Risk Factors For Postoperative Stroke Research Articles

Incidence, predictors, and timing of post-operative stroke following elective total hip arthroplasty and total knee arthroplasty

BackgroundPostoperative stroke is a rare but potentially devastating complication following total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of the current study was to determine the incidence, independent risk factors, and timing of stroke following THA and TKA utilizing the National Surgical Quality Improvement (NSQIP) database.MethodsPatients who underwent elective primary THA and TKA were identified in the 2005–2016 NSQIP database. Thirty-day postoperative strokes were identified, timing was characterized, and an incidence curve was created. Multivariate analyses determined the independent predictors of these strokes.ResultsOf 333,117 patients identified, 286 (0.09%) experienced a stroke. Given that THA vs TKA was not a univariate predictor of stroke, the two procedures were considered together. The majority (65%) of strokes occurred before discharge. Of the strokes observed, 25% occurred by postoperative day one, 50% by postoperative day two, and 75% by postoperative day nine. Independent risk factors for postoperative stroke were: age (60–69 years old odds ratio [OR] = 4.2; 70–79 years old OR = 8.1; ≤80 years old OR = 16.1), higher American Society of Anesthesiologists (ASA) score (ASA≥3 OR = 1.7), and smoking [OR = 1.6).ConclusionThe incidence of stroke after THA/TKA was low at 0.09%, with the majority occurring prior to discharge and half occurring by postoperative day two. Patients who were older, sicker, or who were smokers were at greater risk of postoperative stroke. These findings can be used to council patients and to optimize patient care.Level of evidenceLevel III, Retrospective comparative study.

Predictors and outcomes of stroke after transcatheter aortic valve replacement.

Stroke is a devastating complication of transcatheter aortic valve replacement (TAVR). Many studies have investigated risk factors for postoperative stroke, but reliable predictors are not yet well-established. The objective of this study was to further characterize the predictors and outcomes of stroke after TAVR. This is a retrospective cohort study of 1022 patients who underwent TAVR at a single institution between 2012 and 2018. Multivariable logistic regression analysis was used to identify independent predictors of postoperative stroke and Kaplan-Meier method to compare 1-year survival in patients with and without postoperative stroke. Postoperatively, 36 patients experienced a stroke (3.5%) with most developing multiple (63.9%, N = 23), and often bilateral infarcts (50.0%, N = 18). Stroke patients more commonly had peripheral arterial disease (P = .032) and carotid stenosis (P = .013) and were less likely to receive predeployment balloon aortic valvuloplasty (P = .005). Alternative access approach (odds ratio [OR], 2.322; 95% confidence interval [CI]: 1.067-5.054) and history of transient ischemic attack (OR, 2.373; 95% CI: 1.026-5.489) were identified as independent predictors of postoperative stroke. Stroke patients more frequently developed postoperative complications, including prolonged ventilation (P < .001), major vascular complications (P < .001), and new-onset dialysis (P < .001). Operative mortality was greater in stroke patients (19.4% vs 3.7%; P < .001), and 1-year Kaplan-Meier estimates revealed worsened survival (log-rank P = .002). Alternative access approach and a history of transient ischemic attack emerged as independent predictors of postoperative stroke. Patients with stroke suffered more complications and had worse survival, underscoring the importance of characterizing the stroke risk in these patients.

Both left upper lobectomy and left pneumonectomy are risk factors for postoperative stroke

Retrospective studies have found that left upper lobectomy (LUL) may be a new risk factor for stroke, and the potential mechanism is pulmonary vein thrombosis, which more likely develops in the left superior pulmonary vein (LSPV) stump. The LSPV remaining after left pneumonectomy is similar to that remaining after LUL. However, the association between left pneumonectomy, LUL, and postoperative stroke remains unclear. Thus, we sought to analyze whether both LUL and left pneumonectomy are risk factors for postoperative stroke. We prospectively included consecutive patients who underwent resection between November 2016 and March 2018 at our institution with 6 months of follow-up. Baseline demographic and clinical data were taken. A logistic regression model was used to determine independent predictors of postoperative stroke. In our study, 756 patients who underwent an isolated pulmonary lobectomy procedure were screened; of these, 637 patients who completed the 6-month follow-up were included in the analysis. Multivariable logistic regression analysis adjusted for common risk factors showed that the LUL and left pneumonectomy were independent predictors of stroke (odds ratio, 18.12; 95% confidence interval, 2.12–155.24; P = 0.008). Moreover, diabetes mellitus also was a predictor of postoperative stroke. In conclusion, both LUL and left pneumonectomy are significant risk factors for postoperative stroke.

