title: Pathogenesis and Risk Factors for Cerebral Infarct After Surgical Aortic Valve Replacement.
abstract: 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.
authors.affiliation: 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.).
authors.forename: Allie
authors.initials: A
authors.lastname: Massaro
authors.affiliation: 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.). messe@mail.med.upenn.edu.
authors.forename: Steven R
authors.initials: SR
authors.lastname: Messé
authors.affiliation: 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.).
authors.forename: Michael A
authors.initials: MA
authors.lastname: Acker
authors.affiliation: 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.).
authors.forename: Scott E
authors.initials: SE
authors.lastname: Kasner
authors.affiliation: 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.).
authors.forename: Jose
authors.initials: J
authors.lastname: Torres
authors.affiliation: 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.).
authors.forename: Molly
authors.initials: M
authors.lastname: Fanning
authors.affiliation: 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.).
authors.forename: Tania
authors.initials: T
authors.lastname: Giovannetti
authors.affiliation: 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.).
authors.forename: Sarah J
authors.initials: SJ
authors.lastname: Ratcliffe
authors.affiliation: 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.).
authors.forename: Michel
authors.initials: M
authors.lastname: Bilello
authors.affiliation: 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.).
authors.forename: Wilson Y
authors.initials: WY
authors.lastname: Szeto
authors.affiliation: 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.).
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Bavaria
authors.affiliation: 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.).
authors.forename: Emile R
authors.initials: ER
authors.lastname: Mohler
authors.affiliation: 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.).
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Floyd
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000601:surgery*; D001921:Brain / Q000000981:diagnostic imaging*; D002544:Cerebral Infarction / Q000000981:diagnostic imaging / Q000209:etiology*; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012307:Risk Factors
keywords: brain; carotid stenosis; cerebral infarction; embolism; magnetic resonance imaging