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Decreasing incidence of stroke during valvular surgery
M A Borger1, J Ivanov, R D Weisel
1Division of Cardiovascular Surgery, Toronto Hospital, Ontario, Canada.
Insights
Stroke incidence during valvular surgery decreased over 15 years, despite rising risk factors. Key predictors include endocarditis, advanced age, and urgent procedures, suggesting causes like emboli and shock.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Public Health
Background:
- Stroke following valvular surgery remains incompletely understood.
- Identifying stroke predictors and mechanisms is crucial for patient outcomes.
Purpose of the Study:
- To examine the incidence, predictors, and mechanisms of stroke during valvular procedures.
- To analyze stroke trends over a 15-year period.
Main Methods:
- Retrospective review of prospectively gathered data from 5954 patients (1982-1996).
- Stroke defined by persistent neurological deficit, often confirmed by CT imaging.
- Multivariable logistic regression used to identify independent predictors.
Main Results:
- Stroke incidence decreased from 3.8% (1982-1986) to 2.6% (1992-1996).
- Independent predictors: endocarditis, age >74, earlier operation period, urgent timing, concomitant coronary bypass, and reoperation.
- Increasing prevalence of older patients, urgent procedures, and bypass surgery noted in later years.
Conclusions:
- Stroke incidence during valvular surgery has declined over time.
- Despite increased risk factors, improved management or surgical techniques may explain the decrease.
- Major stroke causes identified: atherosclerotic emboli, shock, and septic emboli.
Background:
The predictors and causes of stroke after valvular surgery are incompletely defined. We examined the incidence, predictors, and mechanisms of stroke during valvular procedures over a 15-year time period.
Methods And Results:
We retrospectively reviewed prospectively gathered data on 5954 consecutive patients undergoing valvular procedures at our institution from 1982 to 1996. Stroke was defined as persistent central nervous system deficit, usually with confirmatory CT imaging. Patients were divided into 3 groups according to date of operation: group 1, 1982 to 1986 (n = 1819); group 2, 1987 to 1991 (n = 2022); and group 3, 1992 to 1996 (n = 2113). Chart review was undertaken of all patients who developed stroke (n = 189). Stroke occurred in 3.8% of group 1 patients, 3.3% of group 2, and 2.6% of group 3 (P = 0.120). The decreasing incidence of stroke over time was confirmed by multivariable logistic regression analysis, in which earlier date of operation was an independent risk factor for stroke (P < 0.001). Predictors of stroke identified by multivariable logistic regression were (listed in decreasing order): (1) endocarditis (OR, 3.0; 95% CI, 1.8 to 5.0); (2) age > 74 years (OR, 2.3; 95% CI, 1.5 to 3.7); (3) earlier time period of operation (1982 to 1986: OR, 2.2; 95% CI, 1.5 to 3.2; 1987 to 1991: OR, 1.5; 95% CI, 1.0 to 2.2); (4) urgent timing (OR, 2.0; 95% CI, 1.4 to 2.8); (5) concomitant coronary bypass (OR, 2.0; 95% CI, 1.4 to 2.8); and (6) reoperation (OR, 1.7; 95% CI, 1.2 to 2.4). In more recent years of operation, we found an increasing prevalence of age > 74 years (7.4% in group 1, 9.5% in group 2, and 15.3% in group 3; P < 0.001), urgent timing (11%, 26%, and 34%, P < 0.001), and concomitant coronary bypass surgery (25%, 27%, and 33%; P < 0.001).
Conclusions:
The incidence of stroke during valvular surgery has decreased with time, despite an increased prevalence of risk factors. Predictors of stroke suggest 3 major causes (multivariable predictors in parentheses): atherosclerotic emboli (elderly age, concomitant coronary bypass), shock (urgent timing, reoperation), and septic emboli (endocarditis).
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