Incidence Of Postoperative Stroke Research Articles

Abstract WP180: Gender-specific Risk Of Stroke In Patients With Peripheral Artery Disease

Objective: Peripheral artery disease (PAD) is a common atherosclerotic disease associated with increased morbidity and mortality. We conducted a retrospective review to investigate the role of gender in influencing the incidence of stroke after surgery for PAD. Methods: We conducted a retrospective review using data from the Vascular Quality Initiative database for patients who underwent supra-inguinal and infra-inguinal surgery between 2010 and 2020. The relationship between gender and 30-day post-operative outcomes was calculated as an odds ratio; the threshold of significance was p =0.05 for univariate and multivariable analysis. Gender-based influence of age and adjusted probability of stroke was plotted using Sigma Plot. Results: A total of 79,981 patients were included based on our eligibility criteria, 34% of which were female. Although only 0.6% of patients experienced stroke, risk of stroke was significantly higher in female patients ( p <0.001). Female patients were more commonly hypertensive ( p =0.007) and diabetic ( p =0.003), while also presenting decreased pre-operative use of statin ( p <0.001) and aspirin ( p <0.001) as compared to males. Additional predictors of post-operative stroke include age > 65 years ( p =0.015), hypertension ( p =0.002), and pre-operative use of beta blockers ( p <0.001). Overall, females had higher risk of all-cause morbidity ( p =0.004), stroke ( p <0.001), mortality ( p <0.001), and major adverse cardiovascular events ( p <0.001), while males had increased risk of returning to the operating room ( p =0.006). Regression analysis revealed a significantly stronger bearing of high age on probability of post-operative stroke in women ( p <0.001). Conclusion: Our data suggests that incidence of post-operative stroke and other cardiovascular complications is influenced by gender in surgery of PAD. Future research investigating underlying gender-based mechanisms is necessary to personalize treatment in patients with PAD.

New-Onset Sleep Disorders before Cardiac Surgery May Indicate an Increased Risk of Postoperative Atrial Fibrillation.

We aimed to determine if sleep disorders before cardiac surgery indicate an increased risk of postoperative atrial fibrillation (POAF). In this study, 238 patients undergoing coronary artery bypass grafting in our center were included. Patients were separated into the preoperative sleep disorder group and the control group. The primary endpoint was the incidence of POAF, and the secondary endpoints were the incidence of postoperative stroke, duration of invasive ventilation, length of intensive care unit, and hospitalization stay. Propensity score matching and multivariable logistic regression were used for adjusting potential confounders. A total of 165 (69.3%) patients had sleep disorders before surgery, and 73 well-matched pairs were generated. A higher incidence of POAF was found in the preoperative sleep disorder group (16.4% versus 5.5%, p = 0.034). In multivariable logistic regression, preoperative sleep disorders were correlated to a higher risk of POAF (odds ratio = 4.627, 95% confidence interval: 1.181-18.123, p = 0.028). In the subgroup of patients without long-term sleep disorders, those who experienced preoperative sleep disorders had a higher incidence of POAF (16.1% versus 4.3%, p = 0.024), meanwhile, no difference was found in the subgroup of long-term sleep disorders. New-onset sleep disorders before cardiac surgery may indicate a higher incidence of POAF.

The Effect of Female Sex on Short-Term Outcomes of Patients Undergoing Off-Pump Versus On-Pump Coronary Artery Bypass Grafting.

According to the American Heart Association guideline for coronary artery bypass grafting (CABG), female patients undergoing on-pump CABG (ONCAB) are at higher risk of short-term adverse outcomes than male patients. However, whether off-pump CABG (OPCAB) can improve the short-term outcome of female patients compared to ONCAB remains unclear. We conducted a meta-analysis to study the effect of the female sex on short-term outcomes of OPCAB vs. ONCAB. A total of 31,115 patients were enrolled in 12 studies, including 20,245 females who underwent ONCAB and 10,910 females who underwent OPCAB. The in-hospital mortality in female patients who underwent OPCAB was significantly lower than in those in the ONCAB group with (2.7% vs. 3.4%; odds ratio [OR] 0.76; 95% confidence interval [CI] 0.65-0.89) and without (OR 0.68; 95% CI 0.52-0.89) adjustment for cardiovascular risk factor. The incidence of postoperative stroke in female patients who underwent OPCAB was lower than in those in the ONCAB group (1.2% vs. 2.1%; OR 0.59; 95% CI 0.48-0.73) before cardiovascular risk factor adjustment but was not significant (OR 0.87; 95% CI 0,66-1.16) after adjustment. There was no significant difference in the incidence of postoperative myocardial infarction between women who underwent OPCAB and those in the ONCAB group (1.3% vs. 2.3%; OR 0.88; 95% CI 0.54-1.43). In contrast to the American Heart Association CABG guideline, female patients who had OPCAB don't have unfavorable outcomes compared with the ONCAB group.

