Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators

Clinical and subclinical acute brain injury caused by invasive cardiovascular procedures

Over the past 50 years, the number and invasiveness of percutaneous cardiovascular procedures globally have increased substantially. However, cardiovascular interventions are inherently associated with a risk of acute brain injury, both periprocedurally and postprocedurally, which impairs medical outcomes and increases health-care costs. Current international clinical guidelines generally do not cover the area of acute brain injury related to cardiovascular invasive procedures. In this international Consensus Statement, we compile the available knowledge (including data on prevalence, pathophysiology, risk factors, clinical presentation and management) to formulate consensus recommendations on the prevention, diagnosis and treatment of acute brain injury caused by cardiovascular interventions. We also identify knowledge gaps and possible future directions in clinical research into acute brain injury related to cardiovascular interventions.

Postoperative Brain Attack: Current Perspectives and Future Directions

The incidence of stroke after cardiac surgery poses significant challenges. This expert review piece explores current knowledge, challenges, future directions, and offers insights into improving patient outcomes through optimal prevention, early recognition, and management strategies. By addressing the challenges and opportunities in this area, we can enhance patient care, reduce long-term disabilities, and improve the overall quality of life for affected individuals. This expert review aims to provide a comprehensive framework for managing postoperative stroke: mechanisms, risk factors, diagnosis, treatment, systems of care, and ethical considerations.

Minimizing stroke risk in off-pump CABG: the role of clampless devices and the piggyback proximal anastomosis technique

Introduction

Numerous techniques have been developed to minimize risk of perioperative stroke during coronary artery bypass grafting (CABG), including off-pump approach, preoperative and intraoperative imaging of the ascending aorta (CT scan and epiaortic ultrasound), anaortic CABG with bilateral internal thoracic artery, clampless devices for the construction of proximal anastomosis and minimal aortic manipulation with a single aortic inflow for all proximal grafts (piggyback proximal anastomosis). The aim of this study was to evaluate the clinical outcomes of CABG patients who underwent off pump CABG with proximal anastomosis constructed with the use of a clampless device and in a piggyback fashion.

Methods

This observational study included 112 consecutive patients undergoing CABG with the piggyback proximal technique at the Lankenau Heart Institute between June 2021 and January 2024. Primary endpoints included overall mortality, cardiac-related mortality, stroke, myocardial infarction, repeat revascularization. Intraoperative transit time flow measurement (TTFM) was also analyzed.

Results

The mean age of the cohort was 67.8 ± 8.7 years, with 75.9% (85/112) being male. All patients underwent off-pump CABG. The piggyback anastomosis consisted of vein-on-vein (52.7%, 59/112), artery-on-vein (43.8%, 49/112), and double vein/artery configurations (3.6%, 4/112). Postoperatively, no strokes occurred. At 30 days no patient died or required repeat revascularization. The mean hospital stay was 5.5 [4.0-8.0] days. At a mean follow-up of 1.0 [0.5-1.7] years, no cardiac deaths were recorded, with an overall survival of 98.2% (110/112). Repeat piggyback revascularization was 3.6% (4/112) at a mean of 2.0 ± 0.5 years. TTFM demonstrated superior flow rates in artery-on-vein grafts [50 (40-70) ml/min] compared to vein-on-vein grafts [40 (30-53.5), p < 0.001].

Conclusions

When a proximal anastomosis cannot be avoided during off pump CABG, the combination of a piggyback proximal anastomosis together with the use of a clampless aortic device, demonstrated promising early mid-term outcomes almost nullifying the perioperative risk of clinical stroke. Intraoperative TTFM showed excellent flow rates, especially when arterial grafts were used. The technique is a viable option in high-risk patients with severe aortic disease, offering a safe and effective approach to multivessel revascularization with minimal aortic manipulation. Further studies with longer follow-up are warranted to confirm its long-term benefits.

Comparison of percutaneous coronary intervention vs coronary artery bypass graft for left main coronary artery disease in patients with prior cerebrovascular disease: A systematic review, meta-analysis and meta-regression

Background

Previous studies suggest similar cardiovascular (CV) benefits for either percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) in patients with left main coronary artery disease (LMCAD). However, limited data exist on the influence of prior cerebrovascular disease (CEVD). Thus, we aim to compare the CV outcomes in patients with LMCAD and prior CEVD, undergoing either PCI or CABG.

