Preoperative Stroke Research Articles

Can Household Income Predict Postoperative Outcomes After LVAD Implantation?

<h3>Purpose</h3> Over the last few decades, mechanical circulatory support therapies have become the standard of care for advanced heart failure. However, minimal data exists regarding the association of household income with postoperative outcomes after LVAD implantation. <h3>Methods</h3> We evaluated 169 patients that underwent an LVAD implantation between January 2018 to December 2020. The median income for the cohort was calculated and the patients were divided into two groups: low income (<50th percentile) and high income (≥50th percentile). Baseline demographics and clinical characteristics were summarized using descriptive statistics. A significance level of 0.05 was used. <h3>Results</h3> The low-income group represented 49% and the high-income group corresponded to 51% of the entire cohort. The median yearly income for the cohort was 19800 USD. The low-income group was found to be younger (mean age 49 ±13 vs. 54 ±12 years) (p=0.754) had less dyslipidemia (44% vs. 56%) (p=0.091) and had less preoperative stroke (8% vs. 23%) (p=0.012). The high-income group had less reoperations for bleeding (18% vs. 33%) (p=0.035) had higher rates of postoperative stroke (7.1% vs. 3.6%) (p=0.306), and higher rehospitalization rates (46% vs. 52%) (<i>p</i>=0.141). Thirteen percent (n=15) and eight percent (n=9.5) of the high-income and low-income groups had a heart transplant by the end of the study (<i>p</i>=0.095). The mortality rate was about the same for both groups (table 1). <h3>Conclusion</h3> Despite both groups being similar, the high-income group had less mortality and a higher rate of transplanted patients. Household Income may be an important variable that could affect the results after LVAD placement.

Impact of preoperative stroke on post cardiac surgery stroke incidence

Impact of preoperative stroke on post cardiac surgery stroke incidence

Postoperative Stroke After Type A Aortic Dissection Repair: Hemorrhage Versus Ischemia.

Postoperative stroke is a severe and potentially disabling complication following surgical intervention for acute type A aortic dissection (ATAAD). This retrospective study aims to compare the early and late outcomes between patients who had hemorrhagic and ischemic stroke after undergoing ATAAD repair surgery. Between January 2007 and June 2020, a total of 685 consecutive patients underwent ATAAD repair at our institution. Patients who had a preoperative stroke or were unconscious at presentation were excluded from this study. Of the 656 included for analysis, 102 (15.5%) patients had a postoperative stroke confirmed by computed tomography angiography. The strokes were classified into the ischemia group (n = 83, 12.7%) and hemorrhage group (n = 19, 2.9%). Clinical features, surgical information, postoperative complications, modified Rankin Scale (mRS) scores after discharge, and 5-year cumulative survival rates were compared. Demographics, comorbidities, and presentations of ATAAD were similar between the two groups, except a higher rate of preoperative antithrombotic medication was found in the hemorrhage group. The hemorrhage group was associated with a higher complexity of aortic arch replacement, longer cardiopulmonary bypass, and aortic clamping times than the ischemia group. A higher in-hospital mortality rate (42.1% versus 20.5%; p = 0.048) and a higher median mRS score at the 3-month follow-up after discharge (6[3-6] versus 4[2-6]; p = 0.027) were found in the hemorrhage group. The hemorrhage group showed a lower 5-year cumulative survival rate (23.4% versus 57.8%; p = 0.003) compared with the ischemia group. Postoperative hemorrhagic stroke was associated with poorer neurological outcomes and lower survival rates than those with ischemic stroke. Patients who have complex arch replacement, long cardiopulmonary bypass and aortic clamping times are at risk for postoperative hemorrhagic stroke and should have intensive neurological surveillance for early diagnosis and treatment after ATAAD repair surgery.

The impact of establishing a regional infective endocarditis (IE) network on pre-operative IE-related complications and on post-operative outcome

