Mechanical Thrombectomy Improves Outcome for Large Vessel Occlusion Stroke after Cardiac Surgery
Introduction
Stroke is one of the most devastating complications of surgery, and the highest risk procedures for postoperative stroke are cardiothoracic. Published rates of clinically significant stroke are as high as 10% for multiple valve surgeries1 and 33% in ventricular assist device surgeries,2 and newer endovascular techniques of cardiac intervention such as transcatheter aortic valve placement (TAVR) also put patients at significant risk for stroke.3, 4, 5, 6 The incidence of clinically silent, radiographic infarct after cardiac procedures is much higher, with one study finding radiographic brain infarcts in 69% of patients undergoing aortic valve surgery.7 Until recently, there were few treatment options for postoperative stroke given that recent surgery is a contraindication to the intravenous administration of tissue-type plasminogen activator (tPA). Postoperative interventions were often limited to attempts at intra-arterial pharmacologic thrombolysis, which although they appeared safe did not offer dramatic improvements in outcomes.8 In 2015, the efficacy of modern clot-retrieval techniques for patients presenting with large vessel occlusion (LVO) was proven, and intra-arterial thrombectomy procedures have become the standard of care.9 In 2018, two randomized controlled trials examining longer treatment windows (up to 24 hours after last known normal (LKN) time) showed the superiority of thrombectomy to maximal medical management for candidates with small infarct cores, identified by advanced imaging.10,11 Two previous studies have examined thrombectomy for LVO after cardiac surgery, though neither showed a statistically significant difference in neurologic outcome for patients treated with thrombectomy.12,13 The purpose of this study was to 1) report the incidence of LVOs after cardiac surgery at a large academic center, and 2) examine patient factors, procedural characteristics, postoperative management practices, and neurologic outcomes in these patients. We hypothesized that the availability of new effective treatments for stroke may warrant changes to postoperative management of cardiac surgery patients.
Section snippets
Methods
At our institution, during the first part of the study period, from 2014 to 2017, thrombectomy was attempted for patients presenting within 6 hours of LKN and LVO on CTA, or within the protocol of the DEFUSE-3 trial for later presentation, though no post-CT surgery patients were found eligible for enrollment in DEFUSE-3 due to low ASPECTs scores. Beginning in 2018, thrombectomy was attempted for patients beyond the 6-hour time window, with advanced imaging.
After receiving Institutional Review
Results
All cardiothoracic surgery cases during the study period were examined (n = 7,112 procedures), including 5,184 cases involving valve repair or replacement and 1,060 endovascular procedures. Clinical status was verified at 30 days after surgery by trained research nurses, with 52 patients lost to follow-up. One hundred eighty-one patients were deceased at 30 days after surgery. Acute ischemic stroke within 30 days after surgery was noted in 163 patients (2.3%). Among those with a stroke, 51/163
Discussion
Surgery is a risk factor for stroke, given a proinflammatory state, a higher incidence of preexisting comorbidities in the surgical population, and, in the case of cardiac surgery, the increased risk of cardio-embolic sources from the surgical site as well as a high incidence of arrhythmias perioperatively.5,15 Yet, we found that overall stroke incidence rates are relatively low after cardiac surgery and that LVOs are quite uncommon.
Among patients who presented with LVO, we found that patients
Conclusions
Among patients who had cardiac surgery at a tertiary-care academic medical center, 0.2% (95% CI 0.1–0.4%) had LVO stroke within 30 days (all within the first 2 weeks) postoperatively. LVO patients receiving thrombectomy had a significantly higher rate of good neurologic outcomes compared to those who did not (66.6% vs. 0%, P = .01). Given new expanded treatment windows, twice as many may be eligible for thrombectomy today if screened by advanced neuroimaging. Surgical teams, patients, and all
Funding/Grant Support
None.
Presentations
Work based on portions of this project was presented in electronic abstract format at the Society for NeuroInterventional Surgery Annual Meeting in Miami Beach, FL, July 22, 2019.
Declaration of Competing Interest
None.
Acknowledgments
None.
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