Pathogenesis and Risk Factors for Cerebral Infarct After Surgical Aortic Valve Replacement

Massaro, Allie; Messé, Steven R.; Acker, Michael A.; Kasner, Scott E.; Torres, Jose; Fanning, Molly; Giovannetti, Tania; Ratcliffe, Sarah J.; Bilello, Michel; Szeto, Wilson Y.; Bavaria, Joseph E.; Mohler, Emile R.; Floyd, Thomas F.

doi:10.1161/strokeaha.116.013970

Cited by 27 publications

(20 citation statements)

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“…Of the 109 patients with no stroke and with postoperative brain magnetic resonance imaging, silent infarcts were diagnosed in 54%, but these were not associated with increased in-hospital mortality. These investigators noted that embolic infarcts were associated with aortic arch atheroma (odds ratio [OR] 3.4), old subcortical infarcts (OR 5.5), and higher AV gradient (OR 1.3) [23]. In PARTNER-2A, neurologic assessment was performed routinely and led to a neurologic diagnosis in 6.9% at 30 days and 11% at 2 years.…”

Section: Neurologic Eventsmentioning

confidence: 99%

“…Randomized trials and retrospective studies show equipoise in terms of survival between TAVR and SAVR in intermediate-risk patients [23][24][25]; however, complications such as paravalvular leak, vascular complications, and new pacemaker implantation may remain higher in TAVR, with stroke, bleeding, and acute kidney injury higher after SAVR.…”

Section: Tavr and Savr In Intermediate-risk Patientsmentioning

confidence: 99%

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Outcomes in 937 Intermediate-Risk Patients Undergoing Surgical Aortic Valve Replacement in PARTNER-2A

Thourani

Forcillo

Szeto

et al. 2018

The Annals of Thoracic Surgery

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Section: Neurologic Eventsmentioning

confidence: 99%

Section: Tavr and Savr In Intermediate-risk Patientsmentioning

confidence: 99%

Outcomes in 937 Intermediate-Risk Patients Undergoing Surgical Aortic Valve Replacement in PARTNER-2A

Thourani

Forcillo

Szeto

et al. 2018

The Annals of Thoracic Surgery

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“…Also in agreement with our results, atheromatous plaque is another principal cause of embolism and poorer outcomes during surgery on the aortic valve. 39,40 However, our analysis comparing CABG with and without foramen ovale repair, the main difference being opening of the heart, found that there was a trend but not a significant difference in RAO incidence.…”

Section: Discussionmentioning

confidence: 71%

Perioperative Retinal Artery Occlusion

et al. 2017

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Purpose To study the incidence and risk factors for retinal artery occlusion (RAO) in cardiac surgery. Design Retrospective study using the National Inpatient Sample (NIS). Methods The NIS was searched for cardiac surgery. Retinal artery occlusion was identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Postulated risk factors based on literature review were included in multivariate logistic models. Main Outcome Measures Diagnosis of RAO. Results A total of 5 872 833 cardiac operative procedures were estimated in the United States from 1998 to 2013, with 4564 RAO cases (95% confidence interval [95% CI], 4282–4869). Nationally estimated RAO incidence was 7.77/10 000 cardiac operative procedures from 1998 to 2013 (95% CI, 7.29–8.29). Associated with increased RAO were giant cell arteritis (odds ratio [OR], 7.73; CI, 2.78–21.52; P < 0.001), transient cerebral ischemia (OR, 7.67; CI, 5.31–11.07; P < 0.001), carotid artery stenosis (OR, 7.52; CI, 6.22–9.09; P < 0.001), embolic stroke (OR, 4.43; CI, 3.05–6.42; P < 0.001), hypercoagulability (OR, 2.90; CI, 1.56–5.39; P < 0.001), myxoma (OR, 2.43; CI, 1.39–4.26; P = 0.002), diabetes mellitus (DM) with ophthalmic complications (OR, 1.89; CI, 1.10–3.24; P = 0.02), and aortic insufficiency (OR, 1.85; CI, 1.26–2.71; P = 0.002). Perioperative bleeding, aortic and mitral valve surgery, and septal surgery increased the odds of RAO. Negatively associated with RAO were female gender (OR, 0.77; CI, 0.66–0.89; P < 0.001), thrombocytopenia (OR, 0.79; CI, 0.62–1.00; P = 0.049), acute coronary syndrome (OR, 0.72; CI, 0.58–0.89; P = 0.003), atrial fibrillation (OR, 0.82; CI, 0.70–0.95; P = 0.01), congestive heart failure (OR, 0.73; CI, 0.60–0.88; P < 0.001), DM 2 (OR, 0.74; CI, 0.61–0.89; P = 0.001), and smoking (OR, 0.82; CI, 0.70–0.97; P = 0.02). Conclusions Risk factors for RAO in cardiac surgery include giant cell arteritis, carotid stenosis, stroke, hypercoagulable state, and DM with ophthalmic complications; associated with lower risk were female gender, thrombocytopenia, acute coronary syndrome, atrial fibrillation, congestive heart failure, DM 2, and smoking. Surgery in which the heart was opened (e.g., septal repair) versus surgery in which it was not (e.g., CABG) and perioperative bleeding increased the risk of RAO.

