Atrial Septal Defect and the Risk of Ischemic Stroke in the Perioperative Period of Noncardiac Surgery

https://doi.org/10.1016/j.amjcard.2019.06.030Get rights and content

Stroke is a serious complication of noncardiac surgery. Congenital defects of the interatrial septum may be a potent risk factor for perioperative stroke. The aim of the present study was to determine the association between atrial septal defect (ASD) or patent foramen ovale (PFO) and in-hospital perioperative ischemic stroke after non-cardiac surgery in a large nationwide cohort of patients hospitalized in the United States. Patients undergoing noncardiac surgery between 2004 and 2014 were identified using the Healthcare Cost and Utilization Project's National Inpatient Sample. Patients without an in-hospital echocardiogram were excluded. The presence of an ostium secundum-type ASD or PFO was identified by ICD-9 diagnosis code 745.5. The primary study outcome was perioperative acute ischemic stroke. Between 2004 and 2014, there were 639,985 admissions for noncardiac surgery with an in-hospital echocardiogram. An ASD or PFO was documented in 9,041 (1.4%) hospitalizations. Perioperative ischemic stroke occurred more frequently in patients with an ASD or PFO compared with those without an ASD or PFO (35.1% vs 6.0%, p <0.001). The association between ASD or PFO and ischemic stroke persisted after adjustment for demographics and clinical covariates (adjusted odds ratio 6.30, 95% confidence interval, 5.59 to 7.10) and in all non-cardiac surgery subtypes. In conclusion, in a large, nationwide analysis of patients undergoing noncardiac surgery, a diagnosis of ASD or PFO was associated with an increased risk of acute ischemic stroke overall and in all surgical subtypes. Additional measures are necessary to mitigate stroke risk in patients with septal defects who are planned for non-cardiac surgery.

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Background

Worldwide, more than 300 million surgeries are performed annually.1 Stroke is a serious complication of surgery that is associated with long-term morbidity and mortality.2 The risk of perioperative stroke varies based on patient characteristics and surgical factors, with the highest risks in patients undergoing cardiac and vascular procedures.2 Congenital defects of the interatrial septum may be a potent risk factor for perioperative stroke. Atrial septal defects (ASD) are present in 1.6 per

Methods

Patients undergoing noncardiac surgery between 2004 and 2014 were identified using the Healthcare Cost and Utilization Project's National Inpatient Sample.12 The NIS is a large administrative database that contains data from more than 7 million hospitalizations in the United States each year. The NIS approximates a 20% stratified sample of all discharges from nonfederal hospitals in the United States.12 Patients were eligible for inclusion if they had a principal International Classification of

Results

Between 2004 and 2014, we identified 639,985 admissions for noncardiac surgery in which in-hospital diagnostic echocardiography was performed. An ASD or PFO was documented in 9,041 (1.4%) of noncardiac surgical hospitalizations with an in-hospital echocardiogram. Patients with a diagnosis of ASD or PFO were younger, more likely to be white, and more likely to have peripheral vascular disorders, a history of venous thromboembolism, and prior stroke compared with patients without ASD or PFO.

Discussion

In this analysis of 639,985 hospitalizations for major noncardiac surgery in the United States, a diagnosis of an ASD or PFO by echocardiography was associated with perioperative acute ischemic stroke, even after adjustment for baseline demographics, cardiovascular risk factors, and comorbidities. Similar associations were identified in a sensitivity analysis excluding patients undergoing vascular surgery. In contrast, ASD or PFO was not associated with an increased risk of MI or in-hospital

Disclosures

The authors report no relationships that could be construed as a conflict of interest

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Sponsor/Funding: Dr. Smilowitz is supported in part by an NYU CTSA grant, UL1 TR001445 and KL2 TR001446, from the National Center for Advancing Translational Sciences, National Institutes of Health.”

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Authors contributed equally to this manuscript.

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