Risk Of Postoperative Stroke Research Articles

Abstract TMP97: Association Between Race/Ethnicity and New Onset Atrial Fibrillation and Stroke Following Noncardiac Surgery

Background: Racial differences in postoperative atrial fibrillation (POAF) and stroke rates following noncardiac surgery are not well understood and may be influenced by varying betablocker prescription patterns. 1 Methods: This multicentric retrospective observational study included 205,886 adult patients without pre-existing atrial fibrillation who underwent non-cardiac surgery between 2005 and 2021 at two tertiary care academic healthcare networks in the Bronx, New York, and Boston, Massachusetts. The study population consisted of 133,500 (65%) Non-Hispanic White (NHW), 38,237 (19%) Non-Hispanic Black (NHB), and 34,149 (17%) Hispanic individuals. The exposure variable was self-identified race and ethnicity with NHW patients serving as the reference group. The incidence of POAF within 30 days of surgery and postoperative stroke within the first year after the procedure were assessed. Modified Poisson regression with robust error variances was used to evaluate the association between race/ethnicity and POAF and postoperative stroke, adjusting for pre-defined confounders. Mediation analysis was used to determine whether beta-blocker use modified the association between race/ethnicity and stroke. Results: NHB and Hispanic patients were less likely to develop POAF than NHW patients (NHB: RRadj = 0.59; 95%CI: 0.52-0.68; P < .001; Hispanic: RRadj = 0.65; 95%CI: 0.56-0.76; P < .001) but more likely to experience postoperative stroke (NHB: RRadj = 1.39; 95%CI, 1.30-1.49; P < .001; Hispanic: RRadj = 1.34; 95%CI, 1.24-1.46; P < .001). NHB and Hispanic patients were also more likely to be on preexisting beta-blocker therapy than NHW patients (NHB: RRadj = 1.10; 95%CI: 1.07-1.14; P < .001; Hispanic: RRadj = 1.07; 95%CI: 1.03-1.12; P < .001). Beta-blocker use was significantly associated with an increased risk of postoperative stroke (RRadj = 1.17; 95%CI: 1.11-1.24; P < .001) and explained 16% (95%CI: 14%-20%) and 20% (95%CI: 16%-26%) of the variability in postoperative stroke rates among NHB and Hispanic patients, respectively. Conclusion: NHB and Hispanic patients are at higher risk of developing postoperative stroke following noncardiac surgery compared to NHW patients, despite having a lower risk of POAF. This increased stroke risk may be partially attributable to the higher likelihood of preoperative beta-blocker prescriptions in these populations. Reference 1 - POISE Study Group. The Lancet. 2008 May 31;371(9627):1839-47.

Isolated Middle Cerebral Artery Significantly Increases Risk of Postoperative Stroke after Transcarotid Revascularization in Asymptomatic Patients

Isolated Middle Cerebral Artery Significantly Increases Risk of Postoperative Stroke after Transcarotid Revascularization in Asymptomatic Patients

Impact of Left Ventricular Size on Outcomes Following HeartMate 3 Left Ventricular Assist Device Implantation: Analysis of the European Registry for Patients With Mechanical Circulatory Support (EUROMACS).

We investigated the association of preimplant left ventricular end-diastolic diameter (LVEDD) with outcomes after HeartMate 3 (HM3) left ventricular assist device (LVAD) implantation. Patients from the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) registry who underwent HM3 implantation from August 2014 to February 2023 (n = 834) were analyzed according to preoperative LVEDD: less than or equal to 65 (n = 251), 65-80 (n = 441), and greater than or equal to 80 mm (n = 142). The mean age was 54.4 ± 12.4 years, body surface area (BSA) 2.0 ± 0.23 m2, body mass index (BMI) 27.3 ± 5.0 kg/m2; 87.9% were male and 40% had ischemic cardiomyopathy. Patients with LVEDD less than or equal to 65 mm were older (56.1 ± 11.0 vs. 53.8 ± 13.0 vs. 53.0 ± 12.3 years; p = 0.015), more female (17.9% vs. 11.6% vs. 4.9%; p < 0.001), smaller BSA (1.95 ± 2.03 vs. 2.01 ± 0.22 vs. 2.08 ± 0.22 m2; p < 0.01) and lower BMI (26.6 ± 4.8 vs. 27.4 ± 5.1 vs. 28.2 ± 5.0; p = 0.01) compared to LVEDD 65-80 and greater than or equal to 80 mm, respectively. One year survival was associated with increasing LVEDD (75.7% vs. 84.6% vs. 89.5%; p = 0.003). Patients with LVEDD less than or equal to 65 mm had a higher risk of postoperative right heart failure (14.7% vs.10.4% vs. 6.8%; p = 0.03), the risk for postoperative stroke was similar (10% vs. 12.8% vs. 9.5%; p = 0.4). A small left ventricular (LV) size (LVEDD ≤ 65 mm) was associated with an increase in postoperative right heart failure and unadjusted 1 year mortality in adults who underwent HM3 LVAD implantation.

