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Kroeze VJ, Olsthoorn JR, van Straten AHM, Princee A, Soliman-Hamad MA. Predictors and Outcomes of Stroke After Isolated Coronary Artery Bypass Grafting. A Single-Center Experience in 20,582 Patients. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00246-X. [PMID: 37149473 DOI: 10.1053/j.jvca.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/15/2023] [Accepted: 04/07/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE Stroke remains a devastating complication after cardiac surgical procedures despite perioperative monitoring and management advances. This study aimed to determine the predictors of stroke in a large, contemporary coronary artery surgery population. DESIGN Patient data were analyzed retrospectively. SETTING This single-center study was performed in the Catharina Hospital (Eindhoven). PARTICIPANTS All patients who underwent isolated coronary artery bypass grafting (CABG) between January 1998 and February 2019 were included. INTERVENTIONS Isolated CABG. MEASUREMENTS AND MAIN RESULTS The primary endpoint was a postoperative stroke, defined according to the international updated definition for stroke. Logistic regression was performed to retrieve variables associated with postoperative stroke. A total of 20,582 patients underwent CABG during the period of the study. Stroke was observed in 142 patients (0.7%), of which 75 (52.8%) occurred during the first 72 hours. The incidence of postoperative stroke declined over the years. A significantly higher 30-day mortality rate was seen in patients with stroke (20.4%) compared with 1.8% in the rest of the population; p < 0.001. Multivariate logistic regression analysis showed age, peripheral arterial disease, reexploration for bleeding, perioperative myocardial infarction, and year of surgery as independent predictors for stroke. Patients with postoperative stroke had worse long-term survival (log-rank p < 0.001). Cox regression analysis revealed postoperative stroke (odds ratio 2.13 [1.73-2.64)) as an independent predictor of late mortality. CONCLUSIONS Stroke after CABG is associated with high early and late mortality. Age, peripheral vascular disease, and the year of surgery were associated with postoperative stroke.
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Affiliation(s)
- Vincent J Kroeze
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jules R Olsthoorn
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Anouk Princee
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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Letsou GV, Musfee FI, Zhang Q, Loor G, Lee AD. Stroke and mortality rates after off-pump vs. pump-assisted/no-clamp coronary artery bypass grafting. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:742-748. [PMID: 36168952 DOI: 10.23736/s0021-9509.22.12337-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Ascending aorta manipulation during on-pump coronary artery bypass grafting (CABG) surgery can release embolic matter and may cause stroke. Strategies for lowering the stroke rate associated with coronary artery bypass grafting surgery include off-pump surgery without cardiopulmonary bypass and pump-assisted surgery with minimal aortic manipulation (i.e., without aortic cross-clamping). We examined whether one approach is superior to the other in reducing stroke and perioperative mortality rates. METHODS We reviewed consecutive elective, urgent, and emergency off-pump/no-bypass and pump-assisted/no-clamp coronary artery bypass grafting procedures performed by a single surgeon at our institution from June 2011 through October 2017. RESULTS Of 570 patients analyzed, 395 (69.3%) underwent off-pump/no-bypass surgery, 43 (7.5%) underwent pump-assisted/no-clamp surgery, and 132 (23.2%) transitioned mid-procedure from off-pump/no-bypass to pump-assisted/no-clamp surgery. Patients who were >70 years old, were female, or had diabetes, cardiomegaly, or a history of myocardial infarction or congestive heart failure were more likely to undergo pump-assisted/no-clamp surgery or the combined technique. None of the pump-assisted/no-clamp patients had a stroke, versus 0.3% of the off-pump/no-bypass patients and 0.8% of the combination patients. Stroke and in-hospital mortality rates did not differ by technique. CONCLUSIONS A hybrid strategy incorporating off-pump, pump-assisted, and combined off-pump/pump-assisted techniques achieved very low stroke rates in patients undergoing coronary revascularization. Perioperative mortality was similar for all three techniques. Avoiding aortic clamping may be crucial for decreasing CABG-related stroke rates. Off-pump/no-bypass surgery had no significant advantage over the pump-assisted/no-clamp or combined techniques in reducing the stroke rate after coronary artery bypass grafting surgery.
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Affiliation(s)
- George V Letsou
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Cardiothoracic Transplantation and Circulatory Support, Texas Heart Institute, Houston, TX, USA
| | - Fadi I Musfee
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UT Health School of Public Health, Houston, TX, USA
| | - Qianzi Zhang
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Gabriel Loor
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Cardiothoracic Transplantation and Circulatory Support, Texas Heart Institute, Houston, TX, USA
| | - Andrew D Lee
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
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Stanley ME, Sellke FW. Neurocognitive decline in cardiac surgery patients: what do we know? J Thorac Cardiovasc Surg 2022:S0022-5223(22)00825-X. [DOI: 10.1016/j.jtcvs.2022.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/15/2022] [Accepted: 07/28/2022] [Indexed: 10/16/2022]
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Machado RJ, Saraiva FA, Mancio J, Sousa P, Cerqueira RJ, Barros AS, Lourenço AP, Leite-Moreira AF. A systematic review and meta-analysis of randomized controlled studies comparing off-pump versus on-pump coronary artery bypass grafting in the elderly. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 63:60-68. [PMID: 34792312 DOI: 10.23736/s0021-9509.21.12012-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIM Comparison of short and mid-term outcomes between off-pump CABG (OPCAB) and on-pump CABG (ONCAB) in patients older than 65 throughout a meta-analysis of randomized clinical trials (RCTs). EVIDENCE ACQUISITION A literature search was conducted using 3 databases. RCTs reporting mortality outcomes of OPCAB versus ONCAB among the elderly were included. Data on myocardial infarction, stroke, re-revascularization, renal failure and composite endpoints after CABG were also collected. Random effects models were used to compute statistical combined measures and 95% confidence intervals (CI). EVIDENCE SYNTHESIS Five RCTs encompassing 6221 patients were included (3105 OPCAB and 3116 ONCAB). There were no significant differences on mid-term mortality (pooled HR: 1.02, 95%CI: 0.89-1.17, p=0.80) and composite endpoint incidence (pooled HR: 0.98, 95%CI: 0.88-1.09, p=0.72) between OPCAB and ONCAB. At 30-day, there were no differences in mortality, myocardial infarction, stroke and renal complications. The need for early re-revascularization was significantly higher in OPCAB (pooled OR: 3.22, 95%CI: 1.28-8.09, p=0.01), with a higher percentage of incomplete revascularization being reported for OPCAB in trials included in this pooled result (34% in OPCAB vs 29% in ONCAB, p<0.01). CONCLUSIONS Data from RCTs in elderly patients showed that OPCAB and ONCAB provide similar mid-term results. OPCAB was associated with a higher risk of early rerevascularization. As CABG on the elderly is still insufficiently explored, further RCTs, specifically designed targeting this population, are needed to establish a better CABG strategy for these patients.