Risk Factors Associated with Ischemic Stroke in the Immediate Postoperative Period of Cardiac Surgery.

Stroke remains a major complication of cardiac surgery. Despite all efforts, the incidence of postoperative stroke remains as high as 6%. We aimed to investigate risk factors for ischemic stroke in a contemporary cohort of patients undergoing cardiac surgery. This is a retrospective cohort study of 678 consecutive adult patients who underwent cardiac surgery requiring cardiopulmonary bypass in a tertiary hospital in Brazil between July 1, 2011, and December 31, 2018. The primary outcome was the rate of early (perioperative and seven-day postoperative) stroke, defined as the occurrence of the outcome during the index admission. We developed a predictive model of stroke using the Poisson regression analysis with robust variance. Postoperative stroke occurred in 24 patients (3.5%), 23 (3.3%) were ischemic, and 21 (3.0%) were diagnosed in the first 72 hours after surgical procedure. After multivariate analysis, the following factors were significantly associated with stroke: previous stroke/transient ischemic attack (relative risk [RR]=2.75; 95% confidence interval [CI], 1.11-6.82), carotid artery disease (RR=4.0; 95% CI, 1.43-11.0), previous atrial fibrillation (RR=3.26, 95% CI, 1.31-8.1), and postoperative platelets > 200,000/mm3 (RR=2.26; 95% CI, 1.01-5.1). We developed a contemporary model to determine risk predictors for stroke after cardiac surgery. This model may help clinicians to identify patients at risk and could be useful in clinical practice.

Ventricular Fibrillatory Arrest: A Safe Option in Robotic Totally Endoscopic Intracardiac Surgery

BackgroundModerate hypothermic ventricular fibrillatory arrest during heart surgery is an alternative to cardioplegic arrest in selected patients. We reviewed our experience using a ventricular fibrillatory arrest technique in robotic totally endoscopic intracardiac surgery. MethodsFrom February 2014 through July 2022, 128 patients who underwent robotic totally endoscopic intracardiac surgical procedures performed using moderate hypothermic ventricular fibrillatory arrest were reviewed. Patients were chosen based on the risk of aortic manipulation, complexity of the procedure, grade of aortic valve insufficiency and comorbidities, including history of prior cardiac surgery and peripheral vascular disease. ResultsPatients were a mean age of 65 ± 14 years, and the mean The Society of Thoracic Surgeons score was 2.7 ± 2.9. Fourteen patients (11%) had a history of previous cardiac surgery. The intracardiac procedures were mitral valve surgery in 84 patients (66%), isolated cryomaze procedure in 27 (21%), and other in 17 (13%). The mean ventricular fibrillatory arrest time was 79 ± 26 minutes, and the mean cardiopulmonary bypass time was 174 ± 49 minutes. There was no conversion to sternotomy. Seven patients (5.5%) required inotropic support, and 2 patients (1.6%) needed an intra-aortic balloon pump. There was no incidence of postoperative stroke or clinical myocardial infarction. The mean hospital and intensive care unit lengths of stay were 3.1 ± 1.7 and 1.4 ± 0.7 days, respectively. One death (0.78%) occurred due to respiratory failure. ConclusionsModerate hypothermic ventricular fibrillatory arrest in robotic intracardiac surgery may be a safe and effective alternative in selected patients.

A Partial Clamp During Off-Pump Coronary Artery Bypass Grafting Can be Safely Used When Utilizing the Calcium Score with Computed Tomography For Evaluating The Ascending Aorta.

No previous study has shown that the volume of calcium score is useful for evaluating the aorta when performing a partial clamp (PC). The purpose of this study was to examine the effect of different clamping strategies during off-pump coronary artery bypass grafting (OPCAB), in terms of the incidence of postoperative stroke using the calcium score of the ascending aorta. We retrospectively reviewed 339 patients, who underwent isolated OPCAB between August 2013 and March 2021. There were two groups of patients, depending on the procedure. A PC was used for proximal anastomoses in 130 (38.3%) patients. A clampless proximal facilitating anastomotic device (CFD) was used in 107 (31.5%) patients. We prescribed preoperative CT for all patients, and the Agatston score was used. The calcium score significantly was higher in the CFD group than in the PC group (29.7 ± 66.5 vs. 1819.8 ± 2391.5, < 0.001). The number of distal anastomoses and operative time were not significantly different between the two groups. There was no mortality and three strokes occurred at the 30-day follow up. Two strokes occurred in the PC group (1.5%) and one in the CFD group (0.9%), which was not significantly different (P = 0.98). A PC does not increase postoperative stroke incidence compared with a CFD, when utilizing calcium score evaluation in OPCAB.

