Stroke After Aortic Valve Surgery

Messé, Steven R.; Acker, Michael A.; Kasner, Scott E.; Fanning, Molly; Giovannetti, Tania; Ratcliffe, Sarah J.; Bilello, Michel; Szeto, Wilson Y.; Bavaria, Joseph E.; Hargrove, W. Clark; Mohler, Emile R.; Floyd, Thomas F.; Giovanetti, Tania; Matthai, William H.; Morris, Rohinton J.; Pochettino, Alberto; Price, Catherine; Selnes, Ola A.; Woo, Y. Joseph; Desai, Nimesh D.; Augostides, John G.; Cheung, Albert T.; Hanson, C. William; Horák, Jiří; Kohl, Benjamin; Kukafka, Jeremy D.; Levy, Warren J.; Mickler, Thomas A.; Milas, Bonnie L.; Savino, Joseph S.; Vernick, William J.; Weiss, Stuart J.

doi:10.1161/circulationaha.113.005084

Cited by 179 publications

(63 citation statements)

References 46 publications

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“…20 It has also been found in other disease contexts that using NIHSS-certified examiners, rather than nonneurologists who were not so certified, has resulted in much higher rates of detection of neurologic events than previously reported. 21 Nevertheless, our cohort had comparable rates of higher incidence of aphasia among older patients, women, and those with systemic conditions that produce cardioembolic stroke.…”

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confidence: 73%

Effect of aphasia on acute stroke outcomes

et al. 2016

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Objective: To determine the independent effects of aphasia on outcomes during acute stroke admission, controlling for total NIH Stroke Scale (NIHSS) scores and loss of consciousness.Methods: Data from the Tulane Stroke Registry were used from July 2008 to December 2014 for patient demographics, NIHSS scores, length of stay (LOS), complications (sepsis, deep vein thrombosis), and discharge modified Rankin Scale (mRS) score. Aphasia was defined as a score .1 on question 9 on the NIHSS on admission and hemiparesis as .1 on questions 5 or 6.Results: Among 1,847 patients, 866 (46%) had aphasia on admission. Adjusting for NIHSS score and inpatient complications, those with aphasia had a 1.22 day longer LOS than those without aphasia, whereas those with hemiparesis (n 5 1,225) did not have any increased LOS compared to those without hemiparesis. Those with aphasia had greater odds of having a complication (odds ratio [OR] 1.44, confidence interval [CI] 1.07-1.93, p 5 0.0174) than those without aphasia, which was equivalent to those having hemiparesis (OR 1.47, CI 1.09-1.99, p 5 0.0137). Controlling for NIHSS scores, aphasia patients had higher odds of discharge mRS 3-6 (OR 1.42 vs 1.15). Conclusion:Aphasia is independently associated with increased LOS and complications during the acute stroke admission, adding $2.16 billion annually to US acute stroke care. The presence of aphasia was more likely to produce a poor functional outcome than hemiparesis. These data suggest that further research is necessary to determine whether establishing adaptive communication skills can mitigate its consequences in the acute stroke setting. Neurology ® 2016;87:2348-2354 GLOSSARY CI 5 confidence interval; LOS 5 length of stay; mRS 5 modified Rankin Scale; NIHSS 5 NIH Stroke Scale; OR 5 odds ratio.Stroke is the leading cause of disability in the United States.1 Among its most devastating manifestations is aphasia, affecting 21%-38% of acute stroke patients, 2 of which 80% arise from an ischemic event.3 Poststroke aphasia has higher attributable costs of care after discharge compared to stroke without aphasia, 4 and results in a higher rate of stroke recurrence, believed to be related to failure to understand treatment regimens or to communicate symptoms. [5][6][7] Little is known, however, about how aphasia affects outcomes during the acute stroke admission. The purpose of this study was to determine the association of aphasia on outcomes during the acute stroke admission, derived from a large database from a comprehensive stroke center. We hypothesized that aphasia would have an independent effect on acute stroke outcomes, controlling for NIH Stroke Scale (NIHSS) severity and vascular risk factors. We also sought to compare the effect of aphasia with that of hemiparesis during this clinical period.METHODS Study population. A retrospective analysis of prospectively collected data of all patients with acute ischemic stroke or intracerebral hemorrhage (ICH) who presented to a single TJC Comprehensive Stroke Center between July 200...

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Effect of aphasia on acute stroke outcomes

et al. 2016

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“…In the current issue of Circulation, Messé and colleagues 5 prospectively assessed the incidence of both clinical stroke and silent neurological events in 196 patients ≥65 years of age who underwent SAVR as recorded by serial neurological examinations and MRI. The incidence of clinically overt stroke was 17%, whereas silent infarct was identified in 54% of patients with no neurological symptoms by MRI.…”

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confidence: 99%

Stroke After Aortic Valve Replacement

Waksman

Minha

2014

Circulation

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“…1, 2 Peri-procedural radiographic infarcts are much more common than clinical events, and a greater understanding of the mechanisms of injury could lead to improved stroke prevention.…”

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confidence: 99%

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

Massaro

Messé

Acker

et al. 2016

Stroke

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Background and Purpose Stroke is a potentially devastating complication of cardiac surgery. Identifying predictors of radiographic infarct may lead to improved stroke prevention for surgical patients. Methods We reviewed 129 post-operative brain MRIs from a prospective study of patients undergoing surgical aortic valve replacement (AVR). Acute infarcts were classified as watershed or embolic using pre-specified criteria. Results Acute infarct on MRI was seen in 79 of 129 patients (61%), interrater reliability for stroke etiology was high (κ =0.93). Embolic infarcts only were identified in 60 (46%), watershed only in 2 (2%), and both in 17 (13%). In multivariable logistic regression, embolic infarct was associated with aortic arch atheroma (OR=3.4, 95%CI 1.0-12.0, p=0.055), old subcortical infarcts (OR= 5.5, 95%CI 1.1-26.6, p=0.04), no history of PTCA or CABG (OR=4.0, 95%CI 1.2-13.7, p=0.03), and higher aortic valve gradient (OR=1.3 per 5mmHg, 95%CI 1.09-1.6, p=0.004). Watershed infarct was associated with internal carotid artery stenosis ≥70% (OR=11.7, 95%CI 1.8-76.8, p=0.01) and increased left ventricular ejection fraction (OR=1.6 per 5% increase, 95%CI 1.08-2.4, p=0.02). Conclusions The principal mechanism of acute cerebral infarction after AVR is embolism. There are distinct factors associated with watershed and embolic infarct, some of which may be modifiable.

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Stroke After Aortic Valve Surgery

Cited by 179 publications

References 46 publications

Effect of aphasia on acute stroke outcomes

Effect of aphasia on acute stroke outcomes

Stroke After Aortic Valve Replacement

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

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