Original article: cardiovascular
Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients

https://doi.org/10.1016/S0003-4975(02)04370-9Get rights and content

Abstract

Background

Stroke remains a devastating complication after cardiac surgical procedures despite advances in perioperative monitoring and management. The purpose of this study was to determine the predictors of stroke in a large, contemporary cardiac surgery population.

Methods

Prospective data on 16,184 consecutive patients undergoing cardiac surgery (coronary artery bypass grafting [CABG], n = 8,917; beating heart CABG, n = 1,842; aortic valve surgery, n = 1,830; mitral valve surgery, n = 708; double or triple valve surgery, n = 381; CABG and valve surgery, n = 2,506) between April 1996 and August 2001 were subjected to univariate and multivariate analysis. Stroke was defined as any new permanent (manifest stroke) or temporary neurologic deficit or deterioration (transient ischemic attack or prolonged reversible ischemic neurologic deficit) and was confirmed by computed tomography or magnetic resonance imaging whenever possible.

Results

Overall incidence of stroke was 4.6% and varied between surgical procedures (CABG 3.8%; beating-heart CABG 1.9%; aortic valve surgery 4.8%; mitral valve surgery 8.8%; double or triple valve surgery 9.7%; CABG and valve surgery 7.4%). Of 63 patient-specific and treatment variables, 54 were found to have a significant univariate association with postoperative stroke. Multivariable analysis revealed 10 variables that were independent predictors of stroke: history of cerebrovascular disease, peripheral vascular disease, diabetes, hypertension, previous cardiac surgery, preoperative infection, urgent operation, CPB time more than 2 hours, need for intraoperative hemofiltration, and high transfusion requirement. Beating heart CABG was associated with a lower incidence of stroke in this multivariable analysis.

Conclusions

Identification of predictors for stroke is important for understanding the pathogenesis of this devastating complication as well as for developing preventative strategies. Although retrospective analyses can be subject to selection bias we believe beating heart CABG is associated with a lower incidence of stroke and may therefore improve patient outcomes.

Section snippets

Study population

A total of 16,184 consecutive adult patients undergoing cardiac surgery between April 1996 and August 2001 were included in this study. CABG with cardiopulmonary bypass (CPB) was performed in 8,917 patients and beating heart CABG through a median sternotomy(OPCAB, n = 765) or through a left lateral minithoracotomy (minimally invasive direct coronary artery bypass (MIDCAB, n = 1,077) was performed in 1,842 patients. A total of 1,830 patients had aortic valve repair or replacement with or without

Results

The significant differences in preoperative patient characteristics for the different surgical procedures were as follows (Table 1): Patients in the CABG group were significantly older than the MIDCAB, aortic valve, mitral valve, and double or triple valve groups (p < 0.05). Within the beating heart CABG group, OPCAB patients were significantly older than MIDCAB patients (p < 0.001). Patients undergoing mitral valve surgery were significantly younger than all other groups (p < 0.05), and

Comment

Neurologic complications after cardiac surgical procedures remain a relatively common problem despite improvements in anesthetic and surgical techniques as well as in perioperative monitoring and management. Several previous studies have demonstrated that permanent neurologic deficits occur in as many as 6% of patients undergoing cardiac surgery 1, 2, 3, 4, 5. In the current prospective large-scale series the incidence of stroke was 4.6% with significant variation among different surgical

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