Laimoud Mohamed, Alanazi Mosleh Nazzal, Machado Patricia, Maghirang Mary Jane, Althibait Suha, Al-Mutlaq Shatha, Alomran Munirah, Bou-Saad Imad, Subhi Lamees, Almutairi Reem, Nadhreen Renad, Busaleh Hamza, Pillai Sreedevi, Sidharthan Saranya, Almazeedi Tareq, Al-Halees Zohair
Cardiovascular Critical Care Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.
Critical Care Medicine Department, Cairo University, Cairo, Egypt.
Crit Care Res Pract. 2025 Apr 30;2025:6645363. doi: 10.1155/ccrp/6645363. eCollection 2025.
Many studies have attempted to determine the incidence, predictors, and outcomes of cerebrovascular stroke after cardiac surgery, with different, sometimes contradictory, results because of differences in population risk profiles, study design, and surgical details. We retrospectively reviewed the records of all adult patients who underwent cardiac surgery between January 2018 and January 2023. Univariate, multivariable, and survival analyses were performed to identify the outcomes and predictors of ischemic and hemorrhagic strokes. Of the 1334 patients studied, 70 (5.2%) patients had ischemic stroke, 23 (1.7%) had intracranial hemorrhage (ICH), and 9 (0.7%) had combined ischemic and hemorrhagic strokes. The patients who developed strokes had longer cardiopulmonary bypass (CPB) time (165.5 [126, 234] versus 136 [104, 171] min, < 0.001) and aortic cross-clamping time (112 [79, 163] versus 89 [75, 121.5] min, < 0.001), with higher rates of intra-aortic balloon pump (IABP) use (13.3% vs. 4.4%, < 0.001), veno-arterial extracorporeal membrane oxygenation use (24.8% vs. 12.37%, < 0.001), and mediastinal exploration for bleeding (22.9% vs. 8.9%, < 0.0011). The patients who developed strokes showed increased hospital mortality (37.1% vs. 5.6%, < 0.001), new need for dialysis (29.5% vs. 10.7%, < 0.001), higher rate of tracheostomy (13.3% vs. 1.2%, < 0.001), and longer intensive care unit (ICU) stay (12 [7, 28] versus 3 [2, 8] days, < 0.001) and post-ICU stay (16 [7, 39] versus 5 [3, 10] days, < 0.001). Follow-up for 36.4 (21.67, 50.7) months revealed an insignificant mortality difference, but there was an increased risk of recurrent cerebrovascular strokes. Cox-proportional hazards regression showed an increased risk of hospital mortality after cardiac surgery in patients who developed acute ischemic stroke (HR: 5.075, 95% CI: 3.28-7.851, < 0.001) and ICH (HR: 12.288, 95% CI: 7.576-19.93, < 0.001). Logistic multivariable regression showed that increased age, hyperlactatemia, redo cardiotomy, history of old stroke, CPB time, and perioperative IABP use were the predictors of ischemic stroke. Young age, old ICH, hyperlactatemia, and hypoalbuminemia were the predictors of postoperative ICH. Postoperative ICH, ischemic stroke, atrial fibrillation, chronic kidney disease, blood lactate level 24 h after surgery, and increased age were the independent predictors of mortality. Ischemic and hemorrhagic cerebrovascular strokes are serious complications that increase postoperative mortality and prolong hospitalization after cardiac surgery. Atrial fibrillation was not a significant predictor of postoperative stroke but was a predictor of hospital mortality. Careful attention should be given to maintaining hemodynamic stability and minimizing CPB time, especially in patients with a history of cerebrovascular strokes and redo cardiotomy.
许多研究试图确定心脏手术后脑血管卒中的发生率、预测因素和结局，但由于人群风险特征、研究设计和手术细节的差异，结果各不相同，有时甚至相互矛盾。我们回顾性分析了2018年1月至2023年1月期间所有接受心脏手术的成年患者的记录。进行了单因素、多因素和生存分析，以确定缺血性和出血性卒中的结局和预测因素。在1334例研究患者中，70例（5.2%）发生缺血性卒中，23例（1.7%）发生颅内出血（ICH），9例（0.7%）发生缺血性和出血性卒中合并症。发生卒中的患者体外循环（CPB）时间更长（165.5[126,234]分钟对136[104,171]分钟，<0.001），主动脉阻断时间更长（112[79,163]分钟对89[75,121.5]分钟，<0.001），主动脉内球囊反搏（IABP）使用率更高（13.3%对4.4%，<0.001），静脉-动脉体外膜肺氧合使用率更高（24.8%对12.37%，<0.001），因出血进行纵隔探查的比例更高（22.9%对8.9%，<0.0011）。发生卒中的患者住院死亡率增加（37.1%对5.6%，<0.001），新的透析需求增加（29.5%对10.7%，<0.001），气管切开率更高（13.3%对1.2%，<0.001），重症监护病房（ICU）住院时间更长（12[7,28]天对3[2,8]天，<0.001），ICU后住院时间更长（16[7,39]天对5[3,10]天，<0.001）。36.4（21.67,50.7）个月的随访显示死亡率差异无统计学意义，但复发性脑血管卒中风险增加。Cox比例风险回归显示，发生急性缺血性卒中（HR：5.075，95%CI：3.28-7.851，<0.001）和ICH（HR：12.288，95%CI：7.576-19.93，<0.001）的患者心脏手术后住院死亡率风险增加。多因素逻辑回归显示，年龄增加、高乳酸血症、再次开胸心脏手术、既往卒中史、CPB时间和围手术期IABP使用是缺血性卒中的预测因素。年轻、陈旧性ICH、高乳酸血症和低白蛋白血症是术后ICH的预测因素。术后ICH、缺血性卒中、心房颤动、慢性肾脏病、术后24小时血乳酸水平和年龄增加是死亡率的独立预测因素。缺血性和出血性脑血管卒中是严重并发症，会增加心脏手术后的死亡率并延长住院时间。心房颤动不是术后卒中的重要预测因素，但却是住院死亡率的预测因素。应特别注意维持血流动力学稳定并尽量缩短CPB时间，尤其是有脑血管卒中史和再次开胸心脏手术的患者。
