Stroke after cardiac surgery: short- and long-term outcomes

doi:10.1016/S0003-4975(01)02929-0

The Annals of Thoracic Surgery

Volume 72, Issue 4, October 2001, Pages 1195-1201

https://doi.org/10.1016/S0003-4975(01)02929-0 Get rights and content

Abstract

Background. Stroke remains a devastating complication of cardiac surgery, but stroke prevention remains elusive. Evaluation of early and long-term clinical outcomes and brain-imaging findings may provide insight into stroke prognosis, etiology, and prevention.

Methods. Five thousand nine hundred seventy-one cardiac surgery patients were prospectively studied for clinical evidence of stroke. Stroke and nonstroke patients were compared by early outcomes. Data collected for stroke patients included brain imaging results, long-term functional status, and survival. Outcome predictors were then determined.

Results. Stroke was diagnosed in 214 (3.6%) patients. Brain imaging demonstrated acute infarction in 72%; embolic in 83%, and watershed in 24%. Survival for stroke patients was 67% at 1 year and 47% at 5 years. Independent predictors of survival were cerebral infarct type, creatinine elevation, cardiopulmonary bypass time, preoperative intensive care days, postoperative awakening time, and postoperative intensive care days. Long-term disability was moderate to severe in 69%.

Conclusions. Stroke after cardiac surgery has profound repercussions that are independently related to infarct type and clinical factors. These data are essential for clinical decision making and prognosis determination.

Section snippets

Material and methods

Over a 5.5-year period (January 1992 to July 1997) at the Johns Hopkins Hospital, 5,971 consecutive, adult cardiac surgery patients were followed prospectively for clinical evidence of stroke by one of two research clinicians (MAG, LMB). Data collected for all patients included demographic information, operative procedure, postoperative in-hospital outcomes, discharge disposition, and hospital charges. Patients with focal neurological deficits (motor weakness, dysphagia, aphasia, cognitive

Stroke incidence and early outcomes

Of the 5,971 patients evaluated in this study, 214 (3.6%) patients showed evidence of clinical stroke within the first 9 days after their operation. The presentation of clinical stroke occurred, on average, on postoperative day 0.86 ±1.84, with 74% (158 of 214) presenting on postoperative day 0 and 91% (195 of 214) within the first 3 postoperative days. The incidence of stroke by procedure type is listed in Table 1. Isolated procedures (eg, coronary artery bypass grafting [CABG]) were

Comment

The Johns Hopkins Hospital cardiac surgery stroke database provided a unique opportunity to study stroke in this population, given that all patients were followed prospectively. Failure to capture patients who suffered this complication was therefore minimized. An overall, clinically diagnosed stroke rate of 3.6% is consistent with previous reports 1, 3. Given that 74% of stroke patients were identified on the day of surgery and 91% were identified within the first 3 postoperative days, this

Acknowledgements

We would like to thank Drs Guy M. McKhann and Pamela Talalay for their assistance in the review of this manuscript. Special thanks to the CSICU nurses and staff who care for the cardiac surgical patients and provided assistance in data collection.

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Stroke and delirium occur more frequently after SAVR than is commonly recognized, and these events are associated with disability, depression, cognitive decline, and poorer quality of life at 90 days postoperatively. These findings support the need for new interventions to reduce these events and improve patient-centered outcomes.
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Patients with ICAS are 3.61 times more likely to develop stroke after cardiac surgery. Known predictors for ICAS can be used to develop risk stratification screening tools. Further research with diverse cohorts is required to develop evidence-based guidelines for screening and management of ICAS in cardiac surgery.
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Stroke remains a devastating complication after cardiac surgical procedures despite perioperative monitoring and management advances. This study aimed to determine the predictors of stroke in a large, contemporary coronary artery surgery population.
Patient data were analyzed retrospectively.
This single-center study was performed in the Catharina Hospital (Eindhoven).
All patients who underwent isolated coronary artery bypass grafting (CABG) between January 1998 and February 2019 were included.
Isolated CABG.
The primary endpoint was a postoperative stroke, defined according to the international updated definition for stroke. Logistic regression was performed to retrieve variables associated with postoperative stroke. A total of 20,582 patients underwent CABG during the period of the study. Stroke was observed in 142 patients (0.7%), of which 75 (52.8%) occurred during the first 72 hours. The incidence of postoperative stroke declined over the years. A significantly higher 30-day mortality rate was seen in patients with stroke (20.4%) compared with 1.8% in the rest of the population; p < 0.001. Multivariate logistic regression analysis showed age, peripheral arterial disease, reexploration for bleeding, perioperative myocardial infarction, and year of surgery as independent predictors for stroke. Patients with postoperative stroke had worse long-term survival (log-rank p < 0.001). Cox regression analysis revealed postoperative stroke (odds ratio 2.13 [1.73-2.64)) as an independent predictor of late mortality.
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Postoperative neurologic complications have a significant effect on morbidity, mortality, and long-term disability in patients undergoing cardiac surgery. The etiology of brain injury in patients undergoing cardiac surgery is multifactorial and remains unclear. There are several perioperative causative factors for neurologic complications, including microembolization, hypoperfusion, and systemic inflammatory response syndrome. Despite technologic advances and the development of new anesthetic drugs, there remains a high rate of postoperative neurologic complications. Moreover, despite the strong evidence that volatile anesthesia exerts cardioprotective effects in patients undergoing cardiac surgery, the neuroprotective effects of volatile agents remain unclear. Several studies have reported an association of using volatile anesthetics with improvement of biochemical markers of brain injury and postoperative neurocognitive function. However, there is a need for additional studies to define the optimal anesthetic drug for protecting the brain in patients undergoing cardiac surgery.

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Original article: cardiovascularStroke after cardiac surgery: short- and long-term outcomes

Abstract

Section snippets

Material and methods

Stroke incidence and early outcomes

Comment

Acknowledgements

Curr Probl Cardiol

J Thorac Cardiovasc Surg

Semin Thorac Cardiovasc Surg

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Cardiothorac Vasc Anesth

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Intraoperative hemodynamic predictors of mortality, stroke, and myocardial infarction after coronary artery bypass surgery

Anesth Analg

Risk factors for early or delayed stroke after cardiac surgery

Circulation

Stroke in cardiac surgical patientsdeterminants and outcome

Ann Thorac Surg

Predictors of stroke risk in coronary artery bypass patients

Ann Thorac Surg

Adverse cerebral outcomes after coronary bypass surgery

N Engl J Med

Multicenter preoperative stroke risk index for patients undergoing coronary artery bypass graft surgery

Circulation

Original article: cardiovascular
Stroke after cardiac surgery: short- and long-term outcomes