Optimal temperature management in aortic arch surgery: A systematic review and network meta-analysis.

New temperature management concepts of moderate and mild hypothermic circulatory arrest during aortic arch surgery have gained weight over profound cooling. Comparisons of all temperature levels have rarely been performed. We performed direct and indirect comparisons of deep hypothermic circulatory arrest (DHCA) (≤20°C), moderate hypothermic circulatory arrest (MHCA) (20.1-25°C), and mild hypothermic circulatory arrest (mild HCA) (≥25.1°C) in a network meta-analysis. The literature was systematically searched for all papers published through February 2022 reporting on clinical outcomes after aortic arch surgery utilizing DHCA, MHCA and mild HCA. The primary outcome was operative mortality. The secondary outcomes were postoperative stroke and acute kidney failure (AKI). A total of 34 studies were included, with a total of 12,370 patients. DHCA was associated with significantly higher postoperative incidence of stroke when compared with MHCA (odds ratio [OR], 1.46, 95% confidence interval[CI], 1.19-1.78) and mild HCA: (OR, 1.50, 95% CI, 1.14-1.98). Furthermore, DHCA and MHCA were associated with higher operative mortality when compared with mild HCA (OR 1.71, 95% CI, 1.23-2.39 and OR 1.50, 95% CI, 1.12-2.00, respectively). Separate analysis of randomized and propensity score matched studies showed sustained increased risk of stroke with DHCA in contrast to MHCA and mild HCA (OR, 1.61, 95% CI, 1.18-2.20, pvalue = .0029 and OR, 1.74, 95% CI, 1.09-2.77, pvalue = .019). In the included studies, the moderate to mild hypothermia strategies were associated with decreased operative mortality and the risk of postoperative stroke. Large-scale prospective studies are warranted to further explore appropriate temperature management for the treatment of aortic arch pathologies.

Outcomes and role of shunting during carotid endarterectomy for symptomatic patients.

Shunt placement during carotid endarterectomy (CEA) has often been advocated to protect the ischemic penumbra in patients with symptomatic carotid stenosis. In the present study, we assessed the effect of shunt placement during CEA on postoperative stroke risk in symptomatic patients. We queried the American College of Surgeons National Surgical Quality Improvement Program database (2016-2019) for CEA cases with complete CEA procedure-targeted data available. Symptomatic patients were identified as those with a preoperative diagnosis of stroke on presentation (DS), transient ischemic attack, amaurosis fugax, or temporary monocular blindness. The DS patients were further analyzed according to the severity of their stroke using the modified Rankin scale scores. To better assess the effect of shunt placement on the stroke rate, we compared cases of CEA with the patch angioplasty technique stratified by the use of an intraoperative shunt. Patients who had undergone carotid eversion or primary closure were excluded. The baseline demographics and perioperative outcomes were compared using the χ2 and Mann-Whitney U tests. Multivariate analysis was performed to identify the independent risk factors for postoperative stroke and cranial nerve injury. We identified 4652 cases of CEA with patch angioplasty in symptomatic patients, including 1889 with (40.6%) and 2763 without (59.4%) shunt placement. The distribution of age, race, and sex was similar for both procedures. Compared with patients without a shunt, those with a shunt had significantly higher rates of emergency surgery (9.1% vs 7.0%; P= .010), nonelective surgery (40.3% vs 37.2%; P= .035), general anesthesia (97.0% vs 86.3%; P< .001), and bleeding disorders (27.2% vs 22.7%; P< .001). The 30-day incidence of postoperative stroke was similar between the patients with (3.2%) and without (2.6%) shunt placement (P= .219). Additionally, a subgroup analysis failed to show any benefit from shunt placement on the incidence of postoperative stroke, regardless of the preoperative symptoms or neurologic disability. In contrast, shunt placement was associated with an increased rate of cranial nerve injury (4.1% vs 2.4%; P= .001). Multivariate analysis revealed that nonelective surgery (odds ratio [OR], 1.99; 95% confidence interval [CI], 1.36-2.91; P< .001) and DS (vs transient ischemic attack, amaurosis fugax, or temporary monocular blindness; OR, 1.64; 95% CI, 1.12-2.41; P= .012) were predictive of 30-day postoperative stroke. After adjusting for confounders, shunt placement had no effect on stroke risk at 30days but remained an independent risk factor for cranial nerve injury (adjusted OR, 1.87; 95% CI, 1.32-2.64; P< .001). For symptomatic patients undergoing CEA with patch angioplasty, shunt placement was associated with an increased risk of cranial nerve injury without a reduction in postoperative stroke risk.

