Perioperative Stroke and Mortality After Surgical Aortic Valve Replacement: A Meta-Analysis.

OBJECTIVE: Perioperative stroke rate after surgical aortic valve replacement (SAVR) varies between 1.3% and 6.2%, whereas the operative mortality ranges between 1% and 16.4%. The aim of this study was to determine whether perioperative stroke is a risk factor for operative mortality after SAVR by performing a meta-analysis of relevant studies. MATERIALS AND METHODS: PubMed, EMBASE, and Web of Science databases were searched to retrieve relevant literature. Screening of the articles was done independently on the basis of predetermined criteria. Data from the relevant studies were extracted and a random effects model was used to calculate the odds of mortality among patients with perioperative strokes after aortic valve replacement compared with those without such strokes. Subgroup analyses of patients (1) aged above and below 70 years and (2) undergoing isolated valve replacement procedure were performed. Metaregression to check for association of effect estimate and (1) sex, (2) mechanical valve replacement, (3) New York Heart Association class III/IV, (4) left ventricle ejection fraction <30%, and (5) preoperative atrial fibrillation was performed. RESULTS: Statistical analyses using a random effects model showed that patients with perioperative strokes had 4.74 times greater odds for operative mortality after SAVR, independent of the following covariates: (1) sex, (2) mechanical valve replacement, (3) New York Heart Association class III/IV, (4) left ventricle ejection fraction <30%, and (5) preoperative atrial fibrillation. CONCLUSIONS: Patients with perioperative strokes after SAVR have nearly 5 times greater odds of experiencing operative mortality compared with those without. Thus, perioperative strokes are associated with increased risk of early mortality and require further examination of preventive strategies.

Meta-Analysis of Perioperative Stroke and Mortality in Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) is a rapidly evolving safe method with decreasing incidence of perioperative stroke. There is a void in literature concerning the impact of stroke after TAVI in predicting 30-day stroke-related mortality. The primary aim of this meta-analysis was to determine whether perioperative stroke increases risk of stroke-related mortality after TAVI. Online databases, using relevant keywords, and additional related records were searched to retrieve articles involving TAVI and stroke after TAVI. Data were extracted from the finalized studies and analyzed to generate a summary odds ratio (OR) of stroke-related mortality after TAVI. The stroke rate and stroke-related mortality rate in the total patient population were 3.07% (893 of 29,043) and 12.27% (252 of 2,053), respectively. The all-cause mortality rate was 7.07% (2,053 of 29,043). Summary OR of stroke-related mortality after TAVI was estimated to be 6.45 (95% confidence interval 3.90 to 10.66, p <0.0001). Subgroup analyses were performed among age, approach, and valve type. Only 1 subgroup, transapical TAVI, was not significantly associated with stroke-related mortality (OR 1.97, 95% confidence interval, 0.43 to 7.43, p = 0.42). A metaregression was conducted among females, New York Heart Association class III/IV status, previous stroke, valve type, and implantation route. All failed to exhibit any significant associations with the OR. In conclusion, perioperative strokes after TAVI are associated with >6 times greater risk of 30-day stroke-related mortality. Transapical TAVI is not associated with increased stroke-related mortality in patients who suffer from perioperative stroke. Preventative measures need to be taken to alleviate the elevated rates of stroke after TAVI and subsequent direct mortality.