Risk factors for postoperative stroke in adults patients with moyamoya disease: a systematic review with meta-analysis

BackgroundThis systematic review and meta-analysis aimed to clarify the risk factors for postoperative stroke in adult patients with moyamoya disease (MMD).MethodsWe comprehensively searched MEDLINE/PubMed, Web of Science, and Cochrane Library for eligible published literature with regard to the risk factors and postoperative complications in adult patients with MMD. Statistical analysis was conducted using Stata version 12.0. Pooled odds ratio (OR) with 95% confidence interval (CI) were assessed for each risk factor.ResultsThere were 8 studies encompassing 1649 patients who underwent surgery with MMD were selected for analysis. Preoperative ischemic event significantly increase the risk of postoperative stroke events (OR = 1.40; 95%CI = 1.02–1.92; P = 0.039). PCA involvement correlate with an increased risk of post-infarction (OR = 4.60; 95%CI = 2.61–8.11; P = 0.000). Compared to direct bypass, patients who underwent indirect bypass or combined bypass could significantly increase the risk of postoperative stroke events. (OR = 1.17; 95%CI = 1.03–1.33; p = 0.017). MMD patients with diabetes were associated with an increased risk of postoperative stroke events (OR = 4.02, 95% CI = 1.59–10.16; p = 0.003). MMD patients with hypertension, age at onset and male sex were not associated with an increased risk of postoperative stroke events (P > 0.05).ConclusionsThis systematic review and meta-analysis indicated that preoperative ischemic events, PCA involvement and diabetes were independent risk factors for postoperative stroke in MMD patients. Therefore, in order to ensure the curative effect of patients with MMD, it is very necessary to detect these risk factors and prevent postoperative complications in time.

A Multilevel Analysis of Surgical Category and Individual Patient-Level Risk Factors for Postoperative Stroke.

Many studies supporting the association between specific surgical procedure categories and postoperative stroke (POS) do not account for differences in patient-level characteristics between and within surgical categories. The risk of POS after high-risk procedure categories remains unknown after adjusting for such differences in patient-level characteristics. Using inpatients in the American College of Surgeons National Surgical Quality Initiative Program database, we conducted a retrospective cohort study between January 1, 2000, and December 31, 2010. Our primary outcome was POS within 30 days of surgery. We characterized the relationship between surgical- and individual patient-level factors and POS by using multivariable, multilevel logistic regression that accounted for clustering of patient-level factors with surgical categories. We identified 729 886 patients, 2703 (0.3%) of whom developed POS. Dependent functional status (odds ratio [OR]: 4.11, 95% confidence interval [95% CI]: 3.60-4.69), history of stroke (OR: 2.35, 95%CI: 2.06-2.69) or transient ischemic attack (OR: 2.49 95%CI: 2.19-2.83), active smoking (OR: 1.20, 95%CI: 1.08-1.32), hypertension (OR: 2.11, 95%CI: 2.19-2.82), chronic obstructive pulmonary disease (OR: 1.39 95%CI: 1.21-1.59), and acute renal failure (OR: 2.35, 95%CI: 1.85-2.99) were significantly associated with POS. After adjusting for clustering, patients who underwent cardiac (OR: 11.25, 95%CI: 8.52-14.87), vascular (OR: 4.75, 95%CI: 3.88-5.82), neurological (OR: 4.60, 95%CI: 3.48-6.08), and general surgery (OR: 1.40, 95%CI: 1.15-1.70) had significantly greater odds of POS compared to patients undergoing other types of surgical procedures. Vascular, cardiac, and neurological surgery remained strongly associated with POS in an analysis accounting for the association between patient-level factors and surgical categories.

Impact of acute cerebral ischemic lesions and their volume on the revascularization outcome of symptomatic carotid stenosis