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Affiliation(s)
- Rui J Machado
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Francisca A Saraiva
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jennifer Mancio
- Intensive Care and Perioperative Medicine Department, Royal Brompton and Harefield & Guys and St. Thomas NHS Foundation Trust, London, UK
| | - Patrícia Sousa
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rui J Cerqueira
- Cardiothoracic Surgery Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - António S Barros
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - André P Lourenço
- Anaesthesiology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Adelino F Leite-Moreira
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal - .,Cardiothoracic Surgery Department, Centro Hospitalar Universitário São João, Porto, Portugal
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The relationship between aortic calcification on chest radiograph and neurocognitive impairment after coronary artery bypass grafting. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:166-173. [PMID: 34104510 PMCID: PMC8167480 DOI: 10.5606/tgkdc.dergisi.2021.21285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/04/2021] [Indexed: 11/22/2022]
Abstract
Background
In this study, we aimed to investigate the possible relationship between aortic calcification as detected by preoperative chest radiography and postoperative neurocognitive impairment in patients undergoing coronary artery bypass grafting.
Methods
A total of 124 patients (101 males, 23 females; mean age: 59.9±8.8 years; range, 34 to 84 years) who underwent coronary artery bypass grafting in our clinic between January 2019 and July 2019 were included. Of these patients, 35 whose preoperative chest radiography revealed aortic calcification in the aortic knuckle were included as the patient group. The control group consisted of 89 patients without aortic calcification. The patients with aortic calcification underwent additional imaging with thoracic computed tomography angiography and ascending aorta and aortic arch calcium scores were calculated. Neurocognitive dysfunction was assessed using the Standardized Mini-Mental State Examination. Postoperative delirium was evaluated by confusion assessment method in the intensive care unit. Both groups were compared for demographic, operative and postoperative data.
Results
Of all patients included in the study, the overall cerebrovascular event incidence was 3.2%. Although not statistically significant, the number of patients with neurocognitive decline was higher in the patient group than the control group (48.6% vs. 34.8%, respectively; p=0.157). Both Standardized Mini-Mental State Examination score decline and percentage decline were significantly higher in the patients with high aortic arch calcium scores (>2,250 AU). Carotid artery stenosis was 3.2 times higher in the patient group. In the patients with carotid artery stenosis, the aortic arch calcium scores were also higher (p=0.042).
Conclusion
Aortic calcification detectable on chest radiography with high calcium scores may be associated with neurocognitive impairment and carotid artery stenosis in patients undergoing coronary artery bypass grafting.
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Gatto CST, Piccioni MA, Strunz CMC, Cestari IA, Cunha LCC, Roggerio A, Silva VMD, Zuccato MCF, Cortella LRX, Kakoi AAY, Jatene FB, Auler Junior JOC, Galas FRBG. Blood cell adhesion to arterial filters analysis by scanning electron microscopy and real-time PCR assay: observational clinical study in cardiac surgery patients. Perfusion 2021; 37:144-151. [PMID: 33570010 DOI: 10.1177/0267659120986525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Arterial filter is the part of the cardiopulmonary bypass circuit where blood cells are exposed to high mechanical stress and where cellular aggregates may fasten in large quantities. The aim of this study was to analyse blood cell adhesiveness in the arterial filter through scanning electron microscopy and real-time PCR assay. METHODS Prospective, clinical and observational study performed on 28 patients undergoing cardiac surgery with cardiopulmonary bypass. Arterial filters were analysed by scanning electron microscopy. Real-time PCR assay was performed in extracted material from the arterial filters for analysis of platelet GPIb and CD45 leucocyte gene expression. Blood coagulation was analysed during cardiopulmonary bypass. Patients were followed until hospital discharge or 28 days after surgery. RESULTS All studied arterial filters used in the subject patients showed a degree of adhesion from blood elements at scanning electron microscopy. All studied filters were positive for platelets GPIb gene expression and 15% had CD45 leucocyte gene expression. The GPIb platelet gene expression in blood lowered at the end of cardiopulmonary bypass (p = 0.019). There was negative correlation between blood GPIb platelet gene expression and Clot SR (HEPSCREEN2 ReoRox®) (rho = 0.635; p = 0.027). The filter fields count was correlated to the D-dimer dosage (rho = 0.828; p < 0.001). CONCLUSION There was adhesion of blood elements, especially nucleated platelets, on all arterial filters studied. Although the arterial filter worked as a safety device, that possibly prevented arterial embolisation, it may also have caused greater hyperfibrinolysis during cardiopulmonary bypass.
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Affiliation(s)
| | - Marilde Albuquerque Piccioni
- Anesthesiology Department, InCor Heart Institute of Clinical Hospital of University of São Paulo, São Paulo, Brazil
| | - Celia Maria Cassaro Strunz
- Clinical Laboratory, InCor Heart Institute of Clinical Hospital of University of São Paulo, São Paulo, Brazil
| | - Idágene Aparecida Cestari
- Bioengineering Department, InCor Heart Institute of Clinical Hospital of University of São Paulo, São Paulo, Brazil
| | - Ligia Cristina Camara Cunha
- Anesthesiology Department, InCor Heart Institute of Clinical Hospital of University of São Paulo, São Paulo, Brazil
| | - Alessandra Roggerio
- Clinical Laboratory, InCor Heart Institute of Clinical Hospital of University of São Paulo, São Paulo, Brazil
| | - Vanessa Monteiro da Silva
- Clinical Laboratory, InCor Heart Institute of Clinical Hospital of University of São Paulo, São Paulo, Brazil
| | | | | | - Adélia Aparecida Yuka Kakoi
- Bioengineering Department, InCor Heart Institute of Clinical Hospital of University of São Paulo, São Paulo, Brazil
| | - Fabio Biscegli Jatene
- Cardiovascular Surgery Department, InCor Heart Institute of Clinical Hospital of University of São Paulo, São Paulo, Brazil
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Bouchez S, De Somer F. The evolving role of the modern perfusionist: insights from transesophageal echocardiography. Perfusion 2020; 36:222-232. [PMID: 32729372 DOI: 10.1177/0267659120944094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transesophageal echocardiography is a relatively non-invasive, mobile, safe imaging technique that is ideal for providing real-time information on cardiac anatomy and function during heart surgery. The technology has evolved from two-dimensional to real-time three-dimensional imaging during cardiac procedures, which has significantly benefited preoperative planning, intraoperative guidance, evaluation, and postoperative follow-up. Transesophageal echocardiography may serve the clinical perfusionist by providing imaging guidance for identifying potential problems before cardiopulmonary bypass, guiding the proper placement of cannulas, monitoring cardiac performance on cardiopulmonary bypass, and providing useful feedback during weaning from cardiopulmonary bypass. Although the perfusionist should be able to understand all echocardiographic images and measurements in depth, perfusion-related echocardiographic information can or should be used to optimize the clinical practice of the modern perfusionist. Vice versa, whenever the perfusionist suspects a problem, the surgical team including the sonographer should verify this "clinical treat" by echocardiography whenever possible.