Relation between uric acid and stroke in aortic dissection.

Stroke is one of the severe complications following surgery in patients with acute type A aortic dissection (ATAAD). This study investigates the relationship between the preoperative serum uric acid to serum creatinine ratio (SUA/Scr) and postoperative stroke in patients undergoing total arch replacement with elephant trunk implantation for aortic dissection. We included ATAAD patients who were hospitalized and underwent surgery between June 1, 2015 and June 1, 2023, with complete clinical information. Preoperative SUA and Scr levels were collected to calculate SUA/Scr. The association between SUA/Scr and postoperative stroke was analyzed using univariate and multivariate logistic regression, as well as subgroup analysis. The optimal cut-off value of SUA/Scr was determined by receiver operating characteristic (ROC) curve analysis. A total of 332 patients were included in the study. Patients who developed postoperative stroke had lower SUA/Scr compared to those who did not (P=0.03). Univariate logistic regression indicated that higher SUA/Scr was associated with a reduced risk of postoperative stroke [odds ratio (OR) =0.80; 95% confidence interval (CI): 0.65-0.98; P=0.03]. This association remained significant after adjusting for confounding factors (OR =0.66; 95% CI: 0.45-0.97; P=0.04). Subgroup analysis revealed that the association between higher SUA/Scr and reduced risk of postoperative stroke was significant only in male patients (OR =0.81; 95% CI: 0.65-1.01; P=0.046) and those younger than 65 years (OR =0.82; 95% CI: 0.66-1.02; P=0.048), and was observed only in patients who underwent non-axillary artery cannulation (OR =0.65; 95% CI: 0.50-0.84; P=0.001), left femoral artery cannulation (OR =0.74; 95% CI: 0.58-0.96; P=0.02), and bilateral cerebral perfusion (OR =0.51; 95% CI: 0.32-0.81; P=0.004). The ROC curve analysis identified 3.36 as the optimal cut-off value for SUA/Scr. A higher SUA/Scr is associated with a reduced risk of postoperative stroke in patients with aortic dissection undergoing total arch replacement with stented elephant trunk implantation and may serve as a potential predictor of postoperative stroke.

Risk of neurologic events after surgery for mitral valve insufficiency and concomitant Cox-maze IV procedure for atrial fibrillation. A nationwide register-based study.

Analysis of the long-term risks of ischaemic stroke and cerebral bleeding in patients with atrial fibrillation after mitral valve surgery and concomitant Cox-maze IV procedure. In total, 397 patients with symptomatic degenerative mitral valve insuffciency and atrial fibrillation, underwent mitral valve surgery and Cox-maze IV in Sweden between 2009 and 2017. In this retrospective nationwide analysis, patients were followed in national patient registers until 30 September 2022. There were 4 deaths within 30 days (1.0%). Mean follow-up was 8.7 (0.1-13.4) years. Survival without ischaemic stroke or cerebral haemorrhage at 5 and 10 years were 90% and 74%, respectively. Nineteen patients experienced an ischaemic stroke, of which 4 were fatal. Five of 34 patients (14.7%) with a history of stroke preoperatively experienced ischaemic stroke during follow-up. The linearized rate of ischaemic stroke per patient-year was 0.6% and was similar regardless of left atrial appendage closure during surgery or whether a mechanical valve was inserted. The observed ischaemic stroke rate was lower than the predicted rate for all CHA2DS2-VASc score groups. Fourteen patients suffered cerebral bleeding, of which 3 were fatal. Patients who experienced cerebral bleeding were older and had higher mechanical valve implantation rate than those without cerebral bleeding. Surgery for mitral valve insufficiency and concomitant Cox-maze IV can be performed with low perioperative risk. There is a low continuing risk of stroke long-term postoperatively that correlates with a higher CHA2DS2-VASc score. Patients with preoperative stroke are at increased risk of postoperative stroke despite atrial fibrillation surgery.

Role of anticoagulation therapy in modifying stroke risk associated with new-onset atrial fibrillation after non-cardiac surgery.

