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J Thorac Cardiovasc Surg 2003;126:358-364
© 2003 The American Association for Thoracic Surgery

Surgery for acquired cardiovascular disease

Early and late stroke after mitral valve replacement with a mechanical prosthesis: risk factor analysis of a 24-year experience

^a Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan,
^b Department of Cardiology, National Cardiovascular Center, Osaka, Japan
^c Department of Public Health, Kitasato University, Kanagawa, Japan

Read at the Eighty-second Annual Meeting of The American Association for Thoracic Surgery, Washington, DC, May 5-8, 2002.

Received for publication June 3, 2002; revisions received July 8, 2002; revisions received January 15, 2003; accepted for publication February 18, 2003.

^* Address for reprints: Ko Bando, MD, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka 565-8565, Japan
kobando{at}hsp.ncvc.go.jp

OBJECTIVE: We evaluated risk factors for mortality and stroke after mechanical mitral valve replacement between May 1977 and December 2001.

METHODS: Early and late mortality and stroke were assessed. Potential predictors of mortality and stroke were entered into a Cox proportional hazards model. Actuarial survival and freedom from stroke were determined by a log-rank test.

RESULTS: Mitral valve replacement was performed in 812 patients. Concomitant procedures included left atrial appendage closure in 493 (61%) patients, tricuspid annuloplasty-replacement in 348 (43%) patients, maze procedure in 185 (23%) patients, plication of the left atrium in 148 (18%) patients, and other procedures in 151 (19%) patients. Five-year actuarial survival was 91.1% ± 2.3%. Freedom from stroke at 8 years was significantly better in patients with sinus rhythm versus atrial fibrillation (P < .001). Ninety-nine percent of patients with mitral valve replacement combined with a maze procedure were free from stroke, whereas only 89% of patients with mitral valve replacement alone were free from stroke at 8 years after surgical intervention. Seventy-two patients had late stroke; sixty-five patients (90%) were in atrial fibrillation, and 47 (65%) patients had the left atrial appendage closed. Multivariate analysis showed that late atrial fibrillation (odds ratio, 3.39; 95% confidence interval, 1.72-6.67; P = .0001) and omission of the maze procedure (odds ratio, 3.40; 95% confidence interval, 1.14-10.14; P = .003) were the significant risk factors for late stroke.

CONCLUSIONS: Persistent atrial fibrillation was the most significant risk factor for late stroke after mechanical mitral valve replacement. Restoration of sinus rhythm with a maze procedure nearly eliminated the risk of late stroke, whereas neither closure of the left atrial appendage nor therapeutic anticoagulation prevented this complication.