In-hospital Postoperative Stroke Research Articles

Report on outcomes of valve-in-valve transcatheter aortic valve implantation and redo surgical aortic valve replacement in the Netherlands.

ObjectiveWe sought to investigate real-world outcomes of patients with degenerated biological aortic valve prostheses who had undergone valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) or reoperative surgical aortic valve replacement (redo-SAVR) in the Netherlands.MethodsPatients who had undergone ViV-TAVI or redo-SAVR for a degenerated biological aortic valve prosthesis in the Netherlands between January 2014 and December 2018 were eligible for this retrospective study. Patients with a prior homograft, active endocarditis or mechanical aortic valve prosthesis were excluded. Patients were matched using the propensity score. The primary endpoint was a composite of 30-day all-cause mortality and in-hospital postoperative stroke. Secondary endpoints were all-cause mortality at different time points, in-hospital postoperative stroke, pacemaker implantation and redo procedures within one year. Baseline characteristics and outcome data were collected from the Netherlands Heart Registration.ResultsFrom 16 cardiac centres, 653 patients were included in the study (374 ViV-TAVI and 279 redo-SAVR). European System for Cardiac Operative Risk Evaluation I (EuroSCORE I) was higher in ViV-TAVI patients (19.4, interquartile range (IQR) 13.3–27.9 vs 13.8, IQR 8.3–21.9, p < 0.01). After propensity score matching, 165 patients were matched with acceptable covariate balance. In the matched cohorts, the primary endpoint was not significantly different for ViV-TAVI and redo-SAVR patients (odds ratio 1.30, 95% confidence interval 0.57–3.02). Procedural, 30-day and 1‑year all-cause mortality rates, incidence of in-hospital postoperative stroke, pacemaker implantation and redo procedures within one year were also similar between cohorts.ConclusionPatients with degenerated aortic bioprostheses treated with ViV-TAVI or redo-SAVR have similar mortality and morbidity.Supplementary InformationThe online version of this article (10.1007/s12471-021-01608-0) contains supplementary material, which is available to authorized users.

Carotid Artery Disease as a Predictor of In-Hospital Postoperative Stroke After Coronary Artery Bypass Grafting From 1999 to 2011

In this study, the risk factors for stroke after coronary artery bypass grafting (CABG) were examined. In particular, the role of asymptomatic carotid artery stenosis (both unilateral and bilateral) as a predictor of in-hospital postoperative stroke was investigated. Finally, the trends surrounding in-hospital postoperative stroke from 1999 to 2011 also were examined. The purpose of the study was to appropriately identify patients at high risk for stroke after CABG and spark discussion about the perioperative management of such patients. Data from the Nationwide Inpatient Sample from 1999 to 2011 were analyzed retrospectively. The study cohort was identified using the International Classification of Diseases, Ninth Revision, Clinical Modification and Projection Clinical Classification Software codes. Exploratory statistics, univariate analyses, and multivariable regression were used for this study. The analysis demonstrated that both asymptomatic unilateral and bilateral carotid stenoses were independent risk factors for in-hospital postoperative stroke. In addition, increasing age, female sex, increasing van Walraven score, paralysis, neurologic disorders, history of infective endocarditis, asymptomatic basilar stenosis, and cerebral occlusion all were demonstrated to be statistically significant predictors of stroke. Patients with carotid stenosis and a van Walraven score >14 were found to be particularly vulnerable to in-hospital postoperative stroke. Lastly, predictors of carotid stenosis were examined, and increasing age, female sex, and increasing van Walraven score all were found to be significant predictors of asymptomatic carotid stenosis. This study examined risk factors for stroke after CABG in a large, longitudinal, and population-based database. The study found that both unilateral and bilateral asymptomatic carotid stenoses are indeed risk factors for in-hospital postoperative stroke. In addition, a number of other predictors were identified. These results can be used to identify patients at high risk for perioperative stroke and hopefully decrease the rate of a devastating complication of CABG.

The prognostic significance of declining health-related quality of life scores at 6 months after coronary artery bypass surgery

Health-related quality of life (HRQoL) measured on the EQ-5D (European quality of life-5 dimensions)-questionnaire has been shown to improve after coronary artery bypass grafting (CABG), this study investigated whether changes in HRQoL predict later morbidity. Included were 404 consecutive patients undergoing isolated CABG between 2008 and 2010 who filled the EQ-5D-questionnaire at baseline and 6 months postoperatively. Records were reviewed for later major adverse cardiac and cerebrovascular events (MACCE) after 6 months. Follow-up was 38.6 months (10-58). Patients who suffered later MACCE more often had suffered an in-hospital postoperative stroke, had a longer in-hospital stay, had lower HRQoL scores at 6 months and deteriorated on several EQ-5D-subscales. Logistic regression showed 6 months visual analogue scale scores and declining function scores to be independent predictors of later MACCE. Deteriorating function and HRQoL-scores at 6 months as compared to baseline postoperatively predict later adverse cardiovascular events after CABG.