Methods

A comprehensive search from (January 2000 to August 2024) identified three relevant studies. Outcomes analyzed included all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE), myocardial infarction (MI), and risk of stroke in patients undergoing either PCI or CABG for LMCAD. Data analysis employed a random effects model and presented hazard ratios (HR) along with their 95 % confidence intervals (CI).

Results

Three studies involving 760 patients (361 PCI, 399 CABG) were included. PCI was associated with a significantly higher risk of MACCE (HR = 2.56; 95 % CI = 1.23-5.37; p = 0.01; I2 = 86 %) and MI (HR = 2.97; 95 % CI = 1.72-5.13; p < 0.0001; I2 = 0 %) compared to CABG. No significant differences were observed in all-cause mortality (HR = 1.35; 95 % CI = 0.92-1.98; p = 0.12; I2 = 0 %) or recurrent stroke (HR = 0.83; 95 % CI = 0.40-1.70; p = 0.60; I2 = 1 %). The risk of repeat revascularization was higher in PCI, though not statistically significant (HR = 3.44; 95 % CI = 0.50-23.60; p = 0.21; I2 = 70 %).

Conclusion

PCI significantly elevates the risk of MACCE and MI in patients with LMCAD and prior CEVD compared to CABG. However, risks of all-cause mortality, repeat stroke, and revascularization were non-significant. Comorbidities may drive the elevated risk, underscoring the need for tailored strategies in this population.

Benefits of prophylactic carotid revascularization in patients with asymptomatic carotid artery stenosis undergoing coronary artery bypass surgery: A narrative review

Patients undergoing coronary artery bypass grafting (CABG) are at increased risk of perioperative stroke. Carotid atherosclerosis has been identified as an independent risk factor for stroke during and in the early postoperative period of cardiac surgery. However, the pathogenesis of peri-CABG stroke is multifactorial and frequently involves other noncarotid causes, such as cardiac emboli and aortic atheroma. Therefore, routine population-wide screening of carotid stenosis is not recommended, but target screening of patients at high risk of carotid-related perioperative stroke can have benefits. Carotid duplex sonography is recommended as an initial screening tool. Elimination of carotid stenosis before cardiac surgery is indicated in patients in whom carotid atherosclerosis is suspected to be the primary contributor to perioperative stroke. In patients with advanced carotid atherosclerosis, an individualized revascularization approach, including simultaneous or staged procedures, is advocated. The prevailing consensus is that synchronous surgery is safer than staged procedures. Carotid artery stenting represents a less invasive alternative, but its role in high-risk patients requires further investigation. In conclusion, the risk of perioperative stroke in patients undergoing CABG involves different factors, and carotid artery stenosis is involved in its pathogenesis only in some patients. Therefore, individualized approaches and careful consideration of patient risk factors are essential in determining the need for carotid screening and revascularization before CABG.

Analysis of Acute Cerebrovascular Accidents following Cardiovascular Surgical Procedures: A Comprehensive 17-year Study Involving 24,412 Patients at a Leading Tertiary Care Institution in the United Kingdom

BACKGROUND

The primary objective of this study is to quantify the incidence of stroke following cardiac surgery over 17 years at our center. Additionally, we evaluated the potential risk factors leading to postoperative stroke in these patients.

METHODS

Patient characteristics and perioperative data were collected for 24,412 patients undergoing surgery at our center between January 2005 and December 2021. We identified the patients who developed postoperative stroke and assessed potential risk factors. Chi-squared and Mann-Whitney U-tests were used for intergroup comparisons. Independent risk factors were evaluated by univariate logistic regression analysis.

RESULTS

In our cohort, we identified 346 patients (1.4%) with postoperative stroke. After adjusting for possible confounders, the following were significant risk factors: previous cardiac surgery (odds ratio [OR]: 1.6; 95% confidence interval [CI]: 1.2-2.2; P = 0.004), EuroSCORE II of 1-1.9 (OR: 2.1; CI :1-4.2; P = 0.048), 2-4.9 (OR: 3.3; CI: 1.7-6.6; P = 0.001), 5-9.9 (OR: 3.6; CI: 1.7-7.5; P = 0.001), and ≥10 (OR: 3.4; CI: 1.6-7.5; P = 0.002), EuroSCORE additive of 5-9 (OR: 2.4; CI: 1.2-4.7; P = 0.013) and ≥10 (OR: 2.7; CI: 1.2-6.2; P = 0.020), requiring new postoperative hemofiltration/dialysis (OR: 4