Stroke After Aortic Valve Surgery: Results From a Prospective Cohort

• Published in: Circulation (New York, N.Y.) Vol. 129; no. 22; pp. 2253 - 2261
• Main Authors: Messé, Steven R, Acker, Michael A, Kasner, Scott E, Fanning, Molly, Giovannetti, Tania, Ratcliffe, Sarah J, Bilello, Michel, Szeto, Wilson Y, Bavaria, Joseph E, Hargrove, W Clark, Mohler, Emile R, Floyd, Thomas F, Giovanetti, Tania, Matthai, William H, Morris, Rohinton J, Pochettino, Alberto A, Price, Catherine E C, Selnes, Ola A, Woo, Y Joseph, Desai, Nimesh D, Augostides, John G, Cheung, Albert T, Hanson, C William, Horak, Jiri, Kohl, Benjamin A, Kukafka, Jeremy D, Levy, Warren J, Mickler, Thomas A, Milas, Bonnie L, Savino, Joseph S, Vernick, William J, Weiss, Stuart J
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD by the American College of Cardiology Foundation and the American Heart Association, Inc 03-06-2014; Lippincott Williams & Wilkins
• Subjects: Aged; Aged, 80 and over; Aortic Valve - surgery; Aortic Valve Stenosis - surgery; Biological and medical sciences; Blood and lymphatic vessels; Cardiology. Vascular system; Cohort Studies; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Female; Heart Valve Prosthesis Implantation - adverse effects; Hospital Mortality; Humans; Incidence; Length of Stay - statistics & numerical data; Magnetic Resonance Imaging; Male; Medical sciences; Neurology; Prospective Studies; Retrospective Studies; Severity of Illness Index; Stroke - epidemiology; Stroke - mortality; Stroke - pathology; Vascular diseases and vascular malformations of the nervous system; Nervous system diseases; Stroke; magnetic resonance imaging; Cardiovascular disease; Heart valve; Nuclear magnetic resonance imaging; Cerebral disorder; Result; Vascular disease; Prospective; surgical procedures; Treatment; Surgery; Cohort study; Central nervous system disease; Medical imagery; Procedure; Circulatory system; Cardiology; Aortic valve; Cerebrovascular disease; Public health; aortic valve; stroke
• ISSN: 0009-7322; 1524-4539
• DOI: 10.1161/CIRCULATIONAHA.113.005084

BACKGROUND—The incidence and impact of clinical stroke and silent radiographic cerebral infarction complicating open surgical aortic valve replacement (AVR) are poorly characterized.
METHODS AND RESULTS—We performed a prospective cohort study of subjects ≥65 years of age who were undergoing AVR for calcific aortic stenosis. Subjects were evaluated by neurologists preoperatively and postoperatively and underwent postoperative magnetic resonance imaging. Over a 4-year period, 196 subjects were enrolled at 2 sites (mean age, 75.8±6.2 years; 36% women; 6% nonwhite). Clinical strokes were detected in 17%, transient ischemic attack in 2%, and in-hospital mortality was 5%. The frequency of stroke in the Society for Thoracic Surgery database in this cohort was 7%. Most strokes were mild; the median National Institutes of Health Stroke Scale was 3 (interquartile range, 1–9). Clinical stroke was associated with increased length of stay (median, 12 versus 10 days; P=0.02). Moderate or severe stroke (National Institutes of Health Stroke Scale ≥10) occurred in 8 (4%) and was strongly associated with in-hospital mortality (38% versus 4%; P=0.005). Of the 109 stroke-free subjects with postoperative magnetic resonance imaging, silent infarct was identified in 59 (54%). Silent infarct was not associated with in-hospital mortality or increased length of stay.
CONCLUSIONS—Clinical stroke after AVR was more common than reported previously, more than double for this same cohort in the Society for Thoracic Surgery database, and silent cerebral infarctions were detected in more than half of the patients undergoing AVR. Clinical stroke complicating AVR is associated with increased length of stay and mortality.