Association of Timing of SAVR After Stroke

Study Questions:

What is the association of time elapsed between previous stroke and SAVR with the risk of recurrent perioperative stroke, major adverse cardiovascular events (MACE), and mortality among patients with aortic valve stenosis?

Methods:

The investigators conducted a cohort study using data from Danish administrative registries that included all patients with aortic valve stenosis >18 years old, who underwent SAVR between 1996 and 2014 (n = 14,030). Patients who received simultaneous mitral, tricuspid, or pulmonary valve surgery and patients with endocarditis 1 year prior to surgery were excluded. Data were analyzed from March 2017 to January 2018, and time elapsed between prior stroke and SAVR (<3 months, 3 to <12 months, ≥12 months, and no prior stroke). The main outcome measures were 30-day risks of MACE, ischemic stroke, and all-cause mortality reported as absolute events and multivariable adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Restricted cubic spline regression models were additionally applied on the subgroup with prior stroke.

Results:

Of the 14,030 patients, 616 (190 [30.8%] women; mean [standard deviation] age, 72.0 [9.1] years) with prior stroke underwent surgery, and 13,414 (4,837 [36.1%] women; mean age, 69.8 [10.8] years) without prior stroke underwent surgery. The absolute risk of ischemic stroke was significantly increased in patients with stroke <3 months prior to surgery compared with patients with no prior stroke (18.4% [37 of 201] vs. 1.2% [160 of 13,219]; odds ratio, 14.69; 95% CI, 9.69-22.27). Likewise, compared with patients without stroke, patients with stroke <3 months prior to surgery were at significantly increased risk of MACE (23.3% [53 of 227] vs. 5.7% [768 of 13,414]; OR, 4.57; 95% CI, 3.24-6.44), but not all-cause mortality (6.8% [50 of 730] vs. 3.6% [374 of 10,370]; OR, 1.45; 95% CI, 0.83-2.54). Spline analyses supported a declining risk over time, reaching nadir after 2-4 months.

Conclusions:

The authors concluded that previous stroke is a major risk factor of recurrent ischemic stroke and MACE in patients undergoing SAVR.

Perspective:

This study reports that patients with recent stroke (i.e., within 3 months) had markedly heightened risk of recurrent stroke during surgery, and the risk declined with time. Furthermore, the risk of recurrent stroke declines with time and reaches a nadir after approximately 4 months. These data suggest that postponement of SAVR for at least 3-4 months after a stroke, if possible, may reduce the risk of recurrent stroke during surgery. As this is an observational study, additional prospective studies are indicated to confirm these findings. For now, it seems reasonable to avoid aortic valve surgery or any surgery within the first 3 months after a stroke unless the procedure is urgent or emergent and delaying would be harmful to the patient.

Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Aortic Valve Stenosis, Brain Ischemia, Cardiac Surgical Procedures, Geriatrics, Heart Valve Diseases, Heart Valve Prosthesis, Outcome Assessment (Health Care), Secondary Prevention, Risk Factors, Stroke, Transcatheter Aortic Valve Replacement, Vascular Diseases


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