title: Long-Term Risk of Ischemic Stroke After the Cox-Maze III Procedure for Atrial Fibrillation.
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. 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.
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital, Uppsala, Sweden. Electronic address: anders.albage@akademiska.se.
authors.forename: Anders
authors.initials: A
authors.lastname: Albåge
authors.affiliation: Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Ulrik
authors.initials: U
authors.lastname: Sartipy
authors.affiliation: Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Göran
authors.initials: G
authors.lastname: Kennebäck
authors.affiliation: Department of Internal Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.
authors.forename: Birgitta
authors.initials: B
authors.lastname: Johansson
authors.affiliation: Department of Cardiovascular Surgery, Sahlgrenska University Hospital/Sahlgrenska, Gothenburg, Sweden.
authors.forename: Henrik
authors.initials: H
authors.lastname: Scherstén
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital, Uppsala, Sweden.
authors.forename: Lena
authors.initials: L
authors.lastname: Jidéus
mesh_terms: D020517:Atrial Appendage / Q000601:surgery; D001281:Atrial Fibrillation / Q000601:surgery*; D002545:Brain Ischemia / Q000453:epidemiology* / Q000209:etiology; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000379:methods; D002423:Cause of Death / Q000639:trends; D005260:Female; D005500:Follow-Up Studies; D005544:Forecasting; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology; D011379:Prognosis; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D013548:Sweden / Q000453:epidemiology