Association of Timing of Aortic Valve Replacement Surgery After Stroke With Risk of Recurrent Stroke and Mortality

Abstract

Importance: Timing of surgical aortic valve replacement (SAVR) in patients with aortic valve stenosis and previous stroke for the risk of recurrent stroke is insufficiently investigated.

Objective: To evaluate 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.

Design, setting, and participants: This cohort study using data from Danish administrative registries included all patients with aortic valve stenosis older than 18 years 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.

Exposures: Time elapsed between prior stroke and SAVR (<3 months, 3-<12 months, ≥12 months, and no prior stroke).

Main outcomes and measures: Thirty-day risks of MACE, ischemic stroke, and all-cause mortality reported as absolute events and multivariable adjusted odds ratios with 95% confidence intervals. Restricted cubic spline regression models were additionally applied on the subgroup with prior stroke.

Results: Of the 14 030 included patients, 616 patients (190 [30.8%] women; mean [SD] age, 72.0 [9.1] years) with prior stroke underwent surgery, and 13 414 (4837 [36.1%] women; mean [SD] age, 69.8 [10.8] years) without prior stroke underwent surgery. The absolute risk of ischemic stroke was significantly increased in patients with stroke less than 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 less than 3 months prior surgery were at significantly increased risk of MACE (23.3% [53 of 227] vs 5.7% [768 of 13 414]; odds ratio, 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]; odds ratio, 1.45; 95% CI, 0.83-2.54). Spline analyses supported a declining risk over time, reaching nadir after 2 to 4 months.

Conclusions and relevance: Previous stroke is a major risk factor of recurrent ischemic stroke and MACE in patients undergoing SAVR, especially if time elapsed between previous stroke and surgery is less than 3 months.

Figure 1.. Crude Events and Adjusted Odds Ratios (ORs) for 30-Day Major Adverse Cardiovascular Events (MACE), Ischemic Stroke, and All-Cause Mortality Stratified in 4 Groups

Major adverse cardiac events include acute myocardial infarction, ischemic stroke, or cardiovascular death. Odds ratios adjusted for age, sex, concomitant coronary artery bypass grafting surgery, ischemic heart disease, chronic heart failure, prior acute myocardial infarction, atrial fibrillation, peripheral artery disease, renal disease, chronic obstructive pulmonary disease, diabetes, antithrombotic therapy, and calendar year.

Figure 2.. Association of Major Adverse Cardiovascular Events (MACE), Recurrent Stroke, and All-Cause Mortality With Time Since Prior Stroke Among Patients With Prior Stroke

Restricted cubic splines regression of the association of time elapsed between prior stroke with risk of MACE, ischemic stroke, and all-cause mortality among patients with prior stroke. All splines were adjusted for age, sex, and concomitant coronary artery bypass grafting surgery. The median time between stroke and surgery (9.2 months) was used as a reference. From left to right, the knots indicate the fifth, 25th, 50th, 75th, and 95th percentile. Gray lines indicate 95% CIs.