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Stroke debility during non-full sternotomy versus full sternotomy access cardiac valve operations
Ahmad S Abdelrazek1, Kevin L Greason1, Alex Lee2
1Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
Insights
Cardiac valve operations using partial sternotomy increase stroke risk compared to full sternotomy, though most strokes are mild. Thoracotomy does not show increased stroke risk. Stroke risk remains low overall.
Area of Science:
- Cardiovascular Surgery
- Neurosurgery
- Clinical Outcomes Research
Background:
- Previous studies suggest a higher stroke risk with non-full sternotomy in cardiac valve operations.
- The clinical impact and severity of these strokes remain underexplored.
Purpose of the Study:
- To determine the incidence and clinical significance of postoperative stroke after cardiac valve operations.
- To compare stroke risk between full sternotomy, partial sternotomy, and thoracotomy access methods.
Main Methods:
- Analysis of 12,406 patients undergoing cardiac valve operations (Jan 1997-Mar 2021).
- Access methods included full median sternotomy (88%), partial sternotomy (1.8%), and thoracotomy (11%).
- Stroke was assessed using the modified Rankin Scale (mRS) at discharge; multivariable logistic regression analyzed stroke risk.
Main Results:
- Stroke rates were 1.0% (full sternotomy), 2.7% (partial sternotomy), and 1.2% (thoracotomy) (P=.044).
- Partial sternotomy significantly increased stroke risk versus full sternotomy (OR 3.73, P=.010).
- Thoracotomy did not show a significant increase in stroke risk versus full sternotomy (OR 1.34). Most strokes were mild (mRS ≤2, 62%). Stroke-related mortality was low (1.3%).
Conclusions:
- Partial sternotomy is associated with an increased risk of stroke compared to full sternotomy.
- Thoracotomy access for cardiac valve operations is not associated with an increased stroke risk.
- The overall risk of stroke is low, with the majority of strokes resulting in mild disability.
Objective:
Previous studies have reported an increased risk of stroke with non-full sternotomy access during cardiac valve operations, but the clinical significance of these strokes has not yet been explored. We sought to determine the incidence and clinical magnitude of postoperative stroke following non-full versus full sternotomy access.
Methods:
We analyzed the records of 12,406 patients who underwent a cardiac valve operation with full median sternotomy (n = 10,863; 88%), partial sternotomy (n = 219; 1.8%), or thoracotomy (n = 1324; 11%) access between January 1997 and March 2021. The primary outcome was permanent stroke, categorized using the modified Rankin Scale (mRS; score 0-6) at discharge. Multivariable logistic regression analysis was used to assess the risk of stroke.
Results:
The rate of stroke was 1.0% in the full sternotomy group, 2.7% in the partial sternotomy group, and 1.2% in the thoracotomy group (P = .044). The majority of strokes were mildly disabling (mRS ≤2), both overall (n = 82; 62%) and in each group (range, 60%-69%). There was an increased risk of stroke with partial versus full sternotomy (odds ratio [OR], 3.73; 95% confidence interval [CI], 1.59-8.78; P = .010) but not with thoracotomy versus full sternotomy (OR, 1.34; 95% CI, 0.48-3.77). There was no differential effect of sternotomy type on stroke risk according to type of valve operation (P = .985). Stroke-related mortality was uncommon (1.3%).
Conclusions:
Partial sternotomy versus full sternotomy is associated with increased risk of stroke, whereas thoracotomy versus full sternotomy is not. The risk of stroke is low, with most strokes being only mildly disabling.
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