Association of Sex With the Use and Outcomes of Carotid Revascularization: A Cohort Study

Background Stroke is a leading cause of death that disproportionately affects women. Treating carotid stenosis with carotid artery stenting (CAS) or carotid endarterectomy (CEA) can prevent ischemic stroke. Yet, the sex‐specific use and long‐term outcomes of these interventions remain unclear. Thus, we sought to investigate sex‐based differences in the treatment and outcomes of carotid stenosis. Methods We analyzed carotid revascularizations in the Vascular Quality Initiative, a national clinical registry. Patients were linked to Medicare claims to identify long‐term outcomes. Our study cohort included patients undergoing index CAS or CEA between 2005 and 2015 who were fee‐for‐service Medicare beneficiaries aged 65+. The primary exposure was sex, and the primary outcome was stroke. Using log‐binomial regression, we estimated the relative risk for CAS treatment accounting for clustering by center. Cox proportional hazards regression was used to estimate the hazard ratio for stroke. We used inverse probability‐weighted risk adjustment based on patient demographics, comorbidities, and disease severity for all analyses. Results In our cohort of 22 341 eligible patients, 39% were women, 13% underwent CAS, and the median survival time was 2.6 years (interquartile range: 1.0–3.4 years). After risk adjustment, women were less likely to undergo CAS than men (adjusted relative risk, 0.89; [95% CI, 0.83–0.96]; P =0.003). Women undergoing carotid revascularization had a 24% increased risk of stroke (adjusted HR, 1.24; [95% CI, 1.10–1.39]; P =0.001) within 5 years of surgery. The higher stroke rate in women was noted following both carotid endarterectomy (adjusted HR, 1.22; [95% CI, 1.07–1.38]; P =0.003) and CAS (adjusted HR, 1.40; [95% CI, 1.06–1.83]; P =0.014). This effect was most pronounced for symptomatic treatment, where women undergoing CEA had a 3% higher risk‐adjusted 5‐year cumulative incidence of stroke (13% versus 10%, Gray's P =0.002). Conclusion Compared with men, women had a higher incidence of postoperative stroke after carotid revascularization, regardless of treatment type. Sex disparities in postrevascularization stroke rates may give rise to concern given the widespread use of revascularization for managing carotid stenosis.

Does the eversion technique have a lower early postoperative stroke rate than the conventional technique in carotid endarterectomy?

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In carotid surgery, Does the eversion technique (ECEA) has an early postoperative lower stroke rate, As compared to conventional carotid endarterectomy (CCEA)? The outcome assessed was the stroke rate in the early potoperative period (30 days) in the two techniques. The best evidence confirmed that there is no statistically significant difference between ECEA and CCEA regarding the early postoperative stroke incidence.

Timing of Revascularization in Ischemic Moyamoya Disease: Association of Early Versus Delayed Surgery with Perioperative and Long-Term Outcomes

Patients with nmoyamoya disease (MMD) who present primarily with ischemic stroke are known to have greater rates of perioperative strokes as compared with those who present with nonstroke symptoms. The optimal timing for revascularization for these patients remains unclear. From 1994 to 2015, 91 patients with MMD presented with signs and symptoms of an acute ischemic stroke with diffusion restriction correlate on magnetic resonance imaging, and these patients were subdivided into those who underwent early revascularization (<90 days from last stroke), versus those who underwent delayed revascularization (≥90 days after last stroke), based on evidence that most neurological recovery after stroke occurs during the first three months. Perioperative and long-term outcomes were compared between the 2 surgical cohorts. In total, 27 patients underwent early revascularization, and 64 patients underwent delayed revascularization. Patients who underwent early revascularization had a statistically greater rate of perioperative stroke (P=0.04) and perioperative mortality (P= 0.03), and overall complication rate (P= 0.049). At last follow-up of 5.2 ± 4.3 years, patients who underwent delayed revascularization had a lower mortality rate (P= 0.01) and a lower overall postoperative stroke incidence (P= 0.002). As a function of time, patients with MMD undergoing delayed revascularization had a statistically higher length of stroke-free survival (P= 0.005). Patients with MMD who present with ischemic stroke are more likely to have perioperative strokes, overall perioperative complications, worse long-term mortality rates, and lower rates of stroke-free survival if revascularization surgery occurred within 90 days of last stroke.

Late Rupture Following Endovascular Aneurysm Repair: Open or Endovascular Repair?

