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Update in the Evaluation and Management of Perioperative Stroke

  • Dilip Kumar Jayaraman
  • Sandhya Mehla
  • Saurabh Joshi
  • Divya Rajasekaran
  • Richard P. GoddeauJrEmail author
Cerebrovascular Disease and Stroke (S Silverman, Section Editor)
  • 36 Downloads
Part of the following topical collections:
  1. Topical Collection on Cerebrovascular Disease and Stroke

Abstract

Purpose of review

This review will review the current knowledge and gaps in the literature on the relationship between surgery and ischemic stroke.

Findings

Surgery and ischemic stroke are interrelated phenomena as surgery is an independent risk factor for stroke and perioperative stroke increases morbidity and mortality leading to poor outcomes after surgery. This relationship and the risk of adverse outcome apply not only the clinically apparent stroke in the perioperative period but also clinically silent brain infarction detected only on radiological studies. The risk of perioperative stroke depends on several factors including (i) patient-related factors (age, history of prior stroke, and other comorbidities), (ii) procedure-related factors (type of surgery/procedure, use of cardiopulmonary bypass, antiplatelet/antithrombotic interruption, and metabolic derangement), and (iii) perioperative atrial fibrillation.

Summary

With observation and retrospective data, the literature is limited to prevention and management of perioperative stroke.

