Risk of neurologic events after surgery for mitral valve insufficiency and concomitant cox-maze IV procedure for atrial fibrillation. A nationwide register-based study.

Objectives: Analysis of the long-term risks of ischaemic stroke and cerebral bleeding in patients with atrial fibrillation after mitral valve surgery and concomitant Cox-maze IV procedure.

Methods: In total, 397 patients with symptomatic degenerative mitral valve insuffciency and atrial fibrillation, underwent mitral valve surgery and Cox-maze IV in Sweden between 2009-2017. In this retrospective nationwide analysis, patients were followed in national patient registers until September 30, 2022.

Results: There were four deaths within 30 days (1.0%). Mean follow-up was 8.7 (0.1-13.4) years. Survival without ischaemic stroke or cerebral Haemorrhage at five and ten years were 90% and 74%, respectively. Nineteen patients experienced an ischaemic stroke, of which four were fatal. Five of 34 patients (14.7%) with a history of stroke preoperatively experienced ischaemic stroke during follow-up. The linearized rate of ischaemic stroke per patient-year was 0.6% and was similar regardless of left atrial appendage closure during surgery or whether a mechanical valve was inserted. The observed ischaemic stroke rate was lower than the predicted rate for all CHA2DS2-VASc score groups. Fourteen patients suffered cerebral bleeding, of which three were fatal. Patients who experienced cerebral bleeding were older, and had higher mechanical valve implantation rate than those without cerebral bleeding.

Conclusions: Surgery for mitral valve insufficiency and concomitant Cox-maze IV can be performed with low perioperative risk. There is a low continuing risk of stroke long-term postoperatively that correlates with higher CHA2DS2-VASc score. Patients with preoperative stroke are at increased risk of postoperative stroke despite atrial fibrillation surgery.