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Original Investigation
June 2018

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

Author Affiliations
  • 1Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Gentofte, Denmark
  • 2The Danish Heart Foundation, Copenhagen, Denmark
  • 3The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
  • 4Department of Cardiology, Lund University Hospital, Lund, Sweden
  • 5Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison
  • 6Division of Cardiology, Department of Medicine, Glostrup University Hospital, Copenhagen, Denmark
  • 7The Multidisciplinary Pain Center, Department of Anaesthesia, Copenhagen University Hospital Herlev and Gentofte, Gentofte, Denmark
  • 8Department of Health, Science, and Technology, Aalborg University, Aalborg, Denmark
  • 9The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
  • 10Department of Cardiology and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
JAMA Cardiol. 2018;3(6):506-513. doi:10.1001/jamacardio.2018.0899
Key Points

Question  Is there a time-dependent association of previous stroke and surgical aortic valve replacement with the risk of adverse outcomes among patients with aortic valve stenosis?

Findings  This cohort study using Danish administrative registry data included 14 030 surgical aortic valve replacements. Patients with prior stroke had 14.7-, 4.0-, and 2.3-fold higher risk of recurrent stroke compared with patients without prior stroke if surgery was performed within 3 months, 3 to less than 12 months, and 12 months or more, respectively, after the incident stroke.

Meaning  Surgical aortic valve replacement within the first 3 months after a stroke may be associated with a particularly pronounced risk of recurrent ischemic stroke.


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.