Massaro Allie, Messé Steven R, Acker Michael A, Kasner Scott E, Torres Jose, Fanning Molly, Giovannetti Tania, Ratcliffe Sarah J, Bilello Michel, Szeto Wilson Y, Bavaria Joseph E, Mohler Emile R, Floyd Thomas F
From the Departments of Neurology (A.M., S.R.M., S.E.K., J.T.) and Radiology (M.B.), and Section of Vascular Medicine, Cardiovascular Division, Department of Medicine (E.R.M.), Hospital of the University of Pennsylvania, Philadelphia; Division of Cardiovascular Surgery, Department of Surgery (M.A.A., M.F., W.Y.S., J.E.B.) and Department of Biostatistics and Epidemiology (S.J.R.), University of Pennsylvania, Philadelphia; Department of Psychology, Temple University, Philadelphia, PA (T.G.); and Department of Anesthesia and Critical Care, State University of New York, Stony Brook (T.F.F.).
Stroke. 2016 Aug;47(8):2130-2. doi: 10.1161/STROKEAHA.116.013970. Epub 2016 Jul 5.
Stroke is a potentially devastating complication of cardiac surgery. Identifying predictors of radiographic infarct may lead to improved stroke prevention for surgical patients.
We reviewed 129 postoperative brain magnetic resonance imagings from a prospective study of patients undergoing surgical aortic valve replacement. Acute infarcts were classified as watershed or embolic using prespecified criteria.
Acute infarct on magnetic resonance imaging was seen in 79 of 129 patients (61%), and interrater reliability for stroke pathogenesis was high (κ=0.93). Embolic infarcts only were identified in 60 patients (46%), watershed only in 2 (2%), and both in 17 (13%). In multivariable logistic regression, embolic infarct was associated with aortic arch atheroma (odds ratio [OR], 3.4; 95% confidence interval [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 percutaneous transluminal coronary angioplasty or coronary artery bypass graft (OR, 4.0; 95% CI, 1.2-13.7; P=0.03), and higher aortic valve gradient (OR, 1.3 per 5 mm Hg; 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).
The principal mechanism of acute cerebral infarction after aortic valve replacement is embolism. There are distinct factors associated with watershed and embolic infarct, some of which may be modifiable.
中风是心脏手术潜在的严重并发症。识别影像学梗死的预测因素可能有助于改善外科手术患者的中风预防。
我们回顾了一项对接受主动脉瓣置换手术患者的前瞻性研究中的129份术后脑磁共振成像。根据预先设定的标准，将急性梗死分为分水岭梗死或栓塞性梗死。
129例患者中有79例（61%）在磁共振成像上显示急性梗死，中风发病机制的评分者间信度较高（κ=0.93）。仅栓塞性梗死60例（46%），仅分水岭梗死2例（2%），两者皆有的17例（13%）。在多变量逻辑回归分析中，栓塞性梗死与主动脉弓动脉粥样硬化相关（比值比[OR]，3.4；95%置信区间[CI]，1.0-12.0；P=0.055）、陈旧性皮质下梗死（OR，5.5；95%CI，1.1-26.6；P=0.04）、无经皮腔内冠状动脉成形术或冠状动脉旁路移植术史（OR，4.0；95%CI，1.2-13.7；P=0.03）以及较高的主动脉瓣梯度（每5mmHg为1.3；95%CI，1.09-1.6；P=0.004）相关。分水岭梗死与颈内动脉狭窄≥70%（OR，11.7；95%CI，1.8-76.8；P=0.01）及左心室射血分数增加（每增加5%为1.6；95%CI，1.08-2.4；P=0.02）相关。
主动脉瓣置换术后急性脑梗死的主要机制是栓塞。有与分水岭梗死和栓塞性梗死相关的不同因素，其中一些可能是可改变的。