Abstract Background Infective endocarditis (IE) requires a high degree of suspicion and advanced level of multidisciplinary management. In 2015, the European guidelines recommended the formation of an endocarditis-team (ET) for optimal treatment of IE. In 2011, we already established an ET within the hospital that was only consulted on demand for certain patients. Since 2015, ET has been increasingly involved in the management of almost all patients with IE. In addition, we established in 2015 a statewide endocarditis- (E) network for the referring hospitals. Purpose We investigated the effect of E-network on reducing referral latency and pre-operative IE-related complications. We also investigated the adherence to the ET management recommendations in our hospital and its impact on post-operative stroke and mortality. Methods We retrospectively analyzed data from patients operated for IE in our center between 01/2007 and 03/2018. We conducted univariate analysis using Chi-square or Fisher's exact test, Multivariate logistic regression models for in-hospital mortality and post-operative stroke, and Kaplan-Meier estimate of 5-years survival. Results Among 630 patients operated for IE in our center, 409 (65%) underwent surgery in the 1st era before 12/2014. S. aureus IE was more frequent in the second era (34% vs 25%, p&amp;lt;0.001). The median time from the onset of symptoms to referral in the 2nd era was halved compared to the first one [7 days (IQR 2–19) vs 15 days (IQR 6–35)]. Patients in the 2nd era were admitted with less IE-related complications, i.e. less preoperative stroke (14% vs 27%, p&amp;lt;0.001), less heart failure (45% vs 69%, p&amp;lt;0.001) less cardiac abscesses (24% vs 34%, p=0.018), less acute renal insufficiency requiring hemodialysis (8% vs 14%, p=0.026). The lack of ET management recommendations was an independent predictor for in-hospital mortality (adjusted OR: 2.13, 95% CI: 1.27–3.53, p=0.004) and post-operative stroke (adjusted OR: 2.23, 95% CI: 1.12–4.39, p=0.02), and was associated with worse 5-years survival (59% compared to 40%, log rank&amp;lt;0.001). Conclusion Endocarditis-network led to earlier referral of patients, which resulted in less IE-related complications on admission. Lack of ET management recommendations was an independent predictor for post-operative stroke, in-hospital mortality and was associated with worse 5-years survival. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Effect of Intraoperative Arterial Hypotension on the Risk of Perioperative Stroke After Noncardiac Surgery: A Retrospective Multicenter Cohort Study.

Intraoperative cerebral blood flow is mainly determined by cerebral perfusion pressure and cerebral autoregulation of vasomotor tone. About 1% of patients undergoing noncardiac surgery develop ischemic stroke. We hypothesized that intraoperative hypotension within a range frequently observed in clinical practice is associated with an increased risk of perioperative ischemic stroke within 7 days after surgery. Adult noncardiac surgical patients undergoing general anesthesia at Beth Israel Deaconess Medical Center and Massachusetts General Hospital between 2005 and 2017 were included in this retrospective cohort study. The primary exposure was intraoperative hypotension, defined as a decrease in mean arterial pressure (MAP) below 55 mm Hg, categorized into no intraoperative hypotension, short (<15 minutes, median [interquartile range {IQR}], 2 minutes [1-5 minutes]) and prolonged (≥15 minutes, median [IQR], 21 minutes [17-31 minutes]) durations. The primary outcome was a new diagnosis of early perioperative ischemic stroke within 7 days after surgery. In secondary analyses, we assessed the effect of a MAP decrease by >30% from baseline on perioperative stroke. Analyses were adjusted for the preoperative STRoke After Surgery (STRAS) prediction score, work relative value units, and duration of surgery. Among 358,391 included patients, a total of 1553 (0.4%) experienced an early perioperative ischemic stroke. About 42% and 3% of patients had a MAP of below 55 mm Hg for a short and a prolonged duration, and 49% and 29% had a MAP decrease by >30% from baseline for a short and a prolonged duration, respectively. In an adjusted analysis, neither a MAP <55 mm Hg (short duration: adjusted odds ratio [ORadj], 0.95; 95% confidence interval [CI], 0.85-1.07; P = .417 and prolonged duration: ORadj, 1.18; 95% CI, 0.91-1.55; P = .220) nor a MAP decrease >30% (short duration: ORadj, 0.97; 95% CI, 0.67-1.42; P = .883 and prolonged duration: ORadj, 1.30; 95% CI, 0.89-1.90; P = .176) was associated with early perioperative stroke. A high a priori stroke risk quantified based on preoperatively available risk factors (STRAS prediction score) was associated with longer intraoperative hypotension (adjusted incidence rate ratio, 1.04; 95% CI, 1.04-1.05; P < .001 per 5 points of the STRAS prediction score). This study found no evidence to conclude that intraoperative hypotension within the range studied was associated with early perioperative stroke within 7 days after surgery. These findings emphasize the importance of perioperative cerebral blood flow autoregulation to prevent ischemic stroke.

Early outcomes of routine delayed shunting in carotid endarterectomy for symptomatic patients.