BackgroundThe influence of acute cerebral ischemic lesions (CILs) on the revascularization outcome of symptomatic carotid stenosis has been scarcely investigated in the literature. This study evaluated the effect of CILs and their volume on the results of carotid revascularization in symptomatic patients. MethodsAll patients with symptomatic carotid artery stenosis who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) between 2005 and 2014 were considered. CILs ipsilateral to the stenosis were identified in the preoperative cerebral computed tomography. The volume was quantified in mm3 and correlated with 30-day rates of stroke and stroke/death by χ2, multivariate analysis, Pearson correlation, and receiver operating characteristic curves. ResultsA total of 489 symptomatic patients were treated by CEA (327 [67%]) or CAS (162 [33%]), 186 (38%) ≤2 weeks and 303 (62%) >2 weeks from symptom onset. CEA and CAS patients had statistically similar rates of stroke (3.3% vs 5.5%; P = .27) and stroke/death (3.8% vs 5.9%; P = .22). CILs were identified in 251 patients (53%) and were associated with similar stroke and stroke/death rate compared with patients without CIL (12 [4.8%] vs 8 [3.5%], P = .46; and 14 [5.6%] vs 8 [3.5%]; P = .26, respectively). The median CIL volume was 1000 mm3 (interquartile range [IQR], 7000 mm3). Patients with postoperative stroke and stroke/death had a significantly higher preoperative CIL volume of 5100 mm3 (IQR, 31,000 mm3) vs 1000 mm3 (IQR, 7000 mm3; P = .01) and 4500 mm3 (IQR, 17,450 mm3) vs 1000 mm3 (IQR, 7000 mm3; P = .03), respectively. The receiver operating characteristic curve analysis showed a volume of 4000 mm3 was predictive of postoperative stroke with 75% sensitivity and 63% specificity. A CIL volume ≥4000 mm3 was an independent risk factor for postoperative stroke, with a stroke rate of 9.3% (n = 9) vs 1.9% (n = 3) for a CIL volume of <4000 mm3 (odds ratio, 4.6; 95% confidence interval, 1.1-19.1; P = .03). ConclusionsCIL volume in symptomatic carotid stenosis seems to influence the 30-day outcome independently from the timing of carotid revascularization. A CIL volume of ≥4000 mm3 could be considered a significant predictor for postoperative stroke after carotid revascularization.

SS25. Impact of Acute Cerebral Ischemic Lesions and Their Volume on the Revascularization Outcome of Symptomatic Carotid Stenosis

The influence of acute ischemic cerebral lesion (CIL) on the revascularization outcome of symptomatic carotid stenosis has been scarcely investigated in the literature. This study evaluated the possible influence of CIL on symptomatic carotid revascularization outcome. All patients with symptomatic carotid artery stenosis who underwent to carotid endarterectomy (CEA) or stenting (CAS) between 2005 and 2014, were considered. CILs ipsilateral to the stenosis were identified in the preoperative cerebral computed tomography, quantified in mm3 and correlated with 30-day stroke and stroke/death by χ2, multivariate analysis, Pearson correlation, and ROC curve. A total of 489 symptomatic patients were treated by CEA (327-67%) or CAS (162-33%), 186 (38%) ≤2 weeks and 303 (62%) >2 weeks from symptoms onset. The stroke and stroke/death rate were not statistically different in CEA and CAS (3.3% vs 5.5%; P = .27; 3.8% vs 5.9%; P = .22). CILs were identified in 251 patients(53%) and were associated with similar stroke and stroke/death rate compared with no CIL patients (4.8% vs 3.5% [P = .46] and 5.6% v s3.5% [P = .26], respectively). However at the Pearson analysis, CIL volume significantly correlates with stroke (r = 0.15, P = .02) and stroke/death (r = 0.14, P = .04), and with stroke independently from the timing of revascularization (< 2 weeks: r = 0.16, P = .03; and >2 weeks: r = 0.21, P = .04). CIL volume correlates with stroke and stroke/death in CAS (r = .27, P = .005 and r = .24, P = .01) but not in CEA (r = 0.05, P = .55 and r = 0.03, P = .65). By the ROC curve analysis, a volume of 4000 mm3 is predictive of postoperative stroke with 75% sensitivity and 63% specificity. CIL volume >4000 mm3 was an independent risk factor for postoperative stroke (OR, 4.6; 95% CI, 1.1-19.1; P = .03). CIL volume in symptomatic carotid stenosis seems to influence the 30-day outcome independently from the timing of carotid revascularization. A CIL volume >4000 mm3 could be considered a significant predictor for postoperative stroke after carotid revascularization.