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“…30 Watershed infarcts were defined as one lesion >1.5cm or more than one lesion <1.5cm in either the cortical border zone (CBZ) or the internal border zone (IBZ). The CBZ was defined as the junction between the anterior, middle and posterior cerebral artery territories, and the IBZ as the junction of the anterior, middle, and posterior cerebral arteries with the Hubner, lenticulostriate, and anterior choroidal artery territories.…”

Section: Methodsmentioning

confidence: 99%

Symptomatic Carotid Occlusion Is Frequently Associated With Microembolization

Liberman

Zandieh

Loomis

et al. 2017

Stroke

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Background and Purpose Symptomatic carotid artery disease is associated with significant morbidity and mortality. The pathophysiologic mechanisms of cerebral ischemia among patients with carotid occlusion remain underexplored. Methods We conducted a prospective observational cohort study of patients hospitalized within seven days of ischemic stroke (IS) or transient ischemic attack (TIA) due to ≥50% carotid artery stenosis or occlusion. Transcranial Doppler (TCD) emboli detection was performed in the middle cerebral artery ipsilateral to the symptomatic carotid. We describe the prevalence of microembolic signals (MES), characterize infarct topography, and report clinical outcomes at 90-days. Results Forty-seven patients, 19 with carotid occlusion and 28 with carotid stenosis, had complete TCD recordings and were included in the final analysis. MES were present in 38%. There was no difference in MES between those with carotid occlusion (7/19, 37%) compared to stenosis (11/28, 39%; p=0.87). In patients with radiographic evidence of infarction (n=39), 38% had a watershed pattern of infarction, 41% had a non-watershed pattern, and 21% had a combination. MES were present in 40% of patients with an exclusively watershed pattern of infarction. Recurrent cerebral ischemia occurred in 9 patients (19%; 6 with TIA, 3 with IS). There was no difference in the rate of recurrence in those with compared to without MES. Conclusion Cerebral embolization plays an important role in the pathophysiology of ischemia in both carotid occlusion and stenosis, even among patients with watershed infarcts. The role of aggressive antithrombotic and/or antiplatelet therapy for symptomatic carotid occlusions may warrant further investigation given our findings.

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Pathogenesis and Risk Factors for Cerebral Infarct After Surgical Aortic Valve Replacement

Cited by 27 publications

References 10 publications

Outcomes in 937 Intermediate-Risk Patients Undergoing Surgical Aortic Valve Replacement in PARTNER-2A

Outcomes in 937 Intermediate-Risk Patients Undergoing Surgical Aortic Valve Replacement in PARTNER-2A

Perioperative Retinal Artery Occlusion

Symptomatic Carotid Occlusion Is Frequently Associated With Microembolization

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