The role of shunting during carotid endarterectomy (CEA) in symptomatic patients is unclear. The aim was to evaluate early outcomes of CEA with routine "delayed" shunt insertion, for patients with symptomatic carotid stenosis. We conducted a single-center retrospective study of symptomatic patients undergoing CEA (2009-2020). All CEAs were performed under general anesthesia using a standardized technique, based on delayed routine shunt insertion after plaque removal. Primary endpoints were 30-days mortality and stroke. A logistic regression was performed to identify clinical and procedural factors associated with postoperative stroke. Two-hundred-sixty-three CEAs were performed for TIA (N.=178, 47%) or acute ischemic stroke (N.=85, 32%). Mean delay of surgery was 6±19 days, and early CEA (<48 hours) was performed in 98 cases (37%). Conventional CEA was performed in 171 patients (67%), eversion CEA in 83 (33%). Early (30-days) mortality was 0.3%. Stroke/death rate was 2.3%. Female sex (OR=5.14, 95% CI: 1.32-24.93; P=0.023), use of anticoagulants (OR=10.57, 95% CI: 2.67-51.86; P=0.001), preoperative stroke (OR=5.34, 95% CI: 1.62-69.21; P=0.006), and the presence of preoperative CT/MRI cerebral ischemic lesions (OR=5.96, 95% CI: 1.52-28.59; P=0.013) were associated with early neurological complications. Statin medication (OR=0.18, 95% CI: 0.04-0.71; P=0.019) and CEA timing <2 days (OR=0.14, 95% CI: 0.03-0.55; P=0.005) were protective from postoperative stroke. CEA outcomes were independent from time period (P=0.201) and operator's volume (P=0.768). A literature systematic review identified other four studies describing the CEA outcomes with routine shunting in symptomatic patients, with a large variability in the selection of patients, surgical technique, and description of the results. Routine delayed shunting after plaque removal seems to be a safe and effective technique, that contributed to maintain a low complication rate in neurologically symptomatic patients. Statin use and expedited timing were associated with improved outcomes using this technique.

Preoperative stroke before cardiac surgery does not increase risk of postoperative stroke

The optimal time when surgery can be safely performed after stroke is unknown. The purpose of this study was to investigate how cardiac surgery timing after stroke impacts postoperative outcomes between 2011–2017 were reviewed. Variables were extracted from the institutional Society of Thoracic Surgeons database, statewide patient registry, and medical records. Subjects were classified based upon presence of endocarditis and further grouped by timing of preoperative stroke relative to cardiac surgery: Recent (stroke within two weeks before surgery), Intermediate (between two and six weeks before), and Remote (greater than six weeks before). Postoperative outcomes were compared amongst groups. 157 patients were included: 54 in endocarditis and 103 in non-endocarditis, with 47 in Recent, 26 in Intermediate, and 84 in Remote. 30-day mortality and postoperative stroke rate were similar across the three subgroups for both endocarditis and non-endocarditis. Of patients with postoperative stroke, mortality was 30% (95% CI 4.6–66). Timing of cardiac surgery after stroke occurrence does not seem to affect postoperative stroke or mortality. If postoperative stroke does occur, subsequent stroke-related mortality is high.

Associations of preoperative stroke and tranexamic acid administration with convulsive seizures in valvular open-heart surgery

In cardiac surgery, use of the antifibrinolytic agent tranexamic acid (TXA) and acute perioperative stroke are both associated with convulsive seizures. We hypothesized that an older (preoperative) stroke increases the risk of TXA-associated seizures as well. To test this hypothesis, we retrospectively analyzed data from 16,110 patients who had undergone open-heart valvular surgery at our institution between 2009 and 2020. The dosing of TXA was moderate. Use of TXA and a history of stroke were both independently associated with convulsive seizure with an adjusted odds ratio (OR) of 2.40 (95%CI: 1.71–3.37) and 1.79 (95%CI: 1.27–2.54), respectively. Compared to patients without TXA administration, the adjusted OR of experiencing a seizure in TXA patients without a history of stroke was 2.44 (95%CI: 1.71–3.46) and in patients receiving TXA with a history of stroke 4.30 (95%CI: 2.65–6.99). However, there was no significant interaction between TXA use and preoperative stroke on convulsive seizures (P = 0.77). Compared to patients without seizure, for patients with seizure, the inverse probability-weighted ORs of in-hospital mortality and 30-day mortality were 3.58 (95%CI: 2.20–5.83) and 4.04 (95%CI: 2.34–6.98), respectively. We conclude that, in patients undergoing open-heart surgery, a history of stroke is independently associated with convulsive seizures but is not a contraindication for TXA use.