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Affiliation(s)
- Stefaan Bouchez
- Department of Anesthesiology, Ghent University Hospital, Ghent, Belgium
| | - Filip De Somer
- Department of Cardiac Surgery, Ghent University Hospital, Ghent, Belgium
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Lorusso R, Moscarelli M, Di Franco A, Grazioli V, Nicolini F, Gherli T, De Bonis M, Taramasso M, Villa E, Troise G, Scrofani R, Antona C, Mariscalco G, Beghi C, Miceli A, Glauber M, Ranucci M, De Vincentiis C, Gaudino M. Association Between Coronary Artery Bypass Surgical Techniques and Postoperative Stroke. J Am Heart Assoc 2019; 8:e013650. [PMID: 31830873 PMCID: PMC6951073 DOI: 10.1161/jaha.119.013650] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The impact of the coronary artery bypass grafting (CABG) technique (on- versus off-pump, single versus multiple aortic clamping) on postoperative neurological outcome remains a matter of controversy. The aim of this study was to assess the association between the incidence of postoperative stroke and the degree of aortic manipulation in one of the largest contemporary CABG series. Methods and Results A retrospective, multicenter, international study was conducted in 25 388 patients undergoing isolated CABG procedures with on-pump CABG (ONCAB) or off-pump CABG (OPCAB) technique including single or multiple aortic clamping. Postoperative stroke was defined as a postoperative neurological deficit lasting more than 24 hours and associated with evidence of a brain lesion on computed tomography. The degree of aortic manipulation was assumed to be higher for on-pump versus off-pump surgery and for multiple versus single or no aortic clamping. Logistic regression and propensity matching were used. ONCAB procedures were performed in 17 231 cases and OPCAB in 8157. The incidence of postoperative stroke was significantly lower in the OPCAB group even after propensity matching (0.4% OPCAB versus 1.2% ONCAB, P=0.02). In the ONCAB group (but not in the OPCAB arm) the use of single aortic clamping was associated with significantly reduced postoperative stroke rate (odds ratio, 0.05; 95% CI, 0.008 to 0.07 [P<0.001]). Conclusions OPCAB and the use of single aortic clamping in the ONCAB arm were associated with a reduced incidence of postoperative stroke. Our data confirm a strong association between aortic manipulation and neurological outcome after CABG surgery.
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Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Unit, Heart and Vascular Centre Maastricht University Medical Centre (MUMC) Cardiovascular Research Institute Maastricht (CARIM) Maastricht The Netherlands.,Cardiac Surgery Unit Community Hospital Brescia Italy
| | - Marco Moscarelli
- Cardiothoracic and Vascular Department Maria Cecilia Hospital GVM Care & Research Cotignola (RA) Italy
| | - Antonino Di Franco
- Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York NY
| | | | | | - Tiziano Gherli
- Cardiac Surgery Unit Ospedale Maggiore University of Parma Italy
| | - Michele De Bonis
- Cardiac Surgery Unit San Raffaele Hospital University of Milan Italy
| | | | - Emmanuel Villa
- Cardiac Surgery Unit Poliambulanza Hospital Fondazione Poliambulanza Brescia Italy
| | - Giovanni Troise
- Cardiac Surgery Unit Poliambulanza Hospital Fondazione Poliambulanza Brescia Italy
| | | | - Carlo Antona
- Cardiac Surgery Unit Ospedale Sacco University of Milan Italy
| | | | - Cesare Beghi
- Cardiac Surgery Unit Ospedale di Circolo University of Varese Italy
| | | | | | - Marco Ranucci
- Cardiac Surgery and Intensive Care Units S. Donato Hospital IRCCS University of Milan Italy
| | - Carlo De Vincentiis
- Cardiac Surgery and Intensive Care Units S. Donato Hospital IRCCS University of Milan Italy
| | - Mario Gaudino
- Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York NY
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Gaudino M, Benedetto U, Bakaeen F, Rahouma M, Tam DY, Abouarab A, Di Franco A, Leonard J, Elmously A, Puskas JD, Angelini GD, Girardi LN, Fremes SE, Taggart DP. Off- Versus On-Pump Coronary Surgery and the Effect of Follow-Up Length and Surgeons' Experience: A Meta-Analysis. J Am Heart Assoc 2019; 7:e010034. [PMID: 30373421 PMCID: PMC6404195 DOI: 10.1161/jaha.118.010034] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background The debate on the relative benefits of off‐pump and on‐pump coronary artery bypass surgery (OPCABG and ONCABG) is still open. We aimed to provide an updated and complete summary of the evidence on the differences between OPCABG and ONCABG and to explore whether the length of the follow‐up and the surgeons’ experience in OPCABG modify the comparative results. Methods and Results All randomized clinical trials comparing OPCABG and ONCABG were included. Primary outcome was follow‐up mortality. Secondary outcomes were operative mortality, perioperative stroke, perioperative myocardial infarction, and late repeated revascularization. Subgroup analyses were performed based on the length of the follow‐up and the percentage of crossover from the OPCABG group (used as a surrogate of surgeon experience with OPCABG). One hundred four trials were included (20 627 patients, OPCABG: 10 288; ONCABG: 10 339). Weighted mean follow‐up time was 3.7 years (range 1–7.5 years). OPCABG was associated with a higher risk of follow‐up mortality (incidence rate ratio 1.11, 95% confidence interval 1.00–1.23, P=0.05). The difference was significant only for trials with mean follow‐up of ≥3 years and for studies with a crossover rate of ≥10%. There was a trend toward lower risk of perioperative stroke and higher need for late repeated revascularization in the OPCABG arm. Conclusions OPCABG is associated with a higher incidence of incomplete revascularization, an increased need for repeated revascularization, and decreased midterm survival compared with ONCABG. Surgeon inexperience in OPCABG is associated with late mortality. See Editorial by Lazar
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Affiliation(s)
- Mario Gaudino
- 1 Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York City NY
| | - Umberto Benedetto
- 2 Bristol Heart Institute School of Clinical Sciences University of Bristol United Kingdom
| | - Faisal Bakaeen
- 3 Department of Thoracic and Cardiovascular Surgery Cleveland Clinic Cleveland OH
| | - Mohamed Rahouma
- 1 Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York City NY
| | - Derrick Y Tam
- 4 Schulich Heart Centre Sunnybrook Health Science University of Toronto Canada
| | - Ahmed Abouarab
- 1 Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York City NY
| | - Antonino Di Franco
- 1 Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York City NY
| | - Jeremy Leonard
- 1 Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York City NY
| | - Adham Elmously
- 1 Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York City NY
| | - John D Puskas
- 5 Department of Cardiovascular Surgery Icahn School of Medicine at Mount Sinai New York City NY
| | - Gianni D Angelini
- 2 Bristol Heart Institute School of Clinical Sciences University of Bristol United Kingdom
| | - Leonard N Girardi
- 1 Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York City NY
| | - Stephen E Fremes
- 4 Schulich Heart Centre Sunnybrook Health Science University of Toronto Canada
| | - David P Taggart
- 6 Nuffield Department of Surgical Sciences University of Oxford United Kingdom
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Alekseevich GY, Rodikov MV, Marchenko AV, Myalyuk PA, Alekseevich GV. [An analysis of postoperative cognitive dysfunction in different methods of coronary artery bypass]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:16-20. [PMID: 28805755 DOI: 10.17116/jnevro20171177116-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To evaluate changes in cognitive functions in patients with coronary heart disease before and after coronary artery bypass grafting (CABG) in a planned manner. MATERIAL AND METHODS The study included 192 patients divided into 3 groups: in group 1 patients (n=88) underwent standard CABG; in group 2 (n=61) different methods of CABG were used; a control group consisted of 43 people. MMSE, FAB, Clock drawing test, Shultz tables, semantic verbal fluency, Wechsler adult intelligence scale were used for neurological testing. RESULTS AND CONCLUSION Postoperative cognitive dysfunction develops 3.2 times more often in patients after standard CABG. Patients in the group with a differentiated approach show a trend towards the improvement of cognitive functions after surgery.