Late rupture following endovascular aneurysm repair (EVAR) carries significant morbidity and mortality. Traditionally treated with open surgery, there has been a growing tendency to perform repair using both simple and advanced endovascular techniques. We aimed to compare the short-term outcomes of patients with late rupture following EVAR treated with open surgery (OS) or endovascular repair (ER). A retrospective cohort study was performed using the Vascular Quality Initiative registry from January 2010 to July 2021. All patients with a prior EVAR who presented with a late rupture were included. A comparison was made of those undergoing OS or ER. Primary outcome was in-hospital mortality. Secondary outcomes included postoperative complications. A total of 264 patients (165 OS, 99 ER) underwent surgery for late rupture after EVAR. Mean age was 77.1 ± 8.0 years, and 212 patients (80.3%) were male. Comorbidities were similar between the groups, however preoperative creatinine was higher in those undergoing ER (1.8 ± 1.6 mg/dL vs 1.4 ± 0.7 mg/dL; P = .026). The preoperative mean maximum aortic diameter was 79.5 ± 23.8 mm. There was no difference in the lowest preoperative blood pressure before OS or ER (95.6 ± 29.7 mm Hg vs 93.0 ± 33.0 mm Hg; P = .526). Total procedure time (256.1 ± 124.4 minutes vs 183.9 ± 102.4 minutes; P < .0001), estimated blood loss (4230.5 ± 3759.9 mL vs 504.2 ± 841.9 mL; P < .0001), and packed red blood cell transfusion (6.6 ± 5.6 units vs 3.1 ± 3.3 units; P < .0001) were all significantly higher for open surgery. The time to extubation was significantly longer for those undergoing OS, with 7.5% being extubated in the OR and 60.6% requiring intubation for more than 24 hours, compared with 39.3% and 34.8%, respectively, of those undergoing ER (P < .0001). There was no difference in intensive care unit length of stay (9.1 ± 9.8 days vs 7.8 ± 11.9 days; P = .360) or total length of stay (15.0 ± 15.9 days vs 11.7 ± 12.5 days; P = .061) for those undergoing OS or ER. No significant difference was found in the in-hospital mortality between OS or ER (29.7% vs 30.3%; P = .917). Return to the OR (32.7% vs 17.4%; P = .007), congestive heart failure (8.0% vs 2.1%; P = .047), temporary dialysis (15.4% vs 1.0%; P = .001), and wound complications (10.5% vs 0.0%; P = .001) occurred more frequently in OS. Those undergoing ER had a higher incidence of postoperative stroke (6.2% vs 1.2%; P = .026), with those strokes being more likely to be major (P = .029). OS and ER for late rupture following EVAR have similar mortality. Those undergoing ER had lower morbidity; however, this approach was associated with a higher incidence of stroke.

Does Dexmedetomidine Reduce the Risk of Atrial Fibrillation and Stroke After Adult Cardiac Surgery? A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BackgroundPostoperative atrial fibrillation is a common consequence of cardiac surgery with increased stroke complications and mortality. Although dexmedetomidine is thought to prevent postoperative atrial fibrillation and stroke because of its sympatholytic and anti-inflammatory properties, data from different studies show the effect of dexmedetomidine on postoperative atrial fibrillation and stroke uncertain in adult patients with cardiac surgery. MethodsA database including EMBASE, PubMed, and Cochrane CENTRAL was searched for randomized controlled trials comparing dexmedetomidine with placebo or other anesthetic drugs in adult cardiac surgery. The primary outcome was the incidence of postoperative atrial fibrillation. The secondary outcomes were the incidence of postoperative stroke, mechanical ventilation duration, intensive care unit length of stay, hospital length of stay, and mortality.ResultsEighteen trials with a total of 2933 patients were enrolled in the meta-analyses. Compared with controls, dexmedetomidine significantly reduced the incidence of postoperative atrial fibrillation [odds ratio, 0.82; 95% CI, 0.69-0.98; P = .03]. There was no significant difference between groups in stroke (odds ratio, 1.36; 95% CI, 0.59-3.16; P = .47), mechanical ventilation duration [weighted mean difference, −0.17; 95% CI, −0.35 to 0.14; P = .39], intensive care unit length of stay (weighted mean difference, −0.03; 95% CI, −0.93 to 0.87; P = .95), hospital length of stay (weighted mean difference, −0.04; 95% CI, −0.40 to 0.32; P = .83) and mortality (odds ratio, 0.72; 95% CI, 0.32-1.60; P = .42).ConclusionPerioperative dexmedetomidine reduced the incidence of postoperative atrial fibrillation in adult patients undergoing cardiac surgery. But there was no significant difference in the incidence of stroke, mechanical ventilation duration, intensive care unit length of stay, hospital length of stay, and mortality.