Abstract MP47: Clinicoradiological Outcomes of Surgical Revascularization for Moyamoya Disease With Minimum 10-Year Follow-Up

Introduction: The long-term progression of disease and recurrence rate of symptomatic events after surgical revascularization for moyamoya disease (MMD) are unknown. Method: Patients with MMD operated on between 1991 and 2009 were prospectively enrolled into the departmental database. Results: 230 revascularization (87% combined direct and indirect and 13% indirect alone) procedures were performed on 129 patients for the treatment of MMD with a long-term bypass patency rate of 98%. Unilateral presentation was identified in 39 (30.2%) compared to 90 (69.8%) with bilateral MMD. Posterior circulation (PC) involvement was identified in 34 (26.4%) patients. Over a median follow-up period of 13 years (range 10-26 years), 15 (38.5%) patients experienced radiographic progression of unilateral disease and 14 (10.9%) experienced PC radiographic progression. Delayed surgical revascularization of the untreated contralateral anterior circulation was performed on 11 (28.2%) patients due to symptomatic progression of disease. Progression of PC disease occurred only in patients with PC involvement upon presentation. Aside from those with unilateral progression, fourteen additional patients (10.9%) experienced delayed cerebrovascular accidents (CVAs), 8 of which were ischemic and 6 were hemorrhagic strokes. Twelve delayed CVAs occurred in a previously revascularized hemisphere while one occurred in an un-diseased hemisphere from a micro pseudoaneurysm. Repeat revascularization was performed in 6 patients while 4 were managed conservatively and 4 were deceased. Relative to baseline presenting mRS, 92.2% of patients were improved or unchanged at 10 year follow-up. On multivariate regression, progression of the PC predicted the development of delayed CVA (Odds ratio 8.1, 95% CI 1.1-59.2) while pre-operative stroke (Odds ratio 3.4, 95% CI 1.2-9.8) presentation and progression of disease was predictive of 10-year outcome (Odds ratio 4.0, 95% CI 1.5-10.6). Conclusion: Good functional outcomes over a median follow-up period of 13 years support the strategy of revascularization for MMD patients. Disease progression of the posterior circulation is common and may reduce pial-pial collaterals resulting in delayed CVAs.

Abstract P563: Prognosis Driven Definition of Carotid Near-Occlusion With Full Collapse

Introduction: Carotid near-occlusion is a severe carotid stenosis causing distal artery collapse of varying degree. Near-occlusion is often divided into a “full collapse” group with a threadlike distal lumen, and the often overlooked “without full collapse” group with a normal-appearing, albeit small, distal lumen. By this division by appearance, symptomatic near-occlusion with full collapse has been reported to have worse short-term prognosis than those without full collapse, no other division has been assessed for prognosis. The aim of this study was to assess if a measurement based definition of full collapse might improve prognostic discrimination. Methods: 99 consecutive patients with symptomatic near-occlusion diagnosed on CT-angiography were included. The risk of preoperative recurrent ipsilateral ischemic stroke within 28 days of presenting event was assessed with Kaplan-Meier analysis, censoring at revascularization. We assessed residual stenosis diameter, distal ICA diameter, ICA-ratio (side-to-side), and ICA-ECA ratio as risk markers. Results: By appearance, the 28-day risk of stroke tended to be higher for full collapse (27%, 11/42) than without full collapse (11%, 6/57), p=0.054 (figure). The best new definition of full collapse was distal ICA diameter ≤2.0 mm and/or ICA ratio ≤0.47. 10 patients were reclassified by this new definition compared to appearance definition, 5 in each direction. By the new definition, 28-day risk of stroke was higher in full collapse (34%, 14/42) than without full collapse (5%, 3/57), p&lt;0.001 (fig 1B). Conclusions: Compared to the appearance based definition, our new definition of separating near-occlusions into with and without full collapse yields similar groups sizes but better prognostic discrimination. This new definition could be used as inclusion criteria in future treatment trials.

Risk factors of early mortality after surgical treatment for infective endocarditis.