The role of antithrombotic therapy in the prevention of ischemic stroke after non-cardiac surgery is unclear. In this study, we tested the hypothesis that the association of new-onset postoperative atrial fibrillation (POAF) on ischemic stroke can be mitigated by postoperative oral anticoagulation therapy. Of 251,837 adult patients (155,111 female (61.6%) and 96,726 male (38.4%)) who underwent non-cardiac surgical procedures at two sites, POAF was detected in 4,538 (1.8%) patients. The occurrence of POAF was associated with increased 1-year ischemic stroke risk (3.6% versus 2.3%; adjusted risk ratio (RRadj) = 1.60 (95% confidence interval (CI): 1.37-1.87), P < 0.001). In patients with POAF, the risk of developing stroke attributable to POAF was 1.81 (95% CI: 1.44-2.28; P < 0.001) without oral anticoagulation, whereas, in patients treated with anticoagulation, no significant association was observed between POAF and stroke (RRadj = 1.04 (95% CI: 0.71-1.51), P = 0.847, P for interaction = 0.013). Furthermore, we derived and validated a computational model for the prediction of POAF after non-cardiac surgery based on demographics, comorbidities and procedural risk. These findings suggest that POAF is predictable and associated with an increased risk of postoperative ischemic stroke in patients who do not receive postoperative anticoagulation.

The impact of preoperative four-chamber strain on failure of the maze IV procedure for atrial fibrillation: insights from conventional and speckle-tracking echocardiography

Abstract Background Prior studies have linked decreased left atrial (LA) and left ventricular (LV) function to the failure of both catheter ablation and surgery for atrial fibrillation (AF). Yet, the effects of right atrial (RA) and right ventricular (RV) function on the failure of interventional therapy remain unexplored. This study evaluates four-chamber strain parameters using conventional echocardiography and speckle-tracking analysis to evaluate the contributions of preoperative left heart and right heart function to the failure of surgery for atrial fibrillation. Methods We retrospectively analyzed 821 patients who had surgical AF ablation, using pre- and postoperative data from electronic records to assess AF recurrence and thromboembolic events. Of these, 531 had LA ablation only and 290 had bi-atrial Maze-IV procedures. Four-chamber strain was evaluated via speckle-tracking on preoperative echos with TomTec Arena, excluding low-quality images. Univariate and multivariate logistic regression analyses were conducted to assess the influence of AF duration, LV ejection fraction, age, and gender on post-PAF surgery AF recurrence, thromboembolic events with results shown as odds ratios (ORs) in the table. An OR over 1.00 indicates a higher recurrence risk per variable increment. SAS software was used for all statistical analysis. Results In our cohort with a median age of 67.4±11.0 (46.2% female), unadjusted analyses revealed that increased LA and RA volumes and decreased RV free wall strain were significantly associated with AF recurrence post-surgical ablation. Conversely, each unit decrease in LA and RA peak reservoir strain corresponded to a 6% increase in the risk of AF recurrence, indicating an inverse relationship. Adjusted analyses for LA and RA end diastolic volumes and strain values showed a similar direction of association with AF recurrence, though these were not statistically significant. Similarly, lower LA and RA peak strains and larger atrial volumes were suggestive of an increased risk for postoperative thromboembolic stroke, but did not reach statistical significance, potentially due to the low event rate (1.8% of the cohort). Conclusion Conventional echocardiography offers a practical tool for identifying patients at high risk for AF recurrence and potential thromboembolic events after AF ablation surgery. Our study confirms that reduced preoperative LA, RA and RV strain values and enlarged volumes of LA and RA are strongly associated with AF recurrence following surgical ablation. Additionally, RA strain and volume are as predictive as LA metrics, underscoring their importance in risk stratification. These echocardiographic parameters may also hold value in forecasting the likelihood of postoperative stroke.