Preoperative and intraoperative risk factors of postoperative stroke in total aortic arch replacement and stent elephant trunk implantation

SummaryBackgroundAcute type A aortic dissection (AAAD) is a disease with high mortality, for which total aortic arch replacement (TAAR) combined with stent elephant implantation (SETI) is a reliable surgical treatment; however, it is associated with a high incidence of postoperative stroke. This retrospective study aimed to find preoperative and postoperative risk factors for postoperative stroke in patients with TAAR combined with SETI, and to provide predictive models and single-factor threshold suggestions.MethodsFrom October 2019 to March 2021, 229 AAAD patients who underwent TAAR and SETI were selected. Patients were divided into stroke group (n = 23) and non-stroke group (n = 206), and preoperative/intraoperative factors were evaluated by independent-samples T-test/ Mann-Whitney U test/Chi-Square test and odds ratio (OR) analysis. The Logistic regression equation and decision tree were used to construct the prediction model of the probability of postoperative stroke. Bayesian-learning model and 2-order derivation were used to calculate the inflection points of the continuous variables.FindingsPlatelet count (PLT), International normalised ratio (INR) value, presence of diabetic history, and cardiopulmonary bypass (CPB) time were independent predictors of postoperative stroke (P-value < 0.05), and the above four factors were used to construct the Logistic regression equation. As for the decision-tree model, a radical model with higher accuracy in stroke predicting was chosen. Three inflection points for the effect of continuous variables (PLT count = 60 × 10^9/L; INR value = 1.82; CPB time = 300 min) on postoperative stroke were found by 2-order derivation.InterpretationPLT count, INR value, presence of diabetic history, and CPB time were significant preoperative and intraoperative risk factors for postoperative stroke, and the identification and modeling of these factors can help us to take more active brain protection measures in high-risk patients.FundingYS was funded by the 10.13039/501100001809National Natural Science Foundation of China (Grant ID 81671942).

Perioperative Bleeding Requiring Blood Transfusions is Associated With Increased Risk of Stroke After Transcatheter and Surgical Aortic Valve Replacement

The authors aimed to investigate the impact of severe bleeding and use of red blood cell (RBC) transfusion on the development of postoperative stroke after surgical (SAVR) and transcatheter aortic valve replacement (TAVR), taken from the FinnValve registry. Nationwide, retrospective observational study. Five Finnish university hospitals participated in the registry. A total of 6,463 patients who underwent SAVR (n=4,333) or TAVR (n=2,130). Patients who underwent TAVR or SAVR with a bioprosthesis with or without coronary revascularization. The incidence of postoperative stroke after SAVR was 3.8%. In multivariate analysis, the number of transfused RBC units (odds ratio [OR], 1.098; 95% confidence interval [CI], 1.064-1.133) was one of the independent predictors of postoperative stroke. The incidence of stroke increased, along with the severity of perioperative bleeding, according to the European Coronary Artery Bypass Grafting (E-CABG) bleeding grades were as follows: grade 0, 2.2% (reference group); grade 1, 3.4% (adjusted OR, 1.841; 95% CI, 1.105-3.066); grade 2, 5.5% (adjusted OR, 3.282; 95% CI, 1.948-5.529); and grade 3, 14.8% (adjusted OR, 7.103; 95% CI, 3.612-13.966). The incidence of postoperative stroke after TAVR was 2.5%. The number of transfused RBC units was an independent predictor of stroke after TAVR (adjusted OR, 1.155; 95% CI, 1.058-1.261). The incidence of postoperative stroke increased, along with the severity of perioperative bleeding, as stratified by the E-CABG bleeding grades: E-CABG grade 0, 1.7%; grade 1, 5.3% (adjusted OR, 1.270; 95% CI, 0.532-3.035); grade 2, 10.0% (adjusted OR, 2.898; 95% CI, 1.101-7.627); and grade 3, 30.0% (adjusted OR, 10.706; 95% CI, 2.389-47.987). Perioperative bleeding requiring RBC transfusion and/or reoperation for intrathoracic bleeding is associated with an increased risk of postoperative stroke after SAVR and TAVR. Patient blood management and meticulous preprocedural planning and operative technique aiming to avoid significant perioperative bleeding may reduce the risk of cerebrovascular complications.

