procedural bioprosthetic ACVD is not associated with a poorer hemodynamic and clinical after Aortic ViV procedure for surgical bioprosthetic failure.Baseline tableSurvival curve

Abstract 12729: Leadless Pacemaker Insertion is Safe in Nonagenarians

Introduction: Increased age is associated with increased frailty and often worse postoperative outcomes. We aim to assess the safety of leadless pacemaker (LPM) insertion in the very elderly population. Methods: We queried the National Readmission Database years 2017-2020 for patients who underwent LPM insertion with the ICD10 code 02HK3NZ. Patients with age 90 or more were included in the nonagenarians group. Patient comorbidities were queried through the appropriate ICD 10 codes. We compared outcomes using multivariate logistic and linear regression, adjusting for patient comorbidities. Results: At baseline, nonagenarians had a higher prevalence of hypertension, history of stroke, A fib./A. flutter, dementia and hypothyroidism. The control group had more of diabetes, coronary disease, chronic kidney disease, chronic pulmonary disease, oxygen use, coagulopathy, anemia, obesity, substance abuse and chronic liver disease (Table 1). Compared to controls, nonagenarians were found to have shorter length of stay (-2.486 days, p &lt;0.001), lower rate of mortality (aOR 0.696, p 0.0187), lower rates of postprocedural cardiac arrest (aOR 0.301, p 0.0267), mechanical ventilation (aOR 0.378, p &lt;0.001), and vasopressor use (aOR 0.583, p 0.001). Nonagenarians were only found to have increased risk of pericardial complications (tamponade, pericardiocentesis, hemopericardium) (aOR 1.596, p 0.0151). There was no significant difference in 30-day readmissions (aOR 0.97, p 0.696), postoperative bleed (aOR 0.84, p 0.072), or stroke (aOR 0.586, p 0.112). Conclusions: Our study demonstrates LPM insertion is safe in the very elderly population. However this is likely a demonstration of survivorship bias as patients in the nonagenarians group had overall less comorbidities. Even though our analysis adjusted for comorbidities, there are always unknown confounders which cannot be accounted for. Age itself does not seem to be a risk factor for worse outcomes in this population.

HIV Infection and 90-Day Stroke Outcomes in Uganda: A Prospective Observational Cohort Study.

Little is known about the impact of HIV infection on the clinical presentation and outcomes after stroke in the modern antiretroviral therapy (ART) era. We aimed to compare stroke characteristics and outcomes between persons with HIV (PWH) and without HIV (PWOH) presenting with stroke in Uganda. We conducted a matched cohort study at Mulago National Referral Hospital and Mbarara Regional Referral Hospital between January 2018 and November 2020. We enrolled consecutive PWH presenting with CT-confirmed acute or subacute stroke (symptom onset ≤14 days) and matched them by sex and stroke type to 2 consecutive available PWOH admitted to the same hospital. We obtained baseline clinical data and followed participants for 90 days from the day of clinical presentation. We compared stroke severity (defined by the NIH stroke scale [NIHSS]) and 90-day all-cause mortality and morbidity (using the modified Rankin Scale [mRS]) by HIV serostatus with and without adjustment for confounders. We enrolled 105 PWH and 157 PWOH with stroke. PWH were younger (mean [SD] age 49 [14] vs 59 [16] years, p < 0.001), and nearly 80% (82/105) were on ART for a median of 5 years and a median CD4 count of 214 cells/uL (interquartile range 140, 337). Compared with PWOH, PWH presented with a 3-point lower median NIHSS (16 vs 19, p = 0.011), a 20% lower proportion of all-cause mortality at 90 days (p = 0.001), and had less disability at 90 days (median mRS 4 vs 5, p = 0.004). Age and NIHSS-adjusted odds ratio of 90-day all-cause mortality in PWH compared with PWOH was 0.45 (95% CI 0.22-0.96, p = 0.037). In the modern ART era, PWH with acute stroke in Uganda present with modest stroke and are significantly less likely to die within 90 days than PWOH. This potentially reflects the protective effects of ART, enhanced health care access, and their younger age at stroke presentation.

Initial experience with transcarotid arterial revascularization with flow reversal in the management of symptomatic carotid stenosis.

The aim of this study was to evaluate the efficacy of transcarotid arterial revascularization (TCAR) as a viable intervention in the treatment of symptomatic carotid artery stenosis. The authors performed a retrospective review of prospectively collected data of the first 62 consecutive patients treated at Rhode Island Hospital in Providence, Rhode Island, who underwent a TCAR for symptomatic carotid artery stenosis between November 11, 2020, and March 31, 2022. Relevant demographic, comorbidity, and perioperative data were extracted through retrospective chart review. Patients with asymptomatic carotid artery stenosis were excluded. The authors also evaluated patients using pertinent physiological and anatomical high-risk criteria as described in the ROADSTER trial. Risk factors were aggregated to form a composite risk total for every patient. The primary outcome of this study was the 30-day adverse outcome rate of stroke, myocardial infarction, and/or death. Periprocedural stroke was identified by clinical symptoms and radiographic findings. Secondary endpoints included device and procedural success, 30-day mortality, 30-day stroke rate, and postoperative complications. The authors analyzed the first 62 patients with > 50% symptomatic carotid artery stenosis who underwent TCAR at their institution. The mean age of the cohort was 71.5 years, and the cohort was predominantly male (67.7%). The most common high-risk medical criteria were age older than 75 years (45.3%) and severe coronary artery disease (13.6%). The most common anatomical high-risk criteria were high bifurcation (35.1%) and contralateral stenosis requiring treatment within 30 days (15.8%). Fifty percent of patients had at least 1 medical high-risk criterion, 50% had at least 1 anatomical risk criterion, and 82% of patients had 2 or more high-risk criteria of any kind. Among this group, all patients (100%) underwent successful revascularization, with 1 (1.6%) requiring intraprocedural conversion to carotid endarterectomy. Postprocedurally, there was 1 nondisabling stroke (1.6%) and 3 deaths (4.8%) within 30 days of the procedure, with only 1 death directly attributable to the procedure. One patient (1.6%) experienced a neck hematoma. In total, 4 patients (6.5%) experienced a major complication. The overall complication rate was 8.0%. The authors' initial experience with TCAR suggests that it might provide an effective alternative to carotid endarterectomy and carotid artery stenting in the management of symptomatic carotid stenosis in patients with high-risk anatomical and medical characteristics.

Developing and externally validating a machine learning risk prediction model for 30-day mortality after stroke using national stroke registers in the UK and Sweden

ObjectivesWe aimed to develop and externally validate a generalisable risk prediction model for 30-day stroke mortality suitable for supporting quality improvement analytics in stroke care using large nationwide stroke registers...