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Affiliation(s)
- G Yu Alekseevich
- Krasnoyarsk State Medical University named after prof. V.F. Voyno-Yasenetsky, Krasnoyarsk, Russia
| | - M V Rodikov
- Krasnoyarsk State Medical University named after prof. V.F. Voyno-Yasenetsky, Krasnoyarsk, Russia
| | - A V Marchenko
- Federal Center for Cardiovascular Surgery, Perm, Russia
| | - P A Myalyuk
- Federal Center for Cardiovascular Surgery, Perm, Russia
| | - G V Alekseevich
- Krasnoyarsk State Medical University named after prof. V.F. Voyno-Yasenetsky, Krasnoyarsk, Russia
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Halkos ME, Anderson A, Binongo JNG, Stringer A, Lasanajak Y, Thourani VH, Lattouf OM, Guyton RA, Baio KT, Sarin E, Keeling WB, Cook NR, Carssow K, Neill A, Glas KE, Puskas JD. Operative strategies to reduce cerebral embolic events during on- and off-pump coronary artery bypass surgery: A stratified, prospective randomized trial. J Thorac Cardiovasc Surg 2017; 154:1278-1285.e1. [PMID: 28728785 DOI: 10.1016/j.jtcvs.2017.04.089] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 03/08/2017] [Accepted: 04/10/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To determine the impact of different aortic clamping strategies on the incidence of cerebral embolic events during coronary artery bypass grafting (CABG). METHODS Between 2012 and 2015, 142 patients with low-grade aortic disease (epiaortic ultrasound grade I/II) undergoing primary isolated CABG were studied. Those undergoing off-pump CABG were randomized to a partial clamp (n = 36) or clampless facilitating device (CFD; n = 36) strategy. Those undergoing on-pump CABG were randomized to a single-clamp (n = 34) or double-clamp (n = 36) strategy. Transcranial Doppler ultrasonography (TCD) was performed to identify high-intensity transient signals (HITS) in the middle cerebral arteries during periods of aortic manipulation. Neurocognitive testing was performed at baseline and 30-days postoperatively. The primary endpoint was total number of HITS detected by TCD. Groups were compared using the Mann-Whitney U test. RESULTS In the off-pump group, the median number of total HITS were higher in the CFD subgroup (30.0; interquartile range [IQR], 22-43) compared with the partial clamp subgroup (7.0; IQR, 0-16; P < .0001). In the CFD subgroup, the median number of total HITS was significantly lower for patients with 1 CFD compared with patients with >1 CFD (12.5 [IQR, 4-19] vs 36.0 [IQR, 25-47]; P = .001). In the on-pump group, the median number of total HITS was 10.0 (IQR, 3-17) in the single-clamp group, compared with 16.0 (IQR, 4-49) in the double-clamp group (P = .10). There were no differences in neurocognitive outcomes across the groups. CONCLUSIONS For patients with low-grade aortic disease, the use of CFDs was associated with an increased rate of cerebral embolic events compared with partial clamping during off-pump CABG. A single-clamp strategy during on-pump CABG did not significantly reduce embolic events compared with a double-clamp strategy.
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Affiliation(s)
- Michael E Halkos
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga.
| | - Aaron Anderson
- Department of Neurology, Emory University School of Medicine, Atlanta, Ga
| | - Jose Nilo G Binongo
- Rollins School of Public Health, Emory University School of Medicine, Atlanta, Ga
| | - Anthony Stringer
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Ga
| | - Yi Lasanajak
- Rollins School of Public Health, Emory University School of Medicine, Atlanta, Ga
| | - Vinod H Thourani
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Omar M Lattouf
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Robert A Guyton
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Kim T Baio
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Eric Sarin
- Department of Cardiothoracic Surgery, Inova Fairfax Healthcare System, Falls Church, Va
| | - William B Keeling
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - N Renee Cook
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Katherine Carssow
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Alexis Neill
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Kathryn E Glas
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Ga
| | - John D Puskas
- Department of Cardiothoracic Surgery, Mount Sinai University School of Medicine, New York, NY
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Bhamidipati D, Goldhammer JE, Sperling MR, Torjman MC, McCarey MM, Whellan DJ. Cognitive Outcomes After Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2017; 31:707-718. [DOI: 10.1053/j.jvca.2016.09.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Indexed: 12/17/2022]
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13
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Fudulu D, Benedetto U, Pecchinenda GG, Chivasso P, Bruno VD, Rapetto F, Bryan A, Angelini GD. Current outcomes of off-pump versus on-pump coronary artery bypass grafting: evidence from randomized controlled trials. J Thorac Dis 2016; 8:S758-S771. [PMID: 27942394 DOI: 10.21037/jtd.2016.10.80] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Coronary artery bypass grafting remains the standard treatment for patients with extensive coronary artery disease. Coronary surgery without use of cardiopulmonary bypass avoids the deleterious systemic inflammatory effects of the extracorporeal circuit. However there is an ongoing debate surrounding the clinical outcomes after on-pump versus off-pump coronary artery bypass (ONCAB versus OPCAB) surgery. The current review is based on evidence from randomized controlled trials (RCTs) and meta-analyses of randomized studies. It focuses on operative mortality, mid- and long-term survival, graft patency, completeness of revascularisation, neurologic and neurophysiologic outcomes, perioperative complications and outcomes in the high risk groups. Early and late survival rates for both OPCAB and ONCAB grafting are similar. Some studies suggest early poorer vein graft patency with off-pump when compared with on-pump, comparable midterm arterial conduit patency with no difference in long term venous and arterial graft patency. A recent, pooled analysis of randomised trials shows a reduction in stroke rates with use off-pump techniques. Furthermore, OPCAB grafting seems to reduce postoperative renal dysfunction, bleeding, transfusion requirement and respiratory complications while perioperative myocardial infarction rates are similar to ONCAB grafting. The high risk patient groups seem to benefit from off-pump coronary surgery.