Abstract TP177: Preoperative Functional Status and Type of Surgery Influences Postoperative Stroke Risk: analysis from the Nationwide Surgical Quality Initiative Program

Introduction: Post-operative stroke (POS) is associated with vascular and cardiac surgery, but this finding has mainly been reported among populations receiving vascular and cardiac procedures. We investigated the association between type of surgery and risk of POS in a large, generalizable inpatient cohort from the American College of Surgeons National Surgical Quality Initiative Program (NSQIP) database. Hypothesis: Cardiac and vascular procedures are associated with an increased risk of POS. Methods: We identified patients that underwent surgery between the years of 2000 and 2010. Our primary outcome was POS within 30 days of surgery. Using a hierarchical model adjusted for age, race, sex, medical comorbidities and dichotomized functional status, we assessed for clustering between type of surgery and POS. We then determined risk factors for POS while adjusting for clustering. Each surgical type was compared against all other surgical types. Results: We identified 729,886 patients, of whom 2,703 (0.3%) developed POS. In the hierarchical analysis, cardiac surgery (incidence rate ratio (IRR) 6.38, 95%CI 5.37-7.55), vascular surgery (IRR 4.41, 95%CI 4.08-4.76), and neurosurgery (IRR 2.05, 95%CI 1.69-2.48) were associated with increased risk of POS. The only patient-level factor associated with surgery type was poor preoperative functional status. Accounting for clustering, patients with poor pre-operative functional status (OR 4.11, 95%CI 3.60-4.69), history of stroke (OR 2.35 95%CI 2.06-2.69), history of transient ischemic attack (OR 2.49 95%CI 2.19-2.83), active smoking (OR 1.20, 95%CI 1.08-1.32), and COPD (OR 1.39 95%CI 1.21-1.59) were at higher risk of POS. There was no interaction between preoperative functional status and type of surgery. Conclusions: In a large cohort of surgical inpatients, we found that the risk of POS was significantly associated with cardiac, vascular, and neurosurgical procedures. Certain patient populations, such as those with a dependent pre-operative functional status, may be at a higher risk of POS and may be more likely to undergo cardiac, vascular, or neurosurgical procedures. Further studies are needed to elucidate the relationship between pre-surgical functional status and type of surgery.

Abstract 15634: Neurologic Impact of Carotid Stenosis in Cardiac Surgery, a Retrospective Study

Context: The impact of carotid disease on the risk of stroke is not well established in patients undergoing surgery on cardiopulmonary bypass (CPB). The aim of this study is to evaluate the relationship between post-operative cerebrovascular events and the characteristics of concomitant carotid stenosis (CS) (degree, laterality and associated symptomatology) in patients undergoing cardiac surgery on CPB. Methodology: Single center retrospective cohort study with prospectively collected data including all patients undergoing cardiac surgery on CPB between January 2002 and February 2014. Data collected included patients’ pre-operative demographic characteristics, operative and post-operative variables, and were taken from a computerized database and patients’ charts. Univariate analysis and multivariate analysis with stepwise approach were performed. Results: Results were obtained for 19,918 patients who met the inclusion criteria. Of these, 474 (2.4%) had at least a unilateral CS ≥50%. By univariate analysis, patients with CS ≥50% had a higher risk of post-operative stroke and/or TIA than those with CS &lt;50% (8.3% vs 2.4%, p&lt;0.0001). In the group of patients with CS ≥50%, neither the laterality of the stenosis (p=0.75) nor the presence of CS-related symptoms (p=0.07) were significantly associated with post-operative stroke and/or TIA. By multivariate analysis, the presence of a ≥50% CS was identified as an independent risk factor for post-operative stroke and/or TIA [OR 2.84; CI95% (1.94-4.16)]. The relationship between the degree of CS (50-99%) and the neurological risk showed a trend toward significance: CS 80-99% vs CS 50-79% [OR 1.77; CI95% (0.81-3.85)], p=0.15. The risk of stroke and/or TIA was highest in the 80-99% CS group [OR 3.80; CI95% (2.14-6.73)]. Conclusion: The presence of a ≥ 50% CS is an independent risk factor for post-operative stroke and/or TIA. Regardless of the presence of preoperative CS-related symptoms, the clinically relevant risk of stroke and/or TIA was highest for CS of 80-99%. These results suggest that a decision to perform prophylactic carotid revascularization prior to cardiac surgery should not only be based on the presence of CS-related symptoms, but also on the severity of carotid stenosis.

