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Long-Term Risk of Ischemic Stroke After the Cox-Maze III Procedure for Atrial Fibrillation

Albåge, Anders; Sartipy, Ulrik; Kennebäck, Göran; Johansson, Birgitta; Scherstén, Henrik; Jidéus, Lena; , ; Sjögren, Johan LU and Ghaidan, Haider LU (2017) In Annals of Thoracic Surgery 104(2). p.523-529
Abstract

Background The long-term risk of stroke after surgical treatment of atrial fibrillation is not well known. We performed an observational cohort study with long follow-up after the “cut-and-sew” Cox-maze III procedure (CM-III), including left atrial appendage excision. The aim was to analyze the incidence of stroke/transient ischemic attack (TIA) and the association to preoperative CHA2DS2-VASc (age in years, sex, congestive heart failure history, hypertension history, stroke/TIA, thromboembolism history, vascular disease history, diabetes mellitus) score. Methods Preoperative and perioperative data were collected in 526 CM-III patients operated in four centers 1994 to 2009, 412 men, mean age of 57.1 ± 8.3 years.... (More)

Background The long-term risk of stroke after surgical treatment of atrial fibrillation is not well known. We performed an observational cohort study with long follow-up after the “cut-and-sew” Cox-maze III procedure (CM-III), including left atrial appendage excision. The aim was to analyze the incidence of stroke/transient ischemic attack (TIA) and the association to preoperative CHA2DS2-VASc (age in years, sex, congestive heart failure history, hypertension history, stroke/TIA, thromboembolism history, vascular disease history, diabetes mellitus) score. Methods Preoperative and perioperative data were collected in 526 CM-III patients operated in four centers 1994 to 2009, 412 men, mean age of 57.1 ± 8.3 years. The incidence of any stroke/TIA was identified through analyses of the Swedish National Patient and Cause-of-Death Registers and from review of individual patient records. The cumulative incidence of stroke/TIA and association with CHA2DS2-VASc score was estimated using methods accounting for the competing risk of death. Results Mean follow-up was 10.1 years. There were 29 patients with any stroke/TIA, including 6 with intracerebral bleedings (2 fatal) and 4 with perioperative strokes (0.76%). The remaining 13 ischemic strokes and six TIAs occurred at a mean of 7.1 ± 4.0 years postoperatively, with an incidence of 0.36% per year (19 events per 5,231 patient-years). In all CHA2DS2-VASc groups, observed ischemic stroke/TIA rate was lower than predicted. A higher risk of ischemic stroke/TIA was seen in patients with CHA2DS2-VASc score 2 or greater compared with score 0 or 1 (hazards ratio 2.15, 95% confidence interval: 0.87 to 5.32) but no difference by sex or stand-alone versus concomitant operation. No patient had ischemic stroke as cause of death. Conclusions This multicenter study showed a low incidence of perioperative and long-term postoperative ischemic stroke/TIA after CM-III. Although general risk of ischemic stroke/TIA was reduced, patients with CHA2DS2-VASc score 2 or greater had a higher risk compared with score 0 or 1. Complete left atrial appendage excision may be an important reason for the low ischemic stroke rate.

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published
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in
Annals of Thoracic Surgery
volume
104
issue
2
pages
7 pages
publisher
Elsevier
external identifiers
  • scopus:85013814515
ISSN
0003-4975
DOI
10.1016/j.athoracsur.2016.11.065
language
English
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yes
id
e84f7934-4f18-4b10-8e5c-41aa74e42cda
date added to LUP
2017-12-07 14:10:27
date last changed
2018-03-18 05:18:33
@article{e84f7934-4f18-4b10-8e5c-41aa74e42cda,
  abstract     = {<p>Background The long-term risk of stroke after surgical treatment of atrial fibrillation is not well known. We performed an observational cohort study with long follow-up after the “cut-and-sew” Cox-maze III procedure (CM-III), including left atrial appendage excision. The aim was to analyze the incidence of stroke/transient ischemic attack (TIA) and the association to preoperative CHA<sub>2</sub>DS<sub>2</sub>-VASc (age in years, sex, congestive heart failure history, hypertension history, stroke/TIA, thromboembolism history, vascular disease history, diabetes mellitus) score. Methods Preoperative and perioperative data were collected in 526 CM-III patients operated in four centers 1994 to 2009, 412 men, mean age of 57.1 ± 8.3 years. The incidence of any stroke/TIA was identified through analyses of the Swedish National Patient and Cause-of-Death Registers and from review of individual patient records. The cumulative incidence of stroke/TIA and association with CHA<sub>2</sub>DS<sub>2</sub>-VASc score was estimated using methods accounting for the competing risk of death. Results Mean follow-up was 10.1 years. There were 29 patients with any stroke/TIA, including 6 with intracerebral bleedings (2 fatal) and 4 with perioperative strokes (0.76%). The remaining 13 ischemic strokes and six TIAs occurred at a mean of 7.1 ± 4.0 years postoperatively, with an incidence of 0.36% per year (19 events per 5,231 patient-years). In all CHA<sub>2</sub>DS<sub>2</sub>-VASc groups, observed ischemic stroke/TIA rate was lower than predicted. A higher risk of ischemic stroke/TIA was seen in patients with CHA<sub>2</sub>DS<sub>2</sub>-VASc score 2 or greater compared with score 0 or 1 (hazards ratio 2.15, 95% confidence interval: 0.87 to 5.32) but no difference by sex or stand-alone versus concomitant operation. No patient had ischemic stroke as cause of death. Conclusions This multicenter study showed a low incidence of perioperative and long-term postoperative ischemic stroke/TIA after CM-III. Although general risk of ischemic stroke/TIA was reduced, patients with CHA<sub>2</sub>DS<sub>2</sub>-VASc score 2 or greater had a higher risk compared with score 0 or 1. Complete left atrial appendage excision may be an important reason for the low ischemic stroke rate.</p>},
  author       = {Albåge, Anders and Sartipy, Ulrik and Kennebäck, Göran and Johansson, Birgitta and Scherstén, Henrik and Jidéus, Lena and ,  and Sjögren, Johan and Ghaidan, Haider},
  issn         = {0003-4975},
  language     = {eng},
  number       = {2},
  pages        = {523--529},
  publisher    = {Elsevier},
  series       = {Annals of Thoracic Surgery},
  title        = {Long-Term Risk of Ischemic Stroke After the Cox-Maze III Procedure for Atrial Fibrillation},
  url          = {http://dx.doi.org/10.1016/j.athoracsur.2016.11.065},
  volume       = {104},
  year         = {2017},
}