Adverse outcomes after surgery after a cerebrovascular accident or acute coronary syndrome: a retrospective observational cohort study

BackgroundDelaying surgery after a major cardiovascular event might reduce adverse postoperative outcomes. The time interval represents a potentially modifiable risk factor but is not well studied. MethodsThis was a longitudinal retrospective population-based cohort study, linking data from Hospital Episode Statistics for NHS England and the Myocardial Ischaemia National Audit Project. Adults undergoing noncardiac, non-neurologic surgery in 2007–2018 were included. The time interval between a preoperative cardiovascular event and surgery was the main exposure. The outcomes of interest were acute coronary syndrome (ACS), acute myocardial infarction (AMI), cerebrovascular accident (CVA) within 1 year of surgery, unplanned readmission (at 30 days and 1 year), and prolonged length of stay. Multivariable logistic regression models with restricted cubic splines were used to estimate adjusted odds ratios (aORs; age, sex, socioeconomic deprivation, and comorbidities). ResultsIn total, 877 430 people had a previous cardiovascular event and 20 582 717 were without an event. CVA, ACS, and AMI in the year after elective surgery were more frequent after prior cardiovascular events (adjusted hazard ratio 2.12, 95% confidence interval [CI] 2.08–2.16). Prolonged hospital stay (aOR 1.36, 95% CI 1.35–1.38) and 30-day (aOR 1.28, 95% CI 1.25–1.30) and 1-yr (aOR 1.60, 95% CI 1.58–1.62) unplanned readmission were more common after major operations in those with a prior cardiovascular event. After adjusting for the time interval between preoperative events until surgery, elective operations within 37 months were associated with an increased risk of postoperative ACS or AMI. The risk of postoperative stroke plateaued after a 20-month interval until surgery, irrespective of surgical urgency. ConclusionsThese observational data suggest increased adverse outcomes after a recent cardiovascular event can occur for up to 37 months after a major cardiovascular event.

Influence of implant strategy on the transition from temporary left ventricular assist device to durable mechanical circulatory support.

Bridging from a temporary microaxial left ventricular assist device (tLVAD) to a durable left ventricular assist device (dLVAD) is playing an increasing role in the treatment of terminally ill patients with heart failure. Scant data exist about the best implant strategy. The goal of this study was to analyse differences in the dLVAD implant technique and effects on patient outcomes. Data from 341 patients (19 European centres) who underwent a bridge-to-bridge implant from tLVAD to dLVAD between January 2017 and October 2022 were retrospectively analysed. The outcomes of the different implant techniques with the patient on cardiopulmonary bypass, extracorporeal life support or tLVAD were compared. A durable LVAD implant was performed employing cardiopulmonary bypass in 70% of cases (n = 238, group 1), extracorporeal life support in 11% (n = 38, group 2) and tLVAD in 19% (n = 65, group 3). Baseline characteristics showed no significant differences in age (P = 0.140), body mass index (P = 0.388), creatinine level (P = 0.659), the Model for End-Stage Liver Disease (MELD) score (P = 0.190) and rate of dialysis (P = 0.110). Group 3 had significantly fewer patients with preoperatively invasive ventilation and cardiopulmonary resuscitation before the tLVAD was implanted (P = 0.009 and P < 0.001 respectively). Concomitant procedures were performed more often in groups 1 and 2 compared to group 3 (24%, 37% and 5%, respectively, P < 0.001). The 30-day mortality data showed significantly better survival after an inverse probability of treatment weighting in group 3, but the 1-year mortality showed no significant differences among the groups (P = 0.012 and 0.581, respectively). Postoperative complications like the rate of right ventricular assist device (RVAD) implants or re-thoracotomy due to bleeding, postoperative respiratory failure and renal replacement therapy showed no significant differences among the groups. Freedom from the first adverse event like stroke, driveline infection or pump thrombosis during follow-up was not significantly different among the groups. Postoperative blood transfusions within 24 h were significantly higher in groups 1 and 2 compared to surgery on tLVAD support (P < 0.001 and P = 0.003, respectively). In our analysis, the transition from tLVAD to dLVAD without further circulatory support did not show a difference in postoperative long-term survival, but a better 30-day survival was reported. The implant using only tLVAD showed a reduction in postoperative transfusion rates, without increasing the risk of postoperative stroke or pump thrombosis. In this small cohort study, our data support the hypothesis that a dLVAD implant on a tLVAD is a safe and feasible technique in selected patients.

Outcomes of Surgical Versus Transcatheter Aortic Valve Replacement in Obese Patients: A Systematic Review and Meta-Analysis.