CAROTID STENOSIS IS AN INDEPENDANT PREDICTOR OF POST-OPERATIVE STROKE IN ON-PUMP CARDIAC SURGERY

Stroke is a devastating, multifactorial complication of heart surgery. The impact of carotid disease on the risk of stroke is not well established in patients undergoing surgery on cardiopulmonary bypass (CPB). The aim of this study is to evaluate the relationship between post-operative cerebrovascular events and the characteristics of concomitant carotid stenosis (CS) (degree, laterality and associated symptomatology) in patients undergoing cardiac surgery on CPB. This is a single center retrospective cohort study with prospectively collected data including all patients undergoing cardiac surgery on CPB between January 2002 and February 2014 in our institution. Data collected included patients’ pre-operative demographic characteristics, operative and post-operative variables, and were taken from a computerized database and patients’ charts. Univariate analysis and multivariate analysis with stepwise approach were performed. Results were obtained for 19,918 patients without prior carotid revascularization who met the inclusion criteria. Of these, 474 (2.4%) had at least a unilateral CS ≥50%. By univariate analysis, patients with CS ≥50% had a higher risk of post-operative stroke and/or TIA than those with CS <50% (8.3% vs 2.4%, p<0.0001). In the group of patients with CS ≥50%, neither the laterality of the stenosis (p=0.75) nor the presence of CS-related symptoms (p=0.07) were significantly associated with post-operative stroke and/or TIA. By multivariate analysis, the presence of a ≥50% CS was identified as an independent risk factor for post-operative stroke and/or TIA [OR 2.84; CI95% (1.94-4.16)]. The relationship between the degree of CS (50-99%) and the neurological risk showed a trend toward significance: CS 80-99% vs CS 50-79% [OR 1.77; CI95% (0.81-3.85)], p=0.15. The risk of stroke and/or TIA was highest in the 80-99% CS group [OR 3.80; CI95% (2.14-6.73)]. In this study analyzing the impact of CS in patients undergoing cardiac surgery on CPB, the presence of a ≥ 50% CS was an independent risk factor for post-operative stroke and/or TIA. Regardless of the presence of preoperative CS-related symptoms, the clinically relevant risk of stroke and/or TIA was highest for CS of 80-99%. These results suggest that a decision to perform prophylactic carotid revascularization prior to cardiac surgery should not only be based on the presence of CS-related symptoms, but also on the severity of carotid stenosis.

Postoperative Blood Urea Nitrogen Is Associated With Stroke in Cardiac Surgical Patients

This case-control study identified perioperative risk factors associated with postoperative stroke risk after all cardiac surgical procedures. Among 5498 adults 18 to 90 years old who underwent cardiac surgical procedures from 2005 to 2010, we identified 180 patients who suffered a stroke within 10 days postoperatively. Controls were randomly selected and frequency matched for sex and age-band to cases. Univariate and multivariate logistic regression analyses were performed to ascertain risk factors for postoperative stroke. Emergency surgical procedures (odds ratio [OR], 3.04; 95% confidence interval [CI], 1.80 to 5.10), current smoking (OR, 1.97; 95% CI, 1.29 to 3.00), peripheral vascular disease (OR, 2.80; 95% CI, 1.41 to 5.53), and previous stroke with residual paralysis (OR, 4.27; 95% CI,1.18 to 15.38) were associated with increased stroke risk. Preoperative blood pressures were higher in patients with cases than in controls (p < 0.0001). Log of immediate postoperative blood urea nitrogen (BUN) was higher in patients with cases than in controls (p < 0.0001). In adjusted multivariable logistic regression, postoperative BUN was associated with increased odds of stroke (OR, 2.37 per 25% increase in BUN, p < 0.0001). Postoperative stroke risk was also predicted by emergency surgical procedures (OR, 2.70, p = 0.014), current smoking (OR, 2.82, p= 0.002), and preoperative diastolic blood pressure (DBP) (OR, 1.77 for every 10-point increase in DBP, p < 0.0001). Receiver operator characteristic curves indicated that postoperative BUN (area under the curve, 0.855) largely explained the increased postoperative stroke risk. In these analyses, we identified BUN as a marker of heightened postoperative stroke risk after cardiac surgical procedures. Postoperative risk markers may improve assessment of delayed postoperative strokes.

Abstract T MP56: Immediate Post-operative Serum Blood Urea Nitrogen is Strongly Associated with Early Post-surgical Stroke Risk in Cardiac Surgical Patients