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Affiliation(s)
- Daniel Fudulu
- Bristol Heart Institute, University Hospitals Bristol, Bristol, UK
| | | | | | | | | | - Filippo Rapetto
- Bristol Heart Institute, University Hospitals Bristol, Bristol, UK
| | - Alan Bryan
- Bristol Heart Institute, University Hospitals Bristol, Bristol, UK
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Srivastava V, Purohit M, Bose A, Bittar MN, Rogers S, Zacharias J. Single crossclamp: Safe training tool for coronary artery bypass grafting. Asian Cardiovasc Thorac Ann 2016; 24:633-7. [PMID: 27388580 DOI: 10.1177/0218492316657242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 05/26/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The single-crossclamp technique for coronary artery bypass grafting is recognized to reduce manipulation of the ascending aorta, and thereby improve neurological outcomes. However, there is a perceived disadvantage of long cardiopulmonary bypass and crossclamp times. Our objective was to evaluate outcomes with this technique and determine whether it is safe for training. METHODS Patients undergoing coronary artery bypass between October 2005 and February 2014 with use of the single-crossclamp method were divided into 2 groups: a consultant group (n = 1024), and a trainee group (n = 504), depending on the primary surgeon. Their outcomes were compared. RESULTS The consultants operated on more nonelective patients who had a higher risk profile (mean additive EuroSCORE I 4.05 vs. 3.80, p = 0.085; logistic EuroSCORE I 4.36 vs. 3.64, p = 0.002). There were 9 (0.9%) deaths in the consultant group and 5 (1%) in the trainee group. The mean number of grafts in the consultant group was greater, but the crossclamp time was similar and cardiopulmonary bypass time was shorter. There were 4 (0.4%) cerebrovascular events in the consultant group and 3 (0.6%) in the trainee group. Postoperative stay was shorter in the trainee group (7.19 vs. 7.97 days, p = 0.033). Other complication rates were similar. CONCLUSIONS The technique has excellent outcomes, especially neurological, and is safe for training junior surgeons.
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Affiliation(s)
- Vivek Srivastava
- Department of Cardiothoracic Surgery, Victoria Hospital, Blackpool, UK
| | - Manoj Purohit
- Department of Cardiothoracic Surgery, Victoria Hospital, Blackpool, UK
| | - Amal Bose
- Department of Cardiothoracic Surgery, Victoria Hospital, Blackpool, UK
| | | | - Shaun Rogers
- Department of Cardiothoracic Surgery, Victoria Hospital, Blackpool, UK
| | - Joseph Zacharias
- Department of Cardiothoracic Surgery, Victoria Hospital, Blackpool, UK
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15
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Mack M. Can we make stroke during cardiac surgery a never event? J Thorac Cardiovasc Surg 2015; 149:965-7. [DOI: 10.1016/j.jtcvs.2014.12.072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 12/25/2014] [Accepted: 12/26/2014] [Indexed: 11/26/2022]
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16
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Cohn WE, Frazier OH, Mallidi HR, Cooley DA. Surgical Treatment of Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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17
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Moss E, Puskas JD, Thourani VH, Kilgo P, Chen EP, Leshnower BG, Lattouf OM, Guyton RA, Glas KE, Halkos ME. Avoiding aortic clamping during coronary artery bypass grafting reduces postoperative stroke. J Thorac Cardiovasc Surg 2014; 149:175-80. [PMID: 25293356 DOI: 10.1016/j.jtcvs.2014.09.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 08/31/2014] [Accepted: 09/08/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of this study was to determine whether the incidence of postoperative stroke could be reduced by eliminating aortic clamping during coronary artery bypass grafting. METHODS From 2002 to 2013, 12,079 patients underwent primary, isolated coronary artery bypass grafting at a single US academic institution. Aortic manipulation was completely avoided by using in situ internal thoracic arteries for inflow in 1552 patients (12.9%) (no-touch), a clampless facilitating device for proximal anastomoses in 1548 patients (12.8%), and aortic clamping in 8979 patients (74.3%). These strategies were assessed in a logistic regression model controlling for relevant variables. RESULTS The overall incidence of postoperative stroke was 1.4% (n = 165), with an unadjusted incidence of 0.6% (n = 10) in the no-touch group, 1.2% (n = 18) in the clampless facilitating device group, and 1.5% (n = 137) in the clamp group (P < .01 for no-touch vs clamp). The ratio of observed to expected stroke rate increased as the degree of aortic manipulation increased, from 0.48 in the no-touch group, to 0.61 in the clampless facilitating device group, and to 0.95 in the clamp group. Aortic clamping was independently associated with an increase in postoperative stroke compared with a no-touch technique (adjusted odds ratio, 2.50; P < .01). When separated by cardiopulmonary bypass use, both the off-pump partial clamp and the on-pump crossclamp techniques increased the risk of postoperative stroke compared with no-touch (adjusted odds ratio, 2.52, P < .01; and adjusted odds ratio, 4.25, P < .001, respectively). CONCLUSIONS A no-aortic touch technique has the lowest risk for postoperative stroke for patients undergoing coronary artery bypass grafting. Clamping the aorta during coronary artery bypass grafting increases the risk of postoperative stroke, regardless of the severity of aortic disease.
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Affiliation(s)
- Emmanuel Moss
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - John D Puskas
- Division of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY
| | - Vinod H Thourani
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Patrick Kilgo
- Rollins School of Public Health, Emory University, Atlanta, Ga
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Omar M Lattouf
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Robert A Guyton
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Kathryn E Glas
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Ga
| | - Michael E Halkos
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga.