Transcatheter aortic valve implantation (TAVI) has been increasingly preferred over surgical aortic valve replacement (SAVR) for treating patients with severe aortic stenosis and intermediate to high surgical risk. Recent studies have indicated that obesity may confer protective benefits in cardiac surgery, known as the obesity paradox. We conducted a systematic review and meta-analysis to explore how obesity influences outcomes of TAVI versus SAVR. We searched and reviewed relevant studies comparing TAVI and SAVR in obese patients with aortic stenosis indexed in PubMed, Embase, and Scopus databases. Data from 5 studies with 16,161 patients (TAVI, n = 2951; SAVR, n = 13,210) were included. There was a lower incidence of postprocedural in-hospital mortality [risk ratio (RR), 0.64; 95% confidence interval (CI), 0.41-0.98; P = 0.04], acute kidney injury (RR, 0.53; 95% CI, 0.38-0.73; P = 0.0001), and shorter duration of in-hospital stay (mean difference: -3.35; 95% CI, -4.93 to -1.76; P = 0.0001) in TAVI versus SAVR. There was no significant difference in the risk of postoperative stroke (RR, 0.93; 95% CI, 0.29-3.02; P = 0.91), major bleeding (RR, 0.71; 95% CI, 0.47-1.07; P = 0.10), and myocardial infarction (RR, 0.64; 95% CI, 0.39-1.06; P = 0.08) between TAVI and SAVR. Higher incidences of PPM implantation (RR, 2.0; 95% CI, 1.38-2.90; P = 0.0003) and major vascular complications (RR, 1.51; 95% CI, 1.01-2.27; P = 0.05) were observed with TAVI. In obese patients, TAVI offers similar results as in the general population when compared with SAVR, except for increased vascular complications. An individualized approach can lead to optimal outcomes in this subpopulation.

A systematic review and meta-analysis of differences between men and women in short-term outcomes following coronary artery bypass graft surgery

We provide an update regarding the differences between men and women in short-term postoperative mortality after coronary artery bypass grafting (CABG) and highlight the differences in postoperative risk of stroke, myocardial infarction, and new onset atrial fibrillation. We included 23 studies, with a total of 3,971,267 patients (70.7% men, 29.3% women), and provided results for groups of unbalanced studies and propensity matched studies. For short-term mortality, the pooled odds ratio (OR) from unbalanced studies was 1.71 (with 95% CI 1.69–1.74, I2 = 0%, p = 0.7), and from propensity matched studies was 1.32 (95% CI 1.14–1.52, I2 = 76%, p < 0.01). For postoperative stroke, the pooled effects were OR = 1.50 (95% CI 1.35–1.66, I2 = 83%, p < 0.01) and OR = 1.31 (95% CI 1.02–1.67, I2 = 81%, p < 0.01). For myocardial infarction, the pooled effects were OR = 1.09 (95% CI = 0.78–1.53, I2 = 70%, p < 0.01) and OR = 1.03 (95% CI = 0.86–1.24, I2 = 43%, p = 0.18). For postoperative atrial fibrillation, the pooled effect from unbalanced studies was OR = 0.89 (95% CI = 0.82–0.96, I2 = 34%, p = 0.18). The short-term mortality risk after CABG is higher in women, compared to men. Women are at higher risk of postoperative stroke. There is no significant difference in the likelihood of postoperative myocardial infarction in women compared to men. Men are at higher risk of postoperative atrial fibrillation after CABG.

Survival and early outcomes following lung transplantation for interstitial lung disease associated with non-scleroderma connective tissue disease: a national cohort study.

The progressive decline in interstitial lung disease associated with non-scleroderma connective tissue disease (ILD-NSCTD) is linked to poor prognosis and frequently results in respiratory failure. Lung transplantation (LTx) offers a viable treatment option, yet its outcomes in ILD-NSCTD remain contentious, particularly across different subtypes. This retrospective cohort study included patients with idiopathic pulmonary fibrosis (IPF) (n=11,610) and ILD-NSCTD (n=610) listed in the United Network for Organ Sharing (UNOS) database who underwent lung transplantation between May 5, 2005, and December 31, 2022. We used the Kaplan-Meier method to evaluate cumulative survival rates and logistic regression to assess the risk of post-operative complications. Compared to IPF patients, those with ILD-NSCTD are generally younger, with a lower proportion of male and white patients. After propensity matching, overall survival rates remained similar between the groups (log-rank, p=0.953). However, ILD-NSCTD was associated with a significantly higher risk of post-operative stroke (adjusted OR 1.75, 95% CI 1.12-2.74, p=0.015) and longer post-operative hospital stays (p<0.001). Subgroup analyses yielded consistent results. Finally, infection was identified as the leading cause of death. Compared to IPF, patients with ILD-NSCTD have a significantly higher risk of post-operative stroke and extended hospital stays, potentially due to complications inherent to ILD-NSCTD. However, the underlying causes of these outcomes remain unclear. Despite these differences, short-term and long-term survival rates are comparable between the two groups, with consistent findings across various ILD-NSCTD subgroups. Therefore, ILD-NSCTD should not be regarded as a relative contraindication for lung transplantation. Nonetheless, the influence of extra-pulmonary complications in ILD-NSCTD patients requires further investigation.