To explore the basic clinical characteristics and relevant factors affecting the early postoperative prognosis in patients with infective endocarditis (IE). A total of 702 patients with IE, who underwent surgery in Xiangya Hospital, Central South University from January 1981 to June 2019, were studied and the data were collected through the paper records and the hospital information system. The patients from January 1981 to June 2010 served as an early group (n=224), and other patients from July 2010 to June 2019 served as a recent group (n=478). Independent risk factors for early postoperative death were determined by logistic regression analysis. The mean age of the 702 patients was 36.7±16.1 years, and the male accounted for 68.1%. Preoperative stroke occurred in 71 patients (10.1%), and dialysis was done in 14 patients (2%) preoperatively. Streptococcus were the pathogenic bacteria in 172 patients, accounting for 59.5% of all positive blood culture results. In the early group, the percentage of IE combined with congenital heart disease was significantly higher than that in the recent group [77 patients (34.4%) in the early group vs 22 patients (4.6%) in the recent group; P<0.05]. Postoperative stroke occurred in 15 patients (2.1%), while 59 patients (7%) required new dialysis postoperatively because of renal insufficiency. Twenty-nine patient died in the post-operation, with 4.1% in 30-day mortality. Logistic regression analysis revealed that the high preoperative New York Heart Association (NYHA) grade of cardiac function (OR=3.22, 95% CI 1.50-6.88; P<0.01), postoperative stroke (OR=5.75, 95% CI 1.22-27.07; P<0.05), postoperative dialysis (OR=15.53, 95% CI 3.50-68.82; P<0.01), perivalvular abscess (OR=13.19, 95% CI 3.83-45.42; P<0.01) and multivalve involvement (OR=3.57, 95% CI 1.24-10.30; P<0.05) were the independent risk factors for early mortality. Streptococcus is the most common pathogenic bacteria in the patients with IE. Surgery for IE can obtain a satisfactory early outcomes. High preoperative NYHA grade of cardiac function, postoperative stroke, postoperative dialysis, perivalvular abscess and multivalve involvement are the independent risk factors for early mortality.

Outcomes of Carotid Artery Replacement With Total Arch Reconstruction for Type A Aortic Dissection

Cerebral malperfusion and carotid artery dissection in patients with acute type A aortic dissections (TAAD) carry high morbidity and mortality. There are limited data on outcomes of concomitant carotid artery replacement with total arch replacement in the setting of TAAD. All patients with acute TAAD who underwent a total arch replacement between 2007 and 2018 were included. Data were retrospectively collected from a prospectively maintained database. Baselines variables were compared, and Kaplan-Meier estimates were used for long-term survival. Cox multivariable regression analysis was used to identify predictors of mortality. A total of 161 patients underwent total arch replacement for acute TAAD. Of these, 111 underwent conventional total arch reconstruction, and 50 had a concomitant carotid artery replacement. Baseline characteristics were similar between both cohorts apart from the carotid replacement cohort having a higher rate of preoperative cerebral malperfusion (48% vs 10.81%, P < .01) and preoperative stroke (28% vs 11.71%, P= .02). There was no difference in (operative) 30-day mortality between the carotid replacement and conventional total arch replacement groups (22% vs 18.9%, P= .81), 1-year mortality (28% vs 27.9%, P= .99), or 5-year mortality (32% vs 29.7%, P= .917). Postoperative stroke was 0% vs 4.5% (P= .301) for the carotid vs conventional total arch replacement cohort. Concomitant carotid artery replacement is a feasible and safe technique to address perioperative cerebral malperfusion, carotid dissection, and neurologic dysfunction associated with carotid artery dissection, with no difference in long-term survival or postoperative stroke when compared with conventional total arch replacement.

Abstract 13604: Virulence of Staphylococcus Infection in Surgically Treated Patients With Endocarditis - A Multi-center Analysis

Introduction: Infective endocarditis (IE) caused by Staphylococcus species have been noted to increase and are believed to be associated with higher morbidity and mortality rates. Hypothesis: Staphylococcus species are more virulent compared to other commonly causative bacteria of IE. Methods: The database of the Clinical Multicenter Project for Analysis of Infective Endocarditis in Germany (CAMPAIGN), comprising 4917 consecutive patients (mean age 62.2±14.6 years) undergoing heart valve surgery, was retrospectively analyzed. Uni- and multivariable regression analyses were used for comparison and risk stratification. The Kaplan Meier method was used for long-term survival estimation of the respective groups. Results: Staphylococcus patients (n=1260) were significantly more morbid than the Non-Staphylocccus group (n=3657) with regard to NYHA IV (21.4% vs. 16.7%*), CAD (29.0% vs. 25.7%; p =0.027), arterial hypertension (64.8% vs. 45.8%*), diabetes (29.9% vs. 24.8%*), renal failure (47.5% vs. 35.2%*), COPD (12.8% vs. 9.9%; p =0.007), PAD (11.3% vs. 6.4%*), preoperative stroke (35.1% vs. 18.0%*) and need for mechanical ventilation (18.2% vs. 6.4%*). Overall, Staphylococcus infections were more prevalent on mitral (51.0% vs. 42.0%*) and tricuspid (9.4% vs. 4.4%*) valves and showed higher incidences of large vegetations (87.0% vs. 56.0%*), mitral regurgitation (62.5% vs. 41.5%*) and preoperative septic embolism (51.8% vs. 28.9%*). Postoperatively, need for tracheostomy (13.7% vs. 7.6%*) and dialysis (29.4% vs. 13.6%*) were also significantly increased. The 30-day mortality for Staphylococcus was significantly higher (21.3% vs. 15.9%*) and long-term survival was significantly worse ( Fig. 1 ). Conclusions: Staphylococcus endocarditis is associated with significantly worse outcome compared to IE by other commonly causative bacteria. Early surgery should be considered to avoid preoperative septic embolism, deterioration and death. *= p &lt;0.0001