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Khan MS, Islam MYU, Ahmed MU, Bawany FI, Khan A, Arshad MH. On pump coronary artery bypass graft surgery versus off pump coronary artery bypass graft surgery: a review. Glob J Health Sci 2014; 6:186-93. [PMID: 24762361 PMCID: PMC4825227 DOI: 10.5539/gjhs.v6n3p186] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 01/27/2014] [Accepted: 01/23/2014] [Indexed: 12/16/2022] Open
Abstract
There are two basic ways of performing coronary artery bypass graft surgery (CABG): on pump CABG and off pump CABG. Off pump CABG is relatively a newer procedure to on-pump CABG and does not require the use of the cardiopulmonary bypass machine. On pump CABG is the more traditional method of performing bypass surgery. However its resultant inflammatory effects cause renal dysfunction, gastrointestinal distress and cardiac abnormalities which have forced the surgeons to look for alternatives to the procedure. An extensive literature search revealed that on pump CABG causes better revascularization as compared to off pump CABG while off pump CABG has a much lower post operative morbidity and mortality especially in high risk patients. We suggest that the technique used should depend on the ease of the surgeon doing the operation as both the methods seem almost equally efficient according to the review.
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Gasparovic H, Borojevic M, Malojcic B, Gasparovic K, Biocina B. Single aortic clamping in coronary artery bypass surgery reduces cerebral embolism and improves neurocognitive outcomes. Vasc Med 2013; 18:275-81. [PMID: 24029541 DOI: 10.1177/1358863x13502699] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aortic manipulation releases embolic material, thereby enhancing the probability of adverse neurologic outcomes following coronary artery bypass grafting (CABG). We prospectively evaluated 59 patients undergoing CABG. Patients in the single (SC, n = 37) and multiple clamp (MC, n = 22) groups were comparable in relation to age and operative risk (p > 0.05). Neurocognitive evaluation consisted of the Auditory Verbal Learning Test (AVLT), Color Trails Test A, the Grooved Pegboard test and the Mini-Mental State Examination. Data acquisition was performed preoperatively, early postoperatively and at the 4-month follow-up. Intraoperative transcranial Doppler (TCD) monitoring was used to quantify the embolic load in relation to different aortic clamping strategies. Preoperative neurocognitive results were similar between the groups (p > 0.05). The incidence of postoperative delirium was greater in the MC group but this failed to reach statistical significance (23% vs 8%, p = 0.14). SC patients had fewer embolization signals (270 ± 181 vs 465 ± 160, p < 0.0001). Early postoperative neurocognitive results were depressed in comparison to preoperative values in both groups (p < 0.05 for multiple comparisons). The magnitude of this cognitive depression was greater in the MC group (p < 0.05 for multiple comparisons). Preoperative levels of neurocognition were restored at follow-up in the SC group in all tests except the AVLT. A trend towards improvements in neurocognitive performances at follow-up was also observed in the MC group. Residual attention, motor skill and memory deficits were, however, documented with multiple tests. In conclusion, the embolic burden was significantly lower in the SC group. This TCD imaging outcome translated into fewer early cognition deficits and superior late restoration of function.
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Affiliation(s)
- Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Rebro Zagreb, Zagreb, Croatia
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20
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Cavallaro P, Itagaki S, Seigerman M, Chikwe J. Operative mortality and stroke after on-pump vs off-pump surgery in high-risk patients: an analysis of 83 914 coronary bypass operations. Eur J Cardiothorac Surg 2013; 45:159-64. [DOI: 10.1093/ejcts/ezt221] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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21
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Borojevic M, Vrljic D, Biocina B. Impact of perioperative risk factors for the development of neurocognitive decline after cardiac surgery. Perfusion 2013; 28:463-4. [PMID: 23474748 DOI: 10.1177/0267659113478994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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22
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Daniel WT, Kilgo P, Puskas JD, Thourani VH, Lattouf OM, Guyton RA, Halkos ME. Trends in aortic clamp use during coronary artery bypass surgery: effect of aortic clamping strategies on neurologic outcomes. J Thorac Cardiovasc Surg 2013; 147:652-7. [PMID: 23477689 DOI: 10.1016/j.jtcvs.2013.02.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 01/10/2013] [Accepted: 02/12/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of the present study was to determine the effect of different clamping strategies during coronary artery bypass grafting on the incidence of postoperative stroke. METHODS In the present case-control study, all patients at Emory hospitals from 2002 to 2009 with postoperative stroke after isolated coronary artery bypass grafting (n = 141) were matched 1:4 to a contemporaneous cohort of patients without postoperative stroke (n = 565). The patients were matched according to the Society of Thoracic Surgeons' predicted risk of postoperative stroke score, which is based on 26 variables. The patients who received on-pump and off-pump coronary artery bypass grafting were matched separately. Multiple logistic regression analysis with adjusted odds ratios was performed to identify the operative variables associated with postoperative stroke. RESULTS Among the on-pump cohort, the single crossclamp technique was associated with a decreased risk of stroke compared with the double clamp (crossclamp plus partial clamp) technique (odds ratio, 0.385; P = .044). Within the on-pump cohort, no significant difference was seen in the incidence of stroke according to clamp use. Epiaortic ultrasound of the ascending aorta increased from 45.3% in 2002 to 89.4% in 2009. From 2002 to 2009, clamp use decreased from 97.7% of cases to 72.7%. CONCLUSIONS During on-pump coronary artery bypass grafting, the use of a single crossclamp compared with the double clamp technique decreased the risk of postoperative stroke. The use of any aortic clamp decreased and epiaortic ultrasound use increased from 2002 to 2009, indicating a change in the operative technique and surgeon awareness of the potential complications associated with manipulation of the aorta.
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Affiliation(s)
- William T Daniel
- Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Patrick Kilgo
- Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - John D Puskas
- Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Vinod H Thourani
- Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Omar M Lattouf
- Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Robert A Guyton
- Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Michael E Halkos
- Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga.
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Fontes MT, Swift RC, Phillips-Bute B, Podgoreanu MV, Stafford-Smith M, Newman MF, Mathew JP. Predictors of cognitive recovery after cardiac surgery. Anesth Analg 2013; 116:435-42. [PMID: 23302978 PMCID: PMC3553229 DOI: 10.1213/ane.0b013e318273f37e] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Postoperative neurocognitive decline occurs frequently. Although predictors of cognitive injury have been well examined, factors that modulate recovery have not. We sought to determine the predictors of cognitive recovery after initial injury following cardiac surgery. METHODS Two hundred eighty-one patients previously enrolled in cognitive studies who experienced cognitive decline 6 weeks after cardiac surgery were retrospectively evaluated. Eligible patients completed a battery of neurocognitive measures and quality-of-life assessments at baseline, 6 weeks, and 1 year after surgery. Factor analysis was conducted to calculate the cognitive index (CI), a unified, continuous measure of cognitive function. Cognitive recovery was defined as 1-year CI greater than baseline CI. Potential predictors of cognitive recovery including patient characteristics, quality-of-life factors, comorbidities, medications, and intraoperative variables were assessed with multivariable regression modeling; P<0.05 was considered significant. RESULTS Of the 229 patients in our final data set, 103 (45%) demonstrated cognitive recovery after initial decline in CI at 6 weeks. Multivariable analyses revealed that more education (odds ratio [OR] 1.332 [1.131-1.569], P<0.001), baseline CI (OR 0.987 [0.976-0.998], P=0.02), less decline in CI at 6 weeks (OR 1.044 [1.014-1.075], P=0.004), and greater activities of daily living at 6 weeks (OR 0.891 [0.810-0.981], P=0.02) were significant predictors of cognitive recovery. CONCLUSION Cognitive recovery occurred in approximately one half of the cardiac surgical patients experiencing early decline. The association between cognitive recovery and Instrumental Activities of Daily Living scores at 6 weeks merits further investigation as it is the only potentially modifiable predictor of recovery.