Keywords

Perioperative stroke Ischemic stroke Risk prevention Atrial fibrillation 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ(B), Culebras A, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(7):2064–89.PubMedGoogle Scholar
  2. 2.
    Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, et al. Heart Disease and Stroke Statistics-2017 Update: a report from the American Heart Association. Circulation. 2017;135(10):e146–603.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Ovbiagele B, Goldstein LB, Higashida RT, Howard VJ, Johnston SC, Khavjou OA, et al. Forecasting the future of stroke in the United States: a policy statement from the American Heart Association and American Stroke Association. Stroke. 2013;44(8):2361–75.PubMedGoogle Scholar
  4. 4.
    Mashour GA, Moore LE, Lele AV, Robicsek SA, Gelb AW. Perioperative care of patients at high risk for stroke during or after non-cardiac, non-neurologic surgery: consensus statement from the Society for Neuroscience in Anesthesiology and Critical Care*. J Neurosurg Anesthesiol. 2014;26(4):273–85.PubMedGoogle Scholar
  5. 5.
    Chen CC, Chen TH, Tu PH, Wu VCC, Yang CH, Wang AYC, et al. Long-term outcomes for patients with stroke after coronary and valve surgery. Ann Thorac Surg. 2018;106(1):85–91.PubMedGoogle Scholar
  6. 6.
    Mashour GA, Shanks AM, Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery. Anesthesiology. 2011;114(6):1289–96.PubMedGoogle Scholar
  7. 7.
    Sharifpour M, Moore LE, Shanks AM, Didier TJ, Kheterpal S, Mashour GA. Incidence, predictors, and outcomes of perioperative stroke in noncarotid major vascular surgery. Anesth Analg. 2013;116(2):424–34.PubMedGoogle Scholar
  8. 8.
    Brown PP, Kugelmass AD, Cohen DJ, Reynolds MR, Culler SD, Dee AD, et al. The frequency and cost of complications associated with coronary artery bypass grafting surgery: results from the United States Medicare program. Ann Thorac Surg. 2008;85(6):1980–6.PubMedGoogle Scholar
  9. 9.
    Reddy RP, Karnati T, Massa RE, Thirumala PD. Association between perioperative stroke and 30-day mortality in carotid endarterectomy: a meta-analysis. Clin Neurol Neurosurg. 2019;181:44–51.PubMedGoogle Scholar
  10. 10.
    • Indja B, et al. Silent brain infarcts following cardiac procedures: a systematic review and meta-analysis. J Am Heart Assoc. 2019;8(9):e010920 Reports that radiographically evident infarction is higher than clinically apparent ischemic stroke.PubMedPubMedCentralGoogle Scholar
  11. 11.
    •• Powers WJ, et al. 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015;46(10):3020–35. This focussed update added mechanical throbectomy to the standard of care and changed the span of management for patients with large-vessel occlusion. This is of particular importance to patients with postoperative stroke because many of these patients may be ineligible for IV thrombolysis.PubMedGoogle Scholar
  12. 12.
    •• Powers WJ, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46–e110. Change in the stroke guidelines and liberalization of tPA contraindication.PubMedGoogle Scholar
  13. 13.
    Furlan AJ, Craciun AR. Risk of stroke during coronary artery bypass graft surgery in patients with internal carotid artery disease documented by angiography. Stroke. 1985;16(5):797–9.PubMedGoogle Scholar
  14. 14.
    Merie C, et al. Risk of stroke after coronary artery bypass grafting: effect of age and comorbidities. Stroke. 2012;43(1):38–43.PubMedGoogle Scholar
  15. 15.
    Breuer AC, Furlan AJ, Hanson MR, Lederman RJ, Loop FD, Cosgrove DM, et al. Central nervous system complications of coronary artery bypass graft surgery: prospective analysis of 421 patients. Stroke. 1983;14(5):682–7.PubMedGoogle Scholar
  16. 16.
    McKhann GM, et al. Predictors of stroke risk in coronary artery bypass patients. Ann Thorac Surg. 1997;63(2):516–21.PubMedGoogle Scholar
  17. 17.
    Brown JM, O’Brien SM, Wu C, Sikora JAH, Griffith BP, Gammie JS. Isolated aortic valve replacement in North America comprising 108,687 patients in 10 years: changes in risks, valve types, and outcomes in the Society of Thoracic Surgeons National Database. J Thorac Cardiovasc Surg. 2009;137(1):82–90.PubMedGoogle Scholar
  18. 18.
    Mohr FW, Holzhey D, Möllmann H, Beckmann A, Veit C, Figulla HR, et al. The German Aortic Valve Registry: 1-year results from 13,680 patients with aortic valve disease. Eur J Cardiothorac Surg. 2014;46(5):808–16.PubMedGoogle Scholar
  19. 19.
    Bateman BT, et al. Perioperative acute ischemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes. Anesthesiology. 2009;110(2):231–8.PubMedGoogle Scholar
  20. 20.