Postoperative troponin increases after noncardiac surgery are associated with raised neurofilament light: a prospective observational cohort study

BackgroundMyocardial and neuronal injury occur commonly after noncardiac surgery. We examined whether patients who had perioperative myocardial injury (PMI) also incurred neuronal injury, and whether myocardial and neuronal injury were associated with similar changes in inflammatory markers or overlapping clinical predictors. MethodsA total of 114 individuals >65 yr old were recruited from two ongoing perioperative cohort studies (NCT02926417; NCT03124303). Plasma samples were collected before and daily after surgery to process assays for troponin I (PMI), neurofilament light (NfL; neuronal injury) and multiplexed plasma cytokines (inflammation). The primary outcome was the change in NfL in individuals with PMI (>40 pg ml−1 increase in troponin above preoperative values). We conducted logistic regression to identify if there were shared clinical predictors for myocardial and neuronal injury. ResultsNinety-six patients had paired NfL and troponin data. Twenty-three of 94 subjects (24%) with PMI had greater increases in NfL (median [inter-quartile range, IQR]: 29 pg ml−1 [3–95 pg ml−1]; 2.8-fold increase) compared with subjects with no troponin increase (8 pg ml−1 [3–20]; 1.3-fold increase; P=0.008). PMI was associated with increased interleukin (IL)-1ra (P=0.005), IL-2 (P=0.045), IL-8 (P=0.002), and IL-10 (P<0.001). Logistic regression showed that intraoperative hypotension was associated with PMI (P=0.043). Preoperative stroke (P=0.041) and blood loss (P=0.002), but not intraoperative hypotension, were associated with increased NfL. ConclusionsPostoperative troponin increases were associated with changes in NfL and inflammatory cytokines. Increases in troponin, but not NfL, were associated with intraoperative hypotension, suggesting differences in the mechanisms contributing to neuronal and myocardial injury.

Younger patients have an increased risk for dementia after coronary artery bypass grafting, a population-based cohort study from the SWEDEHEART registry

Abstract Background Previous studies investigating the association between coronary artery bypass grafting (CABG) and risk for dementia show conflicting results. Purpose To compare the long-term risk for dementia in CABG patients to matched individuals in the general population, and to identify independent predictors for developing dementia after CABG. Methods Data from the SWEDEHEART registry and three other mandatory national registries were merged to compare all patients who underwent isolated CABG in Sweden from 1992 to 2015 (n=111.335) with an age- and sex-matched control individuals from the general population (n=222.396). Cumulative incidence adjusted for the competing risk for death and Cox regression models with Hazard Ratio (HR) and 95% confidence interval (CI) adjusted for age, gender, co-morbidity and socioeconomic variables, were used to calculate the risk of dementia. Median follow-up was 10.1 years (IQR 2.5–14.7) among CABG patients and 10.7 years (5.6–15.7) among the controls. Identified interactions of the excess risk for dementia with sex and age categories (&amp;lt;65, 65-&amp;lt;75, ≥75 years) resulted in analyses being stratified on those sub-cohorts. Results The overall cumulative incidence at 20 years follow up of all-cause dementia was 9.6% (95% CI 9.4–9.9) among CABG patients and 9.0 (8.8–9.2) among individuals in the general population. The adjusted relative risk for all-cause dementia was increased among CABG patients &amp;lt;65 years and 65–75 years, (HR 1.29 (95% CI 1.17–1.41) and HR 1.06 (1.01–1.11), respectively (fig 1). The risk for all-cause dementia was higher in CABG women than in CABG men (HR 1.62 (1.30–2.03) vs HR 1.22 (1.10–1.35)). In the oldest age group (75 years and older) the risk for all cause dementia, vascular dementia and Alzheimer's disease was lower for CABG patients compared to controls (HR 0.73 (0.69–0.78). Female CABG patients &amp;lt;65 years had an increased risk for Alzheimer's disease (HR 1.83 (1.06–3.15). Hypertension, diabetes, preoperative stroke, renal failure, heart failure, atrial fibrillation, depression and low income were independent predictors for all-cause dementia in CABG patients. Conclusion CABG patients younger than 75 years at the time of surgery have an increased risk of all-cause dementia compared to an age- and sex-matched population. Women younger than 65 years that underwent CABG had also a markedly higher risk for Alzheimer disease. Increased awareness of the higher risk for dementia in younger CABG patients is warranted to avoid delay of diagnosis and treatment. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swedish Heart and Lung Foundation, Swedish State