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Affiliation(s)
- Monique T Fontes
- Duke University Medical Center, Division of Cardiothoracic Anesthesiology and Critical Care Medicine, P.O. Box 3094, Durham, NC 27710, USA
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Borojevic M, Colak Z, Biocina B. Importance of standardization of surgical techniques in analyzing neurologic outcomes. J Thorac Cardiovasc Surg 2013; 145:611-2. [PMID: 23321137 DOI: 10.1016/j.jtcvs.2012.09.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Accepted: 09/21/2012] [Indexed: 11/25/2022]
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Lata AL, Hammon JW, Deal DD, Stump DA, Kincaid EH, Kon ND. Cannula design reduces particulate and gaseous emboli during cardiopulmonary bypass for coronary revascularization. Perfusion 2011; 26:239-44. [DOI: 10.1177/0267659110394905] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: The incidence of neurocognitive deficits after coronary bypass surgery remains problematic, with atheroembolism being one of the major causes. External manipulation of aorta and the “sandblasting” effect of the high-velocity perfusion jet can cause dislodgement of atheromatous debris. Description: A new arterial cannula features a tip configuration that diffuses the flow through multiple outlets, providing reduced velocity and shear with one central and three diverted flow streams. Evaluation: Between March 2007 and July 2008 twenty patients having isolated coronary artery bypass operations were instrumented with an Embolus Detection and Classification transducer. These data were compared to 43 patients from a previous study using similar techniques except for a standard open-tip arterial cannula. Total embolic counts were markedly lower in the new cannula group (20±25 vs 174±378) as were both gaseous (11±15 vs 95±211) and particulate counts (9±11 vs 80±194). Conclusions: The select 3D cannula design reduces the sandblasting effect of the perfusion jet and, also, may direct emboli from the heart and cardiopulmonary bypass equipment away from the cerebral circulation.
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Affiliation(s)
- Adrian L Lata
- Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA,
| | - John W Hammon
- Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Dwight D Deal
- Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - David A Stump
- Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Edward H Kincaid
- Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Neal D Kon
- Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Cann C, Wilkes AR, Hall JE, Kumar RA. Are we using our brains? Diagnosis of postoperative cognitive dysfunction. Anaesthesia 2010; 65:1166-9. [DOI: 10.1111/j.1365-2044.2010.06531.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Despite increasing competition from percutaneous interventions and other novel methods of non-surgical coronary revascularization, coronary artery bypass grafting (CABG) remains one of the most definitive and durable treatments for coronary artery disease, especially for those patients with extensive and diffuse disease. In recent years the CABG procedure itself has undergone innovation and evolution. This review article provides a brief historical perspective on the procedure, and examines the current state of modern variations including off-pump, limited-access, and robotic-assisted CABG.
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Affiliation(s)
- Frank W Sellke
- Department of Cardiothoracic Surgery, Alpert Medical School of Brown University, Providence, RI, USA.
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Gasparović H, Malojcić B, Borojević M, Vojković J, Gabelica R, Milicić D, Biocina B. Reduction of microembolic signals with a single-clamp strategy in coronary artery bypass surgery: a pilot study. Heart Surg Forum 2010; 12:E357-61. [PMID: 20037103 DOI: 10.1532/hsf98.20091127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Neurologic deficits are perhaps the most feared form of adverse outcome following cardiac surgery. Aortic trauma generates emboli and hence harbors the potential for neurocognitive injury. The single aortic clamp strategy of coronary artery bypass grafting (CABG) aims at reducing aortic manipulation. We hypothesized that this strategy will lead to a reduction in the number microembolic signals (MES) evaluated by transcranial Doppler (TCD), a surrogate measure of cerebral embolism. METHODS This pilot study was based on a prospective analysis of 22 patients in whom CABG was performed either with a single aortic clamp (SC group) or with a conventional multiple aortic side-clamp technique (MC group). The 2 groups did not differ with respect to mean age (60 + or - 6 years versus 65 + or - 8 years, not statistically significant [NS]) or EuroSCORE (2.1 + or - 1.5 versus 2.9 + or - 2, P = NS). The neurocognitive evaluation was based on the mini-mental state examination (MMSE). The preoperative MMSE values for the SC and MC groups were similar (29.5 + or - 0.5 and 29.2 + or - 1, respectively; P = NS). RESULTS The total number of solid-particle embolization signals secondary to aortic manipulation was lower in the SC group than in the MC group (72 + or - 28 versus 127 + or - 69, P = .02). Neurocognitive performance was moderately reduced in both groups compared with preoperative values. This reduction was more pronounced in the MC group than in the SC group (22.2 + or - 4.1 versus 25.3 + or - 1.6, P = .02). One patient in the MC group had a reversible ischemic neurologic deficit (P = NS). There were no deaths or perioperative myocardial infarctions in either group. CONCLUSIONS The single-clamp CABG strategy led to a reduction in MES, indicating a less pronounced embolic burden than with the conventional side-clamp CABG strategy. This strategy translated into a better performance in postoperative neurocognitive testing in the SC group of patients.
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Affiliation(s)
- Hrvoje Gasparović
- Department of Cardiac Surgery, University Hospital Rebro Zagreb, Kispaticeva 12, 10 000 Zagreb, Croatia.