    Bucerius J, Gummert JF, Borger MA, Walther T, Doll N, Onnasch JF, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg. 2003;75(2):472–8.PubMedGoogle Scholar
  21. 21.
    Axelrod DA, Stanley JC, Upchurch GR Jr, Khuri S, Daley J, Henderson W, et al. Risk for stroke after elective noncarotid vascular surgery. J Vasc Surg. 2004;39(1):67–72.PubMedGoogle Scholar
  22. 22.
    Ng PY, Ng AKY, Subramaniam B, Burns SM, Herisson F, Timm FP, et al. Association of Preoperatively Diagnosed Patent Foramen Ovale With Perioperative Ischemic Stroke. JAMA. 2018;319(5):452–62.PubMedPubMedCentralGoogle Scholar
  23. 23.•
    Echahidi N, et al. Mechanisms, prevention, and treatment of atrial fibrillation after cardiac surgery. J Am Coll Cardiol. 2008;51(8):793–801. Describe factors contributing to the development of perioperative atrial fibrillation and its clinical importance.Google Scholar
  24. 24.
    Bramer S, van Straten AHM, Soliman Hamad MA, van den Broek KC, Maessen JG, Berreklouw E. New-onset postoperative atrial fibrillation predicts late mortality after mitral valve surgery. Ann Thorac Surg. 2011;92(6):2091–6.PubMedGoogle Scholar
  25. 25.
    Bramer S, van Straten AHM, Soliman Hamad MA, Berreklouw E, Martens EJ, Maessen JG. The impact of new-onset postoperative atrial fibrillation on mortality after coronary artery bypass grafting. Ann Thorac Surg. 2010;90(2):443–9.PubMedGoogle Scholar
  26. 26.
    Butt JH, Olesen JB, Havers-Borgersen E, Gundlund A, Andersson C, Gislason GH, et al. Risk of thromboembolism associated with atrial fibrillation following noncardiac surgery. J Am Coll Cardiol. 2018;72(17):2027–36.PubMedGoogle Scholar
  27. 27.
    Chebbout R, Heywood EG, Drake TM, Wild JRL, Lee J, Wilson M, et al. A systematic review of the incidence of and risk factors for postoperative atrial fibrillation following general surgery. Anaesthesia. 2018;73(4):490–8.PubMedGoogle Scholar
  28. 28.
    Joshi KK, et al. Postoperative atrial fibrillation in patients undergoing non-cardiac non-thoracic surgery: a practical approach for the hospitalist. Hosp Pract. 1995;43(4):235–44.Google Scholar
  29. 29.
    Lin MH, et al. Perioperative/posteroperative atrial fibrillation and risk of subsequent stroke and/or mortality. Stroke. 2019;50:1364–71.PubMedGoogle Scholar
  30. 30.
    Naylor AR, Mehta Z, Rothwell PM, Bell PRF. Carotid artery disease and stroke during coronary artery bypass: a critical review of the literature. Eur J Vasc Endovasc Surg. 2002;23(4):283–94.PubMedGoogle Scholar
  31. 31.
    Wolman RL, Nussmeier NA, Aggarwal A, Kanchuger MS, Roach GW, Newman MF, et al. Cerebral injury after cardiac surgery: identification of a group at extraordinary risk. Multicenter Study of Perioperative Ischemia Research Group (McSPI) and the Ischemia Research Education Foundation (IREF) Investigators. Stroke. 1999;30(3):514–22.PubMedGoogle Scholar
  32. 32.
    Limburg M, Wijdicks EF, Li H. Ischemic stroke after surgical procedures: clinical features, neuroimaging, and risk factors. Neurology. 1998;50(4):895–901.PubMedGoogle Scholar
  33. 33.
    Brott TG, Hobson RW II, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11–23.PubMedPubMedCentralGoogle Scholar
  34. 34.
    Barbut D, Grassineau D, Lis E, Heier L, Hartman GS, Isom OW. Posterior distribution of infarcts in strokes related to cardiac operations. Ann Thorac Surg. 1998;65(6):1656–9.PubMedGoogle Scholar
  35. 35.
    de Waard DD, de Borst GJ, Bulbulia R, Huibers A, Halliday A, Asymptomatic Carotid Surgery Trial-1 Collaborative Group. Diastolic blood pressure is a risk factor for peri-procedural stroke following carotid endarterectomy in asymptomatic patients. Eur J Vasc Endovasc Surg. 2017;53(5):626–31.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Head SJ, Milojevic M, Daemen J, Ahn JM, Boersma E, Christiansen EH, et al. Stroke rates following surgical versus percutaneous coronary revascularization. J Am Coll Cardiol. 2018;72(4):386–98.PubMedGoogle Scholar
  37. 37.
    van Dijk D, Spoor M, Hijman R, Nathoe HM, Borst C, Jansen EWL, et al. Cognitive and cardiac outcomes 5 years after off-pump vs on-pump coronary artery bypass graft surgery. JAMA. 2007;297(7):701–8.PubMedGoogle Scholar
  38. 38.
    Hueb W, et al. Five-year follow-up of a randomized comparison between off-pump and on-pump stable multivessel coronary artery bypass grafting. The MASS III Trial. Circulation. 2010;122(11 Suppl):S48–52.PubMedGoogle Scholar
  39. 39.
    Puskas JD, Williams WH, O’Donnell R, Patterson RE, Sigman SR, Smith AS, et al. Off-pump and on-pump coronary artery bypass grafting are associated with similar graft patency, myocardial ischemia, and freedom from reintervention: long-term follow-up of a randomized trial. Ann Thorac Surg. 2011;91(6):1836–42 discussion 1842-3.PubMedGoogle Scholar