Sex as a Predictor of Outcomes for Symptomatic Carotid Stenosis: A Comparative Analysis between CAS and CEA.

Reporting gender-related outcomes for symptomatic carotid lesion revascularization after both endarterectomy (CEA) and carotid artery stenting (CAS) procedures in an unselected group of patients treated by Italian Vascular Specialists. A retrospective study was conducted on patients presenting with recently symptomatic carotid stenosis treated by CAS and by CEA. The primary endpoint was the 30 days any stroke occurrence rate; secondary endpoints were technical success, occurrence of transient ischemic attack (TIA), acute myocardial infarction (AMI) and death. Demographic, clinical and procedural data were all noted in order to identify the outcome's determining factor. A total of 265 patients (193 males and 72 females) were enrolled, and of these 134 (50.5%) underwent CEA and 131 CAS (49.5%). At 30 days, the overall new stroke rate was 3.4% (one fatal), and no TIA, AMI or deaths were observed. Among strokes, seven major and two minor strokes were reported, with six after CEA and three after CAS (p = 0.32; OR: 2; CI95%: 0.48-8.17). The timing of revascularization has been found to be slightly associated with new stroke occurrence: seven out nine strokes were observed in patients treated within 14 days from symptom onset (5.5% vs. 1.4%; p = 0.08, OR: 3.8, CI95%: 0.77-18.56). Lastly, female patients presented a significantly higher risk of post-operative stroke compared to male patients: 6.9% vs. 2.1% (p: 0.05; OR: 3.52; CI95%: 0.91-13.52). Our experience seems to suggest that both CEA and CAS provide safe and effective results in treating patients presenting with symptomatic carotid stenosis. Regardless of the type of revascularization, female sex is an independent risk factor for stroke recurrence after treatment.

Early Valve Surgery for Endocarditis After Acute Embolic Stroke

BackgroundPatients with active endocarditis often suffer acute stroke, with increased risk for hemorrhagic conversion at the time of valve repair or replacement. Controversy persists about timing of operative intervention. MethodsAn institutional Society of Thoracic Surgeons database of all patients with endocarditis was reviewed for patients undergoing valve surgery (2016-2024). Electronic medical records were reviewed for detailed stroke information and longitudinal follow-up. Descriptive statistics and Kaplan-Meier survival curves evaluated outcomes and survival. ResultsOperations for acute active infective endocarditis were performed in 656 patients. Preoperative stroke occurred in 98 patients (14.9%); 86 strokes (87.8%) were embolic, and 16 patients (18.6%) had microhemorrhagic and 12 (12.2%) had hemorrhagic strokes. Median time between preoperative stroke diagnosis and surgery was 5.5 days. The overall incidence of postoperative stroke was 2.1% (14 of 656), with no statistically significant difference in postoperative stroke between patients with vs without preoperative stroke (n = 4 of 98 [4.1%] vs n = 10 of 558 [1.8%]; P = .148). However, the proportion of patients with postoperative hemorrhagic strokes was higher in the preoperative stroke group (3.1% vs 0.5%, P = .016). Finally, of patients with preoperative stroke, early surgery ≤72 hours (n= 38 [38.8%]) was not associated with increased stroke (2.6% vs 5.0%, P = .564). ConclusionsThese contemporary data highlight the feasibility of an early valve surgery strategy for acute endocarditis in the setting of acute stroke, with noninferior postoperative stroke risk.

Complications and Mortality After Surgery in Patients with Chronic Kidney Disease: A Retrospective Cohort Study Based on a Multicenter Clinical Database.

To evaluate the postoperative complications and mortality among patients with chronic kidney disease. Biochemical measurements, diagnosis codes for CKD and comorbid conditions for surgical patients aged ≥20 years were obtained from electronic medical records of three large hospitals in Taiwan in 2009-2017. We conducted this retrospective cohort study by using propensity score-matching methods to balance the baseline characteristics between CKD and non-CKD groups. The multiple logistic regression analysis was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of risks of primary outcome (included postoperative mortality) and secondary outcome (included postoperative infectious complications and non-infectious complications) associated with CKD. Among 31950 eligible surgical patients, the adjusted OR of in-hospital mortality in patients with CKD was 5.49 (95% CI 3.42-8.81) compared with that in non-CKD controls. The adjusted ORs of postoperative septicemia, pneumonia and cellulitis in patients with CKD were 5.90 (95% CI 2.12-16.5), 5.39 (95% CI 1.37-21.16), and 4.42 (95% CI 1.57-12.4), respectively, when compared with the non-CKD patients. CKD was also associated with postoperative stroke (OR 2.21, 95% CI 1.47-3.31). Patients with CKD are at increased risk of postoperative stroke, infectious complications, and mortality. Our study implicated that it is crucial to improve the levels of hemoglobin and K+ in patients with CKD before surgery. Preventive strategies should be developed to improve clinical outcomes in these populations.

