We identified 360,437 patients who underwent isolated surgical AVR between 1998 and 2011 from the National Inpatient Sample (NIH) database. Mean age was 66 ± 32 years. Multivariable regression and propensity matching were used to identify risk factors and the effect of stroke on outcomes. Patients were stratified according to the Elixhauser comorbidity score (ECS) into low- (0–5), medium- (6–15), and high-risk (16+) categories.
Stroke after AVR occurred in 5,092 (1.45%) patients. The incidence of stroke declined from 1.69% in 1999 to 0.94% in 2011 (p < 0.001). Increasing age and higher comorbidities were the main predictors of stroke (each p < 0.001). The highest-volume centers (>200 AVRs/y) had the lowest rate of stroke (1.2%). After multivariable adjustment, high-volume centers had lower odds of stroke in medium-risk (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.37–0.94) and high-risk patients (OR, 0.39; 95% CI, 0.22–0.68) compared with the lowest-volume centers. For low-risk patients, volume was not associated with stroke. Patients who experienced stroke were hospitalized for 4 days longer, had an average of $10,496 higher costs, and had 2.74 (95% CI, 1.97–3.80) times higher odds of in-hospital mortality compared with those who did not experience stroke (all p < 0.001).
The incidence of stroke after AVR has decreased but remains a significant cause of morbidity in medium- and high-risk patients. Superior outcomes can be achieved in medium- to high-risk patients at high-volume centers.