The Impact of Recipient Age on Outcomes of Simultaneous Heart-Lung Transplantation

<h3>Purpose</h3> The shortage of donor organs underscores the importance of identifying risk factors for adverse outcomes in multiorgan transplantation. Heart-lung transplantation (HLTx) is relatively uncommon, and there is a paucity of literature to suggest at what recipient age threshold mortality risk increases. This analysis aimed to identify a threshold of age that predicts adverse post-HLTx outcomes. <h3>Methods</h3> The United Network of Organ Sharing (UNOS) registry was used to identify adult combined HLTx from 2005-2021. The primary outcome was one-year mortality. Threshold regression analysis was used to identify the threshold at which age impacts one-year post-HLTx mortality. Patients were stratified according to the age threshold. Kaplan-Meier analysis was used to model survival, and multivariable Cox proportional hazards regression was used for risk-adjustment. <h3>Results</h3> 453 patients underwent HLTx in the study period. Threshold analysis identified that age >58 years impacted one-year mortality. Using this threshold, 47 (10.38%) patients were included in the older cohort, and 406 patients (89.62%) were included in the younger cohort. Older recipients were more likely to be male, have diabetes, and have higher lung allocation scores compared to younger recipients. On Kaplan Meier analysis, one-year survival was significantly lower in patients >58 years (64.7% vs 82.0%, <i>p</i> = 0.007). On multivariable analysis, the adjusted hazard for one-year mortality in recipients older than 58 years was 2.27 (95% CI [1.21-4.28], <i>p</i> =0.011). Recipient creatinine, total bilirubin, temporary mechanical circulatory support, and non-ABO-identical matching were also independent predictors of one-year mortality. Patients >58 years more frequently required new onset dialysis after HLTx (19.2% vs 12.8%, <i>p</i> = 0.031) and had a higher incidence of postoperative stroke (13.0% vs 4.5%, <i>p</i> = 0.040). <h3>Conclusion</h3> The threshold of recipient age above which one-year mortality risk most increases in HLTx is 58 years. Although age >58 is a risk factor for one-year mortality with over 2-fold increased risk as compared to younger patients, the majority (65%) of older HLTx recipients do survive to 1-year. These data suggest that older age should be heavily considered in the patient selection process for HLTx but may not necessarily need to serve as an absolute contraindication, particularly in the absence of other risk factors.

Outcomes Following Heart Transplantation in Adults with Congenital Heart Disease

<h3>Purpose</h3> The number of adults with congenital heart disease (ACHD) requiring treatment with heart transplant (HT) is growing. Determinants for survival after HT in this challenging population remain unknown. The aim of this study is to investigate the factors associated with outcomes after HT in ACHD. <h3>Methods</h3> We reviewed the UNOS-STAR database and analyzed 35,952 HT from 2000 to 2018. Recipient and donor characteristics, outcomes for patients undergoing HT for ischemic cardiomyopathy (ICM) (n=14,236), nonischemic cardiomyopathy (NICM) (n=20,676), and ACHD (n=1,040) were compared. The mean follow-up for the total study population was 6.20±4.84 years. Kaplan-Meier survival curves with Log-rank statistics as well as Cox-proportional hazards analysis with univariate analysis as well as multivariable regression were used to analyze survival data. Univariable and multivariable forward and reverse binary logistic regression was used to evaluate determinants of hospital mortality. <h3>Results</h3> When compared to the other groups, ACHD recipients had a higher incidence of postoperative stroke, dialysis, and death from acute rejection. Multivariable analysis confirmed that ACHD was associated greater in-hospital death compared to ICM (HR=0.54, P<0.001) and NICM (HR=0.46, P<0.001). Factors associated with increased mortality were history of cerebrovascular disease (HR=1.11, P=0.026), prior history of malignancy (HR=1.12, P=0.006), pre-transplant biventricular support (HR=1.12, P=0.069), postoperative stroke (HR=1.47, P<0.001) and postoperative dialysis (HR=1.71, P<0.001). O blood group donor hearts were also associated with increased in-hospital death compared to blood groups A (HR=0.824, P=0.001), B (HR=0.818, P=0.029), and AB (HR=0.659, P=0.051). In-hospital deaths were less likely with donors who were male (HR=0.851, P=0.011) and with a history of cocaine use (HR=0.826, P=0.012). ACHD patients more likely to receive a subsequent re-transplant. The 5-, 10-, and 15-year survival were 72.3%, 63.4%, and 53.0% for ACHD; 75.8%, 56.1%, and 35.6% for ICM and 79.2%, 64.9%, and 49.0% for NICM. Survival, conditional upon discharge from the hospital was significantly higher in ACHD. <h3>Conclusion</h3> HT in ACHD is associated with a higher early post-operative mortality, better long-term conditional survival, and a higher rate of retransplantation when compared to patients with ICM and NICM.

Off-pump versus on-pump coronary artery bypass grafting for octogenarians: A meta-analysis involving 146 372 patients.