Perioperative care of patients with recent stroke undergoing nonemergent, nonneurological, noncardiac, nonvascular surgery: a systematic review and meta-analysis.

To systematically review and perform a meta-analysis of published literature regarding postoperative stroke and mortality in patients with a history of stroke and to provide a framework for preoperative, intraoperative, and postoperative care in an elective setting. Patients with nonneurological, noncardiac, and nonvascular surgery within three months after stroke have a 153-fold risk, those within 6 months have a 50-fold risk, and those within 12 months have a 20-fold risk of postoperative stroke. There is a 12-fold risk of in-hospital mortality within three months and a three-to-four-fold risk of mortality for more than 12 months after stroke. The risk of stroke and mortality continues to persist years after stroke. Recurrent stroke is common in patients in whom anticoagulation/antiplatelet therapy is discontinued. Stroke and time elapsed after stroke should be included in the preoperative assessment questionnaire, and a stroke-specific risk assessment should be performed before surgical planning is pursued. In patients with a history of a recent stroke, anesthesiology, surgery, and neurology experts should create a shared mental model in which the patient/surrogate decision-maker is informed about the risks and benefits of the proposed surgical procedure; secondary-stroke-prevention medications are reviewed; plans are made for interruptions and resumption; and intraoperative care is individualized to reduce the likelihood of postoperative stroke or death.

Incidence and Risk Factors for Stroke After Combined Heart-Kidney and Heart-Liver Transplantation.

While stroke is a well-recognized complication of isolated heart transplantation, stroke in patients undergoing simultaneous heart-liver (HLT) and heart-kidney transplantation (HKT) has not been explored. This study assessed postoperative stroke incidence, risk factors, and outcomes in HLT and HKT compared with isolated heart transplant. The United Network for Organ Sharing database was queried for adult patients undergoing HLT, HKT, and isolated heart transplants between 1994 and 2022. Patients were stratified by presence of in-hospital stroke after transplant. Post-transplant survival at 1-year was assessed using Kaplan-Meier analysis and log-rank tests. Separate multivariable logistic regression models were constructed to identify risk factors for stroke after HKT and HLT. Of 2326 HKT recipients, 85 experienced stroke, and of 442 HLT recipients, 19 experienced stroke. Stroke was more common after HKT and HLT than after an isolated heart transplant (3.7% vs. 4.3% vs. 2.9%, p=0.01). One-year post-transplant survival was lower in those with stroke among both HKT recipients (64.5% vs. 88.7%, p(log-rank)<0.001) and HLT recipients (43.8% vs. 87.4%, p(log-rank)<0.001. Pre-transplant pVAD, prior stroke, postoperative dialysis, diabetes, prior cardiac surgery, and heart cold ischemic time were independent risk factors for stroke after HKT, after adjusting for age, sex, and need for blood transfusion on the waitlist. For HLT, postoperative dialysis was a significant risk factor. Stroke is more common after HKT and HLT than after isolated heart transplant, and results in poor survival. Independent risk factors for stroke include pre-transplant percutaneous VAD (HKT) and postoperative dialysis (HKT and HLT).

Hemoglobin Drop is Associated with Early Post-operative Stroke Following Revascularization Surgery for Moyamoya Disease.