Objective: To identify perioperative risk factors that are associated with post-operative stroke risk after all cardiac surgical procedures at a large tertiary hospital. Methods: Among 5498 adults aged 18-90 years who underwent cardiac surgery at Johns Hopkins Hospital from 2005-2010, we identified 180 cases who suffered a stroke within 10 days post-operatively. An equal number of controls were randomly selected and frequency-matched for sex and age-band to cases. Univariate and multivariate logistic regression analyses were performed to ascertain risk factors for post-operative stroke. Results: Emergent surgery (OR 3.04, 95% CI 1.80- 5.10), current smoking (OR 1.97, 95% CI 1.29- 3.00), peripheral vascular disease (OR 2.80, 95% CI 1.41-5.53), and previous stroke with residual paralysis (OR 4.27 95% CI 1.18-15.38) were associated with increased stroke risk. Pre-operative blood pressures were higher in cases than in controls (p &lt;0.0001). Log of immediate post-operative BUN was higher in cases than in controls (p&lt; 0.0001). In multivariable logistic regression (adjusted for pre-operative hematocrit, post-operative creatinine, acute myocardial infarction and low ejection fraction), post-operative BUN was associated with increased odds of stroke (OR 2.4 per 25% increase in BUN, p &lt;0.0001). Postoperative stroke risk was also predicted by emergent surgical status (OR=2.7, p=0.014), current smoking (OR= 2.8, p=0.002) and pre-operative diastolic blood pressure (OR: 1.8 for every 10-point increase in DBP, p&lt;0.0001). ROC curves indicated that post-operative BUN (AUC = 0.855) largely explained the increased post-operative stroke risk. AUC for the adjusted final model was 0.896 and the ROC curve that excluded post-operative BUN only yielded an AUC of 0.700. Conclusion: In these analyses we have identified factors that are associated with post-operative stroke for all types of cardiac surgery. Awareness of these exposures may improve stroke risk assessment.

Abstract T MP63: Cardiac Diagnosis is the Major Risk for Stroke in Neonates with Complex Congenital Heart Defects

Background and Objectives: Complex congenital heart defects (CHD), which occur in approximately 3 out of 1000 neonates, require invasive open-heart surgery during the first year of life. In a recent prospective study of infants with various forms of complex CHD, 40% of neonates acquired post-operative brain injury including stroke and periventricular leukomalacia (PVL). However, studies identifying specific risk factors of post-operative stroke have been limited. Herein we examine risk factors for post-operative stroke in a mixed cohort of infants with critical CHD. Methods: Term neonates born with critical CHD from 2009 to present were identified from a single-center prospective study. Exclusion criteria included birth weight less than 2 kg, neonatal depression, perinatal seizures, and evidence of end-organ injury. Magnetic resonance imaging (MRI) to assess pre- and post-operative brain injury was performed immediately prior to and within 10 days after surgery. Results: Of 102 subjects enrolled, 85 neonates were imaged both pre- and post-operatively. Neonates were diagnosed with either hypoplastic left heart syndrome (HLHS, n=41), transposition of the great arteries (TGA, n=29) or other (n=15). A total of 9 arterial ischemic strokes were observed (10.6%), of which 7/9 were post-operative only. The incidence of stroke was significantly higher in infants with HLHS (6/41, 14.6%) than in infants with TGA (0/29, p=0.03). Time-to-surgery, head circumference, birth weight, duration of deep hypothermic circulatory arrest, and volume of pre- or post-operative PVL were not significantly correlated with incidence of stroke. Conclusion: Neonates with HLHS have a higher prevalence of post-operative embolic stroke compared to infants with TGA. Although infants with HLHS have been shown to be at a high risk for both post-operative stroke and PVL, incidence of post-operative stroke is not correlated with volume of post-operative PVL.

Postoperative stroke related to cardiac surgery in octogenarians

Demographics of cardiac surgery patients are changing, with an increase in aged patients. We aim to identify risk factors, mortality, morbidity and increasing postoperative costs due to postoperative stroke in octogenarians following cardiopulmonary bypass (CPB). A total of 418 consecutive patients older than 80 years (Group A) who underwent cardiac surgery with CPB between 2000 and 2012 were matched according to gender, surgical procedure and comorbidities with 426 younger patients (Group B). Risk factors for postoperative stroke were retrospectively evaluated. We identified postoperative stroke in 4.1% of patients in Group A and in 3.5% in Group B (P = 0.65). Early stroke was diagnosed in 13 patients in Group A (76.5%) and 10 patients in Group B (66.7%) (P = 0.53). In multivariate analysis, preoperative anaemia (P = 0.033; odds ratio [OR]: 3.84; 95% CI: 1.11-13.28) was the only risk factor associated with postoperative stroke in Group A. In Group B, preoperative peripheral vascular disease (P = 0.0003; OR: 7.30; 95% CI: 2.47-21.55) and postoperative atrial fibrillation (P = 0.0134; OR: 4.05; 95% CI: 1.33-12.31) were identified as risk factors. Incidence of postoperative stroke after CPB was not significantly higher in our octogenarian population. Although in younger patients peripheral vascular disease and cardiac rhythm disturbances were significant risk factors, it seems that factors related to intraoperative brain oxygenation (secondary to preoperative anaemia) are the most critical determinant of stroke in the elderly.

