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Observational Study
. 2014 Jun 3;129(22):2253-61.
doi: 10.1161/CIRCULATIONAHA.113.005084. Epub 2014 Apr 1.

Stroke after aortic valve surgery: results from a prospective cohort

Steven R Messé  1 , Michael A Acker  1 , Scott E Kasner  1 , Molly Fanning  1 , Tania Giovannetti  1 , Sarah J Ratcliffe  1 , Michel Bilello  1 , Wilson Y Szeto  1 , Joseph E Bavaria  1 , W Clark Hargrove 3rd  1 , Emile R Mohler 3rd  1 , Thomas F Floyd  2 ; Determining Neurologic Outcomes from Valve Operations (DeNOVO) Investigators
Collaborators, Affiliations
Observational Study

Stroke after aortic valve surgery: results from a prospective cohort

Steven R Messé et al. Circulation. .

Abstract

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.

Keywords: aortic valve; magnetic resonance imaging; stroke; surgical procedures.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr. Messé has served as a consultant (modest) for Glaxo Smith Kline and is receiving salary support as co-PI of a study of neuroprotection in high risk thoracic aortic repair sponsored by Glaxo Smith Kline.

Figures

Figure 1
Figure 1
A flow diagram of patients screened and enrolled in the study
Figure 2
Figure 2
Distribution of National Institutes of Stroke Scale (NIHSS) scores among patients with strokes reported in STS compared to those with strokes only in DeNOVO.
Figure 3
Figure 3
Distribution of total infarct volumes on MRI diffusion weighed imaging in mm3, excluding those without infarct present.
Figure 4
Figure 4
Examples of infarcts on MRI. A. Patient with 14 clinically silent infarcts totaling 3292mm3. B. Patient with 7 clinically silent infarcts totaling 2695mm3 (DSHE image is moderate subcortical infarct). C. Patient with a clinical stroke (NIHSS 15) and 34 infarcts totaling 12,033mm3. D. Patient with a clinical stroke (NIHSS 3) 6 small infarcts totaling 412mm3. E. Patient with a single clinically silent infarct measuring 766mm3. F. Patient with a clinical stroke (NIHSS 13) and 27 infarcts totaling 55,871mm3
See this image and copyright information in PMC

Comment in

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