Postoperative stroke is a potentially devastating neurological complication following surgical revascularization for Moyamoya disease. We sought to evaluate whether peri-operative hemoglobin levels were associated with the risk of early post-operative stroke following revascularization surgery in adult Moyamoya patients. Adult patients having revascularization surgeries for Moyamoya disease between 1999-2022 were identified through single institutional retrospective review. Logistic regression analysis was used to test for the association between hemoglobin drop and early postoperative stroke. In all, 106 revascularization surgeries were included in the study. A stroke occurred within 7 days after surgery in 9.4% of cases. There were no significant associations between the occurrence of an early postoperative stroke and patient age, gender, or race. Mean postoperative hemoglobin drop was greater in patients who suffered an early postoperative stroke compared with patients who did not (2.3±1.1g/dL vs. 1.3±1.1g/dL, respectively; P=0.034). Patients who experienced a hemoglobin drop post-operatively had 2.03 times greater odds (95% confidence interval, 1.06-4.23; P=0.040) of having a stroke than those whose hemoglobin levels were stable. Early postoperative stroke was also associated with an increase in length of hospital stay (P<0.001), discharge to a rehabilitation facility (P=0.014), and worse modified Rankin scale at 1 month (P=0.001). This study found a significant association between hemoglobin drop and early postoperative stroke following revascularization surgery in adult patients with Moyamoya disease. Based on our findings, it may be prudent to avoid hemoglobin drops in Moyamoya patients undergoing surgical revascularization.

Machine learning-based models for prediction of the risk of stroke in coronary artery disease patients receiving coronary revascularization.

To construct several prediction models for the risk of stroke in coronary artery disease (CAD) patients receiving coronary revascularization based on machine learning methods. In total, 5757 CAD patients receiving coronary revascularization admitted to ICU in Medical Information Mart for Intensive Care IV (MIMIC-IV) were included in this cohort study. All the data were randomly split into the training set (n = 4029) and testing set (n = 1728) at 7:3. Pearson correlation analysis and least absolute shrinkage and selection operator (LASSO) regression model were applied for feature screening. Variables with Pearson correlation coefficient<9 were included, and the regression coefficients were set to 0. Features more closely related to the outcome were selected from the 10-fold cross-validation, and features with non-0 Coefficent were retained and included in the final model. The predictive values of the models were evaluated by sensitivity, specificity, area under the curve (AUC), accuracy, and 95% confidence interval (CI). The Catboost model presented the best predictive performance with the AUC of 0.831 (95%CI: 0.811-0.851) in the training set, and 0.760 (95%CI: 0.722-0.798) in the testing set. The AUC of the logistic regression model was 0.789 (95%CI: 0.764-0.814) in the training set and 0.731 (95%CI: 0.686-0.776) in the testing set. The results of Delong test revealed that the predictive value of the Catboost model was significantly higher than the logistic regression model (P<0.05). Charlson Comorbidity Index (CCI) was the most important variable associated with the risk of stroke in CAD patients receiving coronary revascularization. The Catboost model was the optimal model for predicting the risk of stroke in CAD patients receiving coronary revascularization, which might provide a tool to quickly identify CAD patients who were at high risk of postoperative stroke.

Abstract WP226: Perioperative Stroke and Cardiac Anomalies Associated With Posterior Cerebral Artery Stenosis in Children With Moyamoya

Introduction: Moyamoya is a progressive steno-occlusive arteriopathy of the intracranial circulation affecting the anterior circulation and less often the posterior circulation. Risk factors and severity of disease progression in children with moyamoya and posterior cerebral artery (PCA) stenosis have not been well described in the literature. Previous research has shown an association between PCA stenosis and increased risk of post-operative stroke. We wanted to further explore this relationship in children with moyamoya and delineate the associated risk factors. Methods: Children with moyamoya who underwent surgical revascularization at our institution between December 2015 and December 2022 were reviewed for presence of PCA stenosis. Clinical and radiographic features were compared between children with moyamoya with and without PCA involvement. Categorical variables were compared using Fisher's exact test and continuous variables using Wilcoxon rank-sum. Associations between perioperative stroke and PCA stenosis were analyzes using a multivariate logistic regression. Results: In our cohort of 160 children with moyamoya, 45 (28%) had PCA stenosis; 26 of these 45 (57%) had PCA stenosis at time of diagnosis. Of the 19 children who did not have PCA stenosis at time of diagnosis but developed it during follow up, the median time to development of PCA stenosis was 1.0 years. Children with moyamoya and PCA stenosis had significant more cardiac anomalies than those without (p=0.02). Other associated disorders were found in 13 (28%) including trisomy 21 (6, 13%), cranial radiation (2,4%) and NF1 (3,7%). Interestingly, we found no significant difference in age, sex or prevalence of bilateral disease between the groups. Children with moyamoya and PCA stenosis had a 3.5 higher odds of having a stroke within 2 weeks of surgery (p=0.049). Conclusion: Children with moyamoya and PCA stenosis had a 3 fold higher odds of perioperative stroke compared to those without PCA stenosis. Genetic evaluations may be warranted given association of PCA stenosis and cardiac anomalies.