Stroke After Coronary Bypass Surgery Is Mainly Related to Diffuse Atherosclerotic Disease

This study aims to investigate the risk factors for postoperative stroke and analysis of outcome after coronary bypass surgery with cardiopulmonary bypass. Between 1999 and 2008, 3248 consecutive patients who underwent isolated coronary surgery with cardiopulmonary bypass were prospectively enrolled in the study. Demographic and perioperative data were analyzed. Postoperative stroke was defined as severe adverse neurological events including permanent deficits or cerebral lesions with radiological demonstration of cerebral infarction within the first postoperative month. In total, 32 patients (0.9%) were determined with stroke. Univariate risk factors for postoperative stroke were determined as preoperative unstable angina (P = .006), Canadian Class of Angina (CCA) ≥ 3 (P = .001), preoperative creatinin level >1.2 mg/dL (P = .001), left main coronary artery disease (P = .04), chronic obstructive lung disease (P = .04), peripheral arterial disease (P < .001), New York Heart Association (NYHA) Class ≥ 3 (P = .004), preoperative renal insufficiency (P = .001), age > 65 years (P = .04), preoperative hypothyroidism (P = .02), postoperative low cardiac output state (P < .001), severe coronary artery disease requiring distal anastomosis ≥ 4 (P = .05), non-elective operation (P = .02), and body mass index ≥ 25 (P = .02). Multivariate analysis revealed peripheral arterial disease (odds ratio [OR], 5.2; 95% confidence interval [CI], 1.9-14.0; P = .001), severe coronary artery disease (OR, 3.1; 95% CI, 1.1-8.5; P = .02), and postoperative low cardiac output state (OR, 5.1; 95% CI, 1.4-18.2; P = .01) as the independent risk factors. Stroke after coronary bypass surgery with cardiopulmonary bypass is mainly related to diffuse atherosclerotic disease.

Statin in Combination With β-Blocker Therapy Reduces Postoperative Stroke After Coronary Artery Bypass Graft Surgery

Statin therapy prior to coronary artery bypass surgery (CABG) has been shown to prevent perioperative events such as myocardial infarction and perioperative death. The effect of statin therapy as a preventive treatment to decrease the stroke risk unrelated to cardiac surgery is also documented. In the setting of CABG, we have found no studies reporting a preventive effect of statin therapy on neurologic outcome. We analyzed 6,813 patients treated by CABG surgery at our institution between 1995 and 2005 for which complete medication history including all drugs taken before and after surgery was available. We analyzed the risk factors for postoperative stroke using a multiple logistic regression analysis, more specifically looking at the effect of preoperative treatment with statin, aspirin, β-blockers, and angiotensin-converting enzyme inhibitors, alone or in combination. At 30 days postoperative, 94 patients suffered a new documented stroke (1.4%). Hypertension, carotid disease, diabetes, and age were all associated with a greater risk of postoperative stroke. When analyzing the four groups of drug therapy, none of the medications alone affected the stroke rate. However, upon multivariable analysis the combination of statin and β-blockers gave an odds ratio of 0.377, suggesting a strong protective effect. Beta-blockers combined with statin confer a protective effect for stroke after CABG.

Short term outcomes of total arterial coronary revascularization in patients above 65 years: a propensity score analysis

BackgroundDespite the advantages of bilateral mammary coronary revascularization, many surgeons are still restricting this technique to the young patients. The objective of this study is to demonstrate the safety and potential advantages of bilateral mammary coronary revascularization in patients older than 65 years.MethodsGroup I included 415 patients older than 65 years with exclusively bilateral mammary revascularization. Using a propensity score we selected 389 patients (group II) in whom coronary bypass operations were performed using the left internal mammary artery and the great saphenous vein.ResultsThe incidence of postoperative stroke was higher in group II (1.5% vs. 0%, P = 0.0111). The amount of postoperative blood loss was higher in group I (908 ± 757 ml vs. 800 ± 713 ml, P = 0.0405). There were no other postoperative differences between both groups.ConclusionBilateral internal mammary artery revascularization can be safely performed in patients older than 65 years. T-graft configuration without aortic anastomosis is particularly beneficial in this age group since it avoids aortic manipulation, which is an important risk factor for postoperative stroke.