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Liu YH, Wang DX, Li LH, Wu XM, Shan GJ, Su Y, Li J, Yu QJ, Shi CX, Huang YN, Sun W. The Effects of Cardiopulmonary Bypass on the Number of Cerebral Microemboli and the Incidence of Cognitive Dysfunction After Coronary Artery Bypass Graft Surgery. Anesth Analg 2009; 109:1013-22. [DOI: 10.1213/ane.0b013e3181aed2bb] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Halkos ME, Puskas JD. Off-Pump Versus On-Pump Coronary Artery Bypass Grafting. Surg Clin North Am 2009; 89:913-22, ix. [DOI: 10.1016/j.suc.2009.06.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Nishiyama K, Horiguchi M, Shizuta S, Doi T, Ehara N, Tanuguchi R, Haruna Y, Nakagawa Y, Furukawa Y, Fukushima M, Kita T, Kimura T. Temporal pattern of strokes after on-pump and off-pump coronary artery bypass graft surgery. Ann Thorac Surg 2009; 87:1839-44. [PMID: 19463605 DOI: 10.1016/j.athoracsur.2009.02.061] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Revised: 02/18/2009] [Accepted: 02/20/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The incidence of strokes has not decreased after coronary artery bypass graft surgery (CABG). The purpose of this study is to identify incidence, risk factors, and temporal pattern of strokes after on-pump and off-pump CABG. METHODS We analyzed 2,516 consecutive patients who underwent first elective isolated CABG. The primary endpoint was strokes within 30 days. The temporal onset of the deficits was classified by consensus as either an "early stroke," which is present just after emergence from anesthesia, or a "delayed stroke," which is present after first awaking from surgery without a neurologic deficit. RESULTS More than half of strokes (29 of 46; 63%) were delayed strokes. Patients undergoing off-pump CABG had significantly lower risk of early stroke (0.1% versus 1.1%, p = 0.0009), whereas the incidence of delayed strokes was not different significantly (0.9% versus 1.4%, p = 0.3484) between patients undergoing on-pump and off-pump CABG. In multivariate analyses, undergoing off-pump CABG was an independent protective factor for all strokes (relative risk 0.29, 95% confidence interval: 0.14 to 0.56, p = 0.0005) and early strokes (relative risk 0.05, 95% confidence interval: 0.003 to 0.24, p < 0.0001), but it was not an independent protective factor for delayed strokes (relative risk 0.54, 95% confidence interval: 0.24 to 1.17, p = 0.1210). CONCLUSIONS Undergoing off-pump CABG reduces the incidence of perioperative stroke mainly by minimizing early strokes; however, the risk of delayed strokes is not different between patients undergoing on-pump and off-pump CABG.
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Affiliation(s)
- Kei Nishiyama
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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Slaughter MS, Sobieski MA, Tatooles AJ, Pappas PS. Reducing emboli in cardiac surgery: does it make a difference? Artif Organs 2008; 32:880-4. [PMID: 18959681 DOI: 10.1111/j.1525-1594.2008.00645.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Particulate embolization remains a serious complication of cardiac surgery. Adverse events associated with particulate embolization affect patient morbidity and long-term survival, and increase the length of hospital stay and the cost of health care. Today, atherosclerosis plays a role in at least two-thirds of all adverse events after coronary artery revascularization, and postoperative stroke is the second most common cause of operative mortality. Because many lower-risk patients now undergo interventional revascularization, higher-risk patients are now typically referred for surgical revascularization. These patients are older and sicker, and have multiple comorbidities, making them more susceptible to adverse events. For these high-risk patients, surgeons should be proactive in attempting to reduce the possibility of emboli. Patients must be carefully assessed before surgery to determine their risk, and if the risk is high, surgeons should consider using newer, innovative devices, and techniques in their operative strategy that have proven to be effective in mitigating some of the potential embolic adverse events. A multifaceted, preventive strategy can make a difference, not only in reducing particulate emboli, but also in reducing morbidity and in lowering the economic burden on the health-care system. This brief review will address three areas of focus that are important for the prevention of particulate embolization: (i) prevalence and morbidity of atherosclerotic disease; (ii) risk factors for adverse neurologic events; and (iii) prevention/mitigation of adverse events for patients undergoing cardiac surgery.
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Affiliation(s)
- Mark S Slaughter
- Division of Cardiac Surgery, Advocate Christ Medical Center, Oak Lawn, IL, USA.
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Bibliography. Current world literature. Diseases of the aorta, pulmonary, and peripheral vessels. Curr Opin Cardiol 2008; 23:646-7. [PMID: 18830082 DOI: 10.1097/hco.0b013e328316c259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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van den Goor JM, Saxby BK, Tijssen JG, Wesnes KA, de Mol BA, Nieuwland R. Improvement of cognitive test performance in patients undergoing primary CABG and other CPB-assisted cardiac procedures. Perfusion 2008; 23:267-73. [DOI: 10.1177/0267659109104561] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac surgical procedures assisted by cardiopulmonary bypass (CPB) impair cognitive functions. Several studies, however, showed that cognitive functions were unaffected in patients undergoing either primary coronary artery bypass grafting (CABG) or more complex surgery assisted by CPB. Therefore, we conducted a straightforward study to compare patient groups who differed significantly in terms of risk factors such as prolonged CPB times. Consecutive patients (n = 54) were included, undergoing either non-primary CABG, e.g. valve and/or CABG, (n = 30) or primary CABG (n = 24), assisted by CPB. Cognitive function was determined pre-operatively on the day of hospital admission, and post-operatively after one and six months using the Cognitive Drug Research computerized assessment battery. Data from the fourteen individual task variables were summarized in four composite scores: Power of Attention (PoA), Continuity of Attention (CoA), Quality of Episodic Memory (QoEM), and Speed of Memory (SoM). In the non-primary CABG patients, both CoA and QoEM improved after 1 month (p = 0.001 and p = 0.016, respectively), whereas, after 6 months, CoA (p = 0.002), QoEM (p = 0.002) and SoM (p < 0.001) were improved. In primary CABG patients, CoA improved at one month after surgery (p = 0.002) and, after six months, not only CoA (p = 0.003), but also QoEM and SoM were improved (p = 0.001 and p = 0.030, respectively). The test performance was similar in non-primary and primary CABG patients after surgery. Our present study shows a post-operative improvement of cognitive composite scores after cardiac surgery assisted by CPB in both non-primary CABG and in primary CABG patients.
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Affiliation(s)
- JM van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, The Netherlands
| | - BK Saxby
- Cognitive Drug Research Ltd, Goring-on-Thames, UK
| | - JG Tijssen
- Cardiology, Academic Medical Centre of the University of Amsterdam, Amsterdam, The Netherlands
| | - KA Wesnes
- Cognitive Drug Research Ltd, Goring-on-Thames, UK
| | - BA de Mol
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, The Netherlands
| | - R Nieuwland
- Clinical Chemistry, Academic Medical Centre of the University of Amsterdam, Amsterdam, The Netherlands
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Halkos ME, Puskas JD, Lattouf OM, Kilgo P, Guyton RA, Thourani VH. Impact of Preoperative Neurologic Events on Outcomes After Coronary Artery Bypass Grafting. Ann Thorac Surg 2008; 86:504-10; discussion 510. [DOI: 10.1016/j.athoracsur.2008.04.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Revised: 03/31/2008] [Accepted: 04/01/2008] [Indexed: 11/25/2022]
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