  40. 40.
    Likosky DS, Baker RA. Five-year outcomes after off-pump or on-pump coronary-artery bypass grafting. N Engl J Med. 2017;376(9):894.PubMedGoogle Scholar
  41. 41.
    Kahlert P, Knipp SC, Schlamann M, Thielmann M, al-Rashid F, Weber M, et al. Silent and apparent cerebral ischemia after percutaneous transfemoral aortic valve implantation: a diffusion-weighted magnetic resonance imaging study. Circulation. 2010;121(7):870–8.PubMedGoogle Scholar
  42. 42.
    Holmes DR Jr, Brennan JM, Rumsfeld JS, Dai D, O’Brien SM, Vemulapalli S, et al. Clinical outcomes at 1 year following transcatheter aortic valve replacement. Jama. 2015;313(10):1019–28.PubMedGoogle Scholar
  43. 43.
    Kapadia S, et al. Insights into timing, risk factors, and outcomes of stroke and transient ischemic attack after transcatheter aortic valve replacement in the PARTNER Trial (Placement of Aortic Transcatheter Valves). Circ Cardiovasc Interv. 2016;9(9).Google Scholar
  44. 44.
    Blackstone EH, Suri RM, Rajeswaran J, Babaliaros V, Douglas PS, Fearon WF, et al. Propensity-matched comparisons of clinical outcomes after transapical or transfemoral transcatheter aortic valve replacement: a placement of aortic transcatheter valves (PARTNER)-I trial substudy. Circulation. 2015;131(22):1989–2000.PubMedGoogle Scholar
  45. 45.
    Van Mieghem NM, et al. Incidence and predictors of debris embolizing to the brain during transcatheter aortic valve implantation. JACC Cardiovasc Interv. 2015;8(5):718–24.PubMedGoogle Scholar
  46. 46.
    Mack MJ, Leon MB, Thourani VH, Makkar R, Kodali SK, Russo M, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med. 2019;380(18):1695–705.PubMedGoogle Scholar
  47. 47.
    Popma JJ, Deeb GM, Yakubov SJ, Mumtaz M, Gada H, O’Hair D, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med. 2019;380(18):1706–15.PubMedGoogle Scholar
  48. 48.
    Knipp SC, Matatko N, Schlamann M, Wilhelm H, Thielmann M, Forsting M, et al. Small ischemic brain lesions after cardiac valve replacement detected by diffusion-weighted magnetic resonance imaging: relation to neurocognitive function. Eur J Cardiothorac Surg. 2005;28(1):88–96.PubMedGoogle Scholar
  49. 49.
    Likosky DS, Marrin CAS, Caplan LR, Baribeau YR, Morton JR, Weintraub RM, et al. Determination of etiologic mechanisms of strokes secondary to coronary artery bypass graft surgery. Stroke. 2003;34(12):2830–4.PubMedGoogle Scholar
  50. 50.
    Elkind MS. Inflammatory mechanisms of stroke. Stroke. 2010;41(10 Suppl):S3–8.PubMedPubMedCentralGoogle Scholar
  51. 51.
    • Hillis LD, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2011;58(24):e123–210. Cardiology guidelines on presurgical carotid disease screening.PubMedGoogle Scholar
  52. 52.
    Naylor AR, Mehta Z, Rothwell PM. A systematic review and meta-analysis of 30-day outcomes following staged carotid artery stenting and coronary bypass. Eur J Vasc Endovasc Surg. 2009;37(4):379–87.PubMedGoogle Scholar
  53. 53.
    Weimar C, Bilbilis K, Rekowski J, Holst T, Beyersdorf F, Breuer M, et al. Safety of simultaneous coronary artery bypass grafting and carotid endarterectomy versus isolated coronary artery bypass grafting: a randomized clinical trial. Stroke. 2017;48(10):2769–75.PubMedPubMedCentralGoogle Scholar
  54. 54.
    • Kramer J, Abraham J, Jones PA. Carotid artery stenting before CABG: a better alternative to treat concomitant coronary and carotid artery disease. Stroke. 2006;37(6):1359; author reply 1360. Case series from single center showing benefit of carotid stenting prior to CABG.PubMedGoogle Scholar
  55. 55.
    • Jorgensen ME, et al. Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery. JAMA. 2014;312(3):269–77. Reports relevance of delay in surgery after stroke.PubMedGoogle Scholar
  56. 56.
    Hornor MA, Duane TM, Ehlers AP, Jensen EH, Brown PS Jr, Pohl D, et al. American College of Surgeons’ Guidelines for the Perioperative Management of Antithrombotic Medication. J Am Coll Surg. 2018;227(5):521–36 e1.PubMedGoogle Scholar
  57. 57.
    Christiansen MN, Andersson C, Gislason GH, Torp-Pedersen C, Sanders RD, Føge Jensen P, et al. Risks of cardiovascular adverse events and death in patients with previous stroke undergoing emergency noncardiac, nonintracranial surgery: the importance of operative Timing. Anesthesiology. 2017;127(1):9–19.PubMedGoogle Scholar
  58. 58.
    Ferraris VA, Saha SP, Oestreich JH, Song HK, Rosengart T, Reece TB, et al. 2012 update to the Society of Thoracic Surgeons guideline on use of antiplatelet drugs in patients having cardiac and noncardiac operations. Ann Thorac Surg. 2012;94(5):1761–81.PubMedGoogle Scholar