The effect of postoperative stroke and myocardial infarction on long-term survival after carotid revascularization

The largest randomized controlled trial that compared the efficacy of carotid endarterectomy (CEA) with carotid artery stenting (CAS) showed equivalent outcomes for the composite end point of postoperative stroke, myocardial infarction (MI), or death. However, CAS had a higher risk of postoperative stroke, and CEA had a higher risk of MI. We hypothesize that there is a differential association of postoperative stroke, compared with that of postoperative MI, with reduced long-term survival after carotid revascularization when compared with neither complication. The Vascular Study Group of New England database was used to identify all CEA and CAS procedures performed between 2003 and 2011. Patients were stratified according to whether they experienced an in-hospital postoperative stroke (minor or major), MI (troponin elevation, electrocardiographic changes, or clinical symptoms), or neither. Primary study end point was survival during the first year and the first 5 years postoperatively. Multivariable Cox proportional hazards models compared the magnitude of association of stroke and MI on survival. Of 8315 patients, 81 (0.97%) experienced postoperative MI, and 63 (0.76%) experienced stroke. During the first year after operation, survival significantly differed among the three groups: neither, 96%; MI, 84%; stroke, 77% (log-rank P< .0001). After adjusting for confounders, survival after postoperative stroke (hazard ratio [HR], 6.6; 95% confidence interval [CI], 3.7-12; P< .0001) was nearly twofold less than that after postoperative MI (HR, 3.6; 95% CI, 2-6.8; P<.0001). During the first 5 years postoperatively, multivariable modeling showed postoperative stroke and postoperative MI remained independent predictors of decreased survival, but the magnitude of association was similar (HR, 2.7; 95% CI, 1.7-4.3 [P< .0001] vs HR, 2.8; 95% CI, 1.8-4.3 [P< .0001]). During the first year after operation, postoperative stroke conferred a twofold lower survival than that after postoperative MI. By 5 years after operation, these survival curves converged, and the survival disadvantage associated with stroke became similar to that of MI. These data suggest that different postoperative complications after carotid revascularization have different implications for patients, with decreased short-term survival in patients experiencing a postoperative stroke. These findings help to inform our interpretation of studies that have used a composite end point in order to evaluate the comparative effectiveness of revascularization strategies.

Carotid endarterectomy was performed with lower stroke and death rates than carotid artery stenting in the United States in 2003 and 2004

Although carotid endarterectomy (CEA) is the gold standard for the treatment of carotid artery stenosis, the recent United States Food and Drug Administration approval of carotid artery stenting (CAS) may have led to its widespread use outside of clinical trials and registries. This study compared in-hospital postoperative stroke and mortality rates after CAS and CEA at the national level. The Nationwide Inpatient Sample (NIS) was queried to identify all patient-discharges that occurred for revascularization of carotid artery stenosis. The International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for CEA (38.12), CAS (00.63), and insertion of noncoronary stents (39.50, 39.90) were used in conjunction with the diagnostic codes for carotid artery stenosis, with (433.11) and without (433.10) stroke. Primary outcome measures included in-hospital postoperative stroke and death rates. Multivariate logistic regressions were performed to evaluate independent predictors of postoperative stroke and mortality. Adjustment was made for age, sex, medical comorbidities, admission diagnosis, procedure type, year, and hospital type. During the calendar years 2003 and 2004, an estimated 259,080 carotid revascularization procedures were performed in the United States. CAS had a higher rate of in-hospital postoperative stroke (2.1% vs 0.88%, P < .0001) and higher postoperative mortality (1.3% vs 0.39%) than CEA. For asymptomatic patients (92%), the postoperative stroke rate was significantly higher for CAS than CEA (1.8% vs 0.86%, P < .0001), but the mortality rate was similar (0.44% vs 0.36%, P = .36). For symptomatic patients (8%), the rates for postoperative stroke (4.2% vs 1.1%, P < .0001) and mortality (7.5% vs 1.0%, P < .0001) were significantly higher after CAS. By multivariate regression, CAS was independently predictive of postoperative stroke (odds ratio [OR], 2.49; 95% confidence interval [CI], 1.91 to 3.25). CAS was also associated with in-hospital postoperative mortality for asymptomatic (OR, 2.37; 95% CI, 1.46 to 3.84) and symptomatic (OR, 2.64; 95% CI, 1.89 to 3.69) patients. As determined from a large representative national sample including the years 2003 and 2004, the in-hospital stroke rate after CAS for asymptomatic patients was twofold higher than after CEA. For symptomatic patients, the respective in-hospital stroke and mortality rates were fourfold and sevenfold higher. These unexpected results indicate that further randomized controlled trials with homogenous symptomatic and asymptomatic patient groups should be performed.