There is an ongoing debate concerning the optimal surgical option of myocardial revascularization for octogenarians. The current meta‐analysis aimed to compare clinical outcomes following off‐pump coronary artery bypass grafting (OPCABG) or conventional coronary artery bypass grafting (CCABG) in octogenarians. PubMed, Cochrane, Web of Science, and EMBASE databases were searched to identify eligible studies from inception to March 2021. The analysis was performed using STATA 15.1. A literature search yielded 18 retrospective studies involving 146 372 patients (OPCABG = 44 522 vs. CCABG = 101 850). Pooled analysis showed a strong trend toward reducing mortality risk in the OPCABG group (odds ratio: 0.75, 95% confidence interval: 0.56–1.00, p = .05). However, it did not reach statistical significance. The sensitive analysis demonstrated that OPCABG was less likely to cause death than CCABG. There were comparable data in myocardial infarction, renal failure, deep sternal wound infection, and hospital stays between the two groups, although the incidence of stroke, atrial fibrillation, prolonged ventilation, and reoperation for bleeding was significantly lower in the OPCAGB group. OPCABG may be an effective surgical strategy for myocardial revascularization, especially in reducing the incidence of postoperative stroke, atrial fibrillation, prolonged ventilation, and reoperation for bleeding.

Clinical impact of del Nido cardioplegia in adult cardiac surgery: A prospective randomized trial

ObjectiveThe study objective was to assess the benefits of del Nido cardioplegia compared with cold blood cardioplegia solution in terms of myocardial protection during adult cardiac surgery. MethodsA total of 474 adult patients undergoing coronary artery bypass grafting, heart valve surgery, thoracic aortic surgery, or combined procedures were randomized to the del Nido cardioplegia group (n = 234) or the cold blood cardioplegia solution group (n = 240) after provided informed consent. The primary end points assessed inotropic support requirements, severe cardiovascular events, and troponin trend within the first 48 hours of intensive care unit stay. Reperfusion arrhythmias, aortic crossclamp and cardiopulmonary bypass times, and other clinical perioperative variables were considered as secondary end points. ResultsNo statistically significant differences were found regarding postoperative inotropic support requirements or the incidence of severe cardiovascular events. The del Nido cardioplegia group showed a higher return to spontaneous sinus rhythm (P< .001), a lower number of defibrillation attempts (P< .001), and an earlier peak troponin value in the postoperative period. Peak blood glucose levels and intravenous insulin requirements were significantly lower in the del Nido cardioplegia group. We found no significant differences regarding aortic crossclamp or cardiopulmonary bypass time. We did observe a lower incidence of postoperative stroke in the del Nido cardioplegia group (2.6% vs 6.7%; P= .035). Conclusionsdel Nido cardioplegia can be used safely and with comparable outcomes compared with traditional cardioplegia solutions. Additional advantages over glycemic control, reperfusion arrhythmias, and its comfortable redosing interval make del Nido an interesting alternative for myocardial protection in adult cardiac surgery. A significant decrease in postoperative stroke will require further research to shed light on the results of this study. Video Abstract [Display omitted]

Risk factors for stroke after total aortic arch replacement using the frozen elephant trunk technique.

OBJECTIVESThis study aimed to analyse risk factors for postoperative stroke, evaluate the underlying mechanisms and report on outcomes of patients suffering a postoperative stroke after total aortic arch replacement using the frozen elephant trunk technique.METHODSTwo-hundred and fifty patients underwent total aortic arch replacement via the frozen elephant trunk technique between March 2013 and November 2020 for acute and chronic aortic pathologies. Postoperative strokes were evaluated interdisciplinarily by a cardiac surgeon, neurologist and radiologist, and subclassified to each’s cerebral territory. We conducted a logistic regression analysis to identify any predictors for postoperative stroke.RESULTSOverall in-hospital was mortality 10% (25 patients, 11 with a stroke). A symptomatic postoperative stroke occurred in 42 (16.8%) of our cohort. Eight thereof were non-disabling (3.3%), whereas 34 (13.6%) were disabling strokes. The most frequently affected region was the arteria cerebri media. Embolism was the primary underlying mechanism (n = 31; 73.8%). Mortality in patients with postoperative stroke was 26.2%. Logistic regression analysis revealed age over 75 (odds ratio = 3.25; 95% confidence interval 1.20–8.82; P = 0.021), a bovine arch (odds ratio = 4.96; 95% confidence interval 1.28–19.28; P = 0.021) and an acute preoperative neurological deficit (odds ratio = 19.82; 95% confidence interval 1.09–360.84; P = 0.044) as predictors for postoperative stroke.CONCLUSIONSStroke after total aortic arch replacement using the frozen elephant trunk technique remains problematic, and most lesions are of embolic origin. Refined organ protection strategies, and sophisticated monitoring are mandatory to reduce the incidence of postoperative stroke, particularly in older patients presenting an acute preoperative neurological deficit or bovine arch.