Machine learning analysis of factors influencing ischemic stroke after coronary artery bypass grafting

Abstract Aims Ischemic Stroke (IS) is a devastating complication of coronary bypass (CABG) surgery, significantly increasing mortality, morbidity, cost, and the need for long-term care, and reducing the quality of life. With the aim of a learning-machine method, we investigated factors influencing the occurrence of IS after CABG. Methods and results We employed a statistical learning method – random forests – to examine which of various variables had the greatest impact on postoperative IS. A dataset including 16,255 consecutive patients undergoing isolated CABG between 1997 and 2017 In one Institution was examined. Along with demographic and clinical variables technical-related factors were included, encompassing surgical technique, number of touches on the aorta, cardiopulmonary bypass, total aortic clamping, use of the side-biting clamp, or number of proximal anastomoses. A ranking score based on the average percent increase in mean squared error and obtained for all variables was employed to quantify the importance of any variable in predicting IS. A total of 641 strokes occurred (3.9%). Total aortic clamp showed the highest incidence of stroke (n=570, 88.95% of total). Total aortic clamp had the highest score among all variables followed by previous stroke and carotid artery disease &amp;gt;50%. In contrast, other variables related to surgical technique showed low ranking scores in predicting IS. In patients undergoing CABG with the use of total aortic, a previous brain ischemic insult as well as age &amp;gt;75 years increase the risk of IS (fIGURE) Conclusions The use of total aortic clamp is the strongest predictor of stroke. A clamp-less technique is recommended whenever possible especially in older patients and those who experienced preoperative stroke or who had significant carotid stenosis. Importance of variables in predicting IS Funding Acknowledgement Type of funding source: None

Improved stability of steerable sheath access by femoro-femoral crossover wire in branched stent graft repair of complex thoraco-abdominal aortic aneurysms.

PurposeThe purpose of this study was to describe a technique to catheterize antegrade branches of a branched aortic endograft by using a steerable sheath stabilized by a through-and-through wire via a femoral access.TechniqueAfter implantation of a branched endovascular graft, a steerable 8.5 F sheath is advanced from the femoral access. After placing the sheath proximal to the branches, a 0.014″ through-and-through wire is established to the contralateral femoral access which is held under slight traction after the curved tip of the sheath is brought into the 180° position. Then catheterization, wire exchange and deployment of the bridging stent is done in standard fashion.ConclusionThe use of a through-and-through wire with a steerable sheath for retrograde femoral access adds stability and precision to this technique. It has the potential to reduce the risk of preoperative stroke in complex aortic endovascular repair by avoiding upper extremity access.