  59. 59.
    Vazquez-Alonso E, et al. National survey on thromboprophylaxis and anticoagulant or antiplatelet management in neurosurgical and neurocritical patients. Rev Esp Anestesiol Reanim. 2015;62(10):557–64.PubMedGoogle Scholar
  60. 60.
    Greenwald DA. Managing antithrombotic agents during endoscopy. Best Pract Res Clin Gastroenterol. 2016;30(5):679–87.PubMedGoogle Scholar
  61. 61.
    Feagins LA. Management of anticoagulants and antiplatelet agents during colonoscopy. Am J Med. 2017;130(7):786–95.PubMedGoogle Scholar
  62. 62.
    Lusk KA, Snoga JL, Benitez RM, Sarbacker GB. Management of direct-acting oral anticoagulants surrounding dental procedures with low-to-moderate risk of bleeding. J Pharm Pract. 2018;31(2):202–7.PubMedGoogle Scholar
  63. 63.
    Omran H, Bauersachs R, Rübenacker S, Goss F, Hammerstingl C. The HAS-BLED score predicts bleedings during bridging of chronic oral anticoagulation. Results from the national multicentre BNK Online bRiDging REgistRy (BORDER). Thromb Haemost. 2012;108(1):65–73.PubMedGoogle Scholar
  64. 64.
    Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e326S–50S.PubMedPubMedCentralGoogle Scholar
  65. 65.
    •• Douketis JD, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373(9):823–33. The value of anticoagulation bridging during the periperative period.PubMedPubMedCentralGoogle Scholar
  66. 66.
    Group PS, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371(9627):1839–47.Google Scholar
  67. 67.
    • Sun LY, et al. Defining an intraoperative hypotension threshold in association with stroke in cardiac surgery. Anesthesiology. 2018;129(3):440–7. The importance of intraoperative hypotension is a major contributor to perioperative stroke.PubMedGoogle Scholar
  68. 68.
    Giustino G, Mehran R, Veltkamp R, Faggioni M, Baber U, Dangas GD. Neurological outcomes with embolic protection devices in patients undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis of randomized controlled trials. JACC Cardiovasc Interv. 2016;9(20):2124–33.PubMedGoogle Scholar
  69. 69.
    Edmonds HL Jr. Multi-modality neurophysiologic monitoring for cardiac surgery. Heart Surg Forum. 2002;5(3):225–8.PubMedGoogle Scholar
  70. 70.
    January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):e1–76.PubMedGoogle Scholar
  71. 71.
    • Kirchhof P, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Kardiol Pol. 2016;74(12):1359–469. The importance of atrial fibrillation duration when considering oral anticoagulation for perioperative atrial fibrillation.PubMedGoogle Scholar
  72. 72.
    Sanna T, Diener HC, Passman RS, di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014;370(26):2478–86.PubMedGoogle Scholar
  73. 73.
    Anderson E, Dyke C, Levy JH. Anticoagulation strategies for the management of postoperative atrial fibrillation. Clin Lab Med. 2014;34(3):537–61.PubMedGoogle Scholar
  74. 74.
    Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870–947.PubMedGoogle Scholar
  75. 75.
    •• Nogueira RG, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378(1):11–21. Groundbreaking trial which makes the intervention for stroke possible in patients in prolonged window.PubMedGoogle Scholar
  76. 76.
    •• Albers GW, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378(8):708–18. Groundbreaking trial which makes the intervention for stroke possible in patients in prolonged window.PubMedPubMedCentralGoogle Scholar
  77. 77.
    • Fountain RB, et al. The PROTECT AF (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients with Atrial Fibrillation) trial. Am Heart J. 2006;151(5):956–61. Shows advancement in stroke prevention and left atrial appendage occluder is now an option for patients with atrial fibrillation ineligible for oral aticoagulation.PubMedGoogle Scholar
  78. 78.
    Reddy VY, Doshi SK, Sievert H, Buchbinder M, Neuzil P, Huber K, et al. Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3-year follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) trial. Circulation. 2013;127(6):720–9.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Dilip Kumar Jayaraman
    • 1
  • Sandhya Mehla
    • 1
  • Saurabh Joshi
    • 2
  • Divya Rajasekaran
    • 3
  • Richard P. GoddeauJr
    • 1
    Email author
  1. 1.Department of NeurologyUniversity of Massachusetts Medical SchoolWorcesterUSA
  2. 2.Division of Cardiology, Department of MedicineUniversity of Connecticut School of MedicineFarmingtonUSA
  3. 3.Division of Neuroradiology, Department of RadiologyUniversity of Massachusetts Medical SchoolWorcesterUSA

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