Coronary and carotid operations under prospective standardized conditions: incidence and outcome

Background. No randomized trial has yet evaluated the hypothetical benefit of carotid endarterectomy with coronary artery bypass grafting. This prospective review was undertaken to determine the differences between observed and predicted complication rates, as well as to define new predictors and assess costs in a standardized population. Methods. A prospective nonrandomized study was undertaken over a 4-year period involving all coronary artery bypass graftings done at one institution. Operative procedure was standardized. All patients underwent preoperative screening for carotid disease. If 80% or more stenosis was present, combined coronary artery bypass grafting and carotid endarterectomy was performed. Results. Of 2,071 patients, 1,987 had coronary artery bypass grafting only. In that group there were 34 strokes (1.7%) and 41 deaths (2.0%). Eighty-four patients underwent combined coronary artery bypass grafting/carotid endarterectomy and in that group there were four strokes (4.7%) and five deaths (5.9%). Independent risk factors for postoperative stroke were age (odds ratio 1.09; 95% confidence interval 1.04, 1.3), hypertension (odds ratio 2.67; 95% confidence interval 1.22, 5.23), extensively calcified aorta (odds ratio 2.82; 95% confidence interval 1.34, 5.97), and bypass time (odds ratio 1.01; 95% confidence interval 1.00, 1.02). Cost of a stroke was significant ( p < 0.05) in both groups. Conclusions. Patients with carotid disease fall into a higher risk group than patients without it. This increased risk is not because of carotid disease alone. Patients without significant carotid disease, who suffered a perioperative stroke, fell into an even higher risk category. Furthermore, carotid endarterectomy was not a significant risk factor by either the univariate or the multivariate analysis.

Invited commentary

The findings of Puskas and associates that age, previous transient ischemic attack, and carotid bruits are independent risk factors for postoperative stroke, confirm the findings of several other authors. The increased early and late mortality of patients sustaining strokes, along with prolongation of hospital stay, are remarkably similar at our institution where we have a 18.5% early mortality for stroke patients, with a 67% 1 year and 46% 5 year survival, and a 24.3 day mean length of stay. The strength of the paper however emanates from the large number of patients studied, and the fact that the data was accumulated prospectively.Nonfocal neurologic deficits, including encephalopathy and cognitive decline, are not addressed in this work. Careful neurologic assessment by neurologists and trained neuropsychometricians is required to determine the incidence of such injury after cardiac operation (20% at our institution). Institutions setting up data collection systems to track postoperative neurologic injury ought to include such personnel.Two of the three predictors of stroke in this work relate to carotid artery disease. While off-pump coronary operations are presently purported to be beneficial in reducing stroke in patients with aortic atherosclerosis, it will require outcomes research, such as this, to determine the influence of off-pump coronary artery bypass grafting in patients with extra or intracranial carotid artery disease. The findings of Puskas and associates that age, previous transient ischemic attack, and carotid bruits are independent risk factors for postoperative stroke, confirm the findings of several other authors. The increased early and late mortality of patients sustaining strokes, along with prolongation of hospital stay, are remarkably similar at our institution where we have a 18.5% early mortality for stroke patients, with a 67% 1 year and 46% 5 year survival, and a 24.3 day mean length of stay. The strength of the paper however emanates from the large number of patients studied, and the fact that the data was accumulated prospectively. Nonfocal neurologic deficits, including encephalopathy and cognitive decline, are not addressed in this work. Careful neurologic assessment by neurologists and trained neuropsychometricians is required to determine the incidence of such injury after cardiac operation (20% at our institution). Institutions setting up data collection systems to track postoperative neurologic injury ought to include such personnel. Two of the three predictors of stroke in this work relate to carotid artery disease. While off-pump coronary operations are presently purported to be beneficial in reducing stroke in patients with aortic atherosclerosis, it will require outcomes research, such as this, to determine the influence of off-pump coronary artery bypass grafting in patients with extra or intracranial carotid artery disease.

Strategies and Techniques for Neuroprotection in Coronary Artery Surgery

Patients undergoing coronary artery bypass grafting are at higher risk of neurologic events than demographi cally similar patients undergoing noncardiac surgery. Postoperative stroke has been shown to occur two to three times more frequently than in age-, gender-, and education-matched patients undergoing noncardiac vas cular or thoracic surgery. The incidence of more subtle brain syndromes, giving rise to symptoms of memory loss and cognitive deterioration as documented in up to 79% of coronary bypass patients, varies depending on whether prospective or retrospective data are analyzed, and whether or not serial cognitive testing is used, and is also significantly higher in coronary bypass patients. Various factors have been identified as causative in the genesis of perioperative neurologic injury in these pa tients. Although there is evidence that microgaseous and microparticulate emboli are instrumental in the production of postoperative cognitive impairment, the role of ascending aortic atherosclerosis is increasingly recognized as being the greatest single risk factor for postoperative stroke.