A Cost Analysis of Pathology Evaluation of Carotid Plaque after Endarterectomy

Overtreatment and overuse of resources are leading causes of rising health care costs. Identification and elimination process of low value services is important in reducing such costs. At many institutions it is routine to send excised plaque after carotid endarterectomy (CEA) for pathology evaluation. With more than 140,000 CEAs performed annually in the United States, this represents an opportunity for potential cost savings. We set out to examine the cost and clinical use of pathology evaluation of plaque after CEA. We performed a retrospective review of patients undergoing CEA at a single institution from 2016 to 2019. Patients were excluded if they had a prolonged postoperative length of stay or if they had a preoperative stroke. Demographics, perioperative outcomes, and billing costs were recorded. We identified 82 total CEAs, of which 42 were excluded according to the aforementioned exclusion criteria. We reviewed 40 CEAs. Mean age of this cohort was 67.2 (±8.3) years. Most (72.5%) were asymptomatic at the time of admission, whereas 27.5% presented with a transient ischemic attack. Mean postoperative length of stay was 1.8days. The primary insurers were 39.5% private, 39.5% Medicare, and 21.1% Medicaid. Mean total charges for the hospitalization were $83,367 (±$42,874). Of this total, professional fees were $3,512 (±$980) and facility fees were $80,395 (±$42,886). Mean pathology charges were $285 (±$88). The pathology professional fee was $61 (±$27), which represented 1.82% (±0.88) of the professional costs. Reimbursement for the facility pathology charge was $229 (±$57) and for the professional pathology charge was $25 (±$14). All plaque samples were submitted for gross examination and hematoxylin and eosin staining. The correlation rate for the clinical and pathologic diagnosis was 100%. The pathology reports simply read "atherosclerotic plaque" and "calcific plaque" in 32.5% and 45% of samples. For the remaining plaques, 12.5% and 10% of reports also noted fibrosis and degenerative changes, respectively. There were no clinical implications or decisions made based on the pathology reports. Cost of pathology evaluation was on average $285, with an average reimbursement of $235. With 140,000 CEAs done annually, this represents a potential $32.9-$39.9 million saved to the health care system. Pathology evaluation of carotid plaque incurs significant costs to the health care system with no clear value for the postoperative care of the patient. Hospital policy regarding mandatory pathologic examination and surgeon preferences regarding plaque analysis should be more closely examined.

Outcome of surgery for acute infective endocarditis: does preoperative stroke have an impact on mortality?

Surgical therapy of infective endocarditis (IE) is challenging and can be associated with high mortality. In this study, we present the early outcomes of patients who underwent cardiac surgery for IE. From 2017 until 2019, 66 patients underwent surgical treatment for IE. Staphylococcus aureus infection was identified in 14 patients (21%). In the same period, about 813 valve replacement procedures were performed with 8% incidence of IE. Mean age was 66 ± 12years and 32% were females. Mean ejection fraction was 55 ± 9%. Seven patients (11%) had stroke due to septic embolism preoperatively. In 20 patients (30%), prosthetic valve endocarditis was an indication for reoperation. Thirty-day postoperative mortality and impact of preoperative stroke were analyzed. Thirty-day mortality was 17% (n = 11). Mean EuroSCORE I was 28 ± 22%. Mean cross clamp time was 63 ± 37min. Fourty patients (61%) underwent one-valve procedure, 25 patients (38%) had double-valve, and one (1%) triple-valve operation. All seven patients with preoperative neurologic dysfunction had unremarkable postoperative course without death or neurologic deterioration. Five of them had no worsening in neurological status, while 2 patients had slight improvement in speech. The comparison between the two groups (patients without preoperative neurological vs. patients with preoperative neurological dysfunction) revealed no significance in the postoperative mortality rate (18% vs. 0% with p = 0.26). Postoperative echocardiography revealed competent valve function in all cases. Surgical treatment for IE still remains a challenge with high morbidity and mortality. Patients with preoperative neurologic dysfunction due to septic embolism have good early postoperative results without increased mortality.

The impact of pre-operative symptoms on carotid endarterectomy Outcomes: Analysis of the ACS-NSQIP carotid endarterectomy database

Carotid artery stenosis accounts for up to 20% of ischemic strokes. Since the 1950 s, one of the primary surgical treatment for this condition is carotid endarterectomy (CEA). Because of improvement of medical therapy for carotid artery atherosclerosis and the increased use of carotid artery stents, CEA is indicated if the risk of stroke and death are low. The goal of this study is to characterize the impact of pre-operative stroke and stroke risk factors on post-operative CEA patient outcomes, using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Vascular Module on CEA. Using the Targeted Vascular Module of the ACS-NSQIP, 22,116 patients who underwent CEA were identified from 2011 to 2016. Univariate analysis and multivariable logistic regression analyses were conducted to identify significant risk factors that predispose patients to stroke. Patients with pre-operative stroke comprise 42.1% of the group, with post-operative stroke being the second most common complication (2.1%). Pre-operative stroke patients were also at a higher risk for transient ischemic attacks, post-operative restenosis, post-operative distal embolization, and other complications. Patients with pre-operative risk factors, including stroke or stroke-like symptoms, high risk physiologic factors, high risk anatomic factors, and contralateral internal carotid artery stenosis were at a higher risk of developing post-operative stroke and other complications. Patients with these pre-operative risk factors should be closely monitored for post-operative complications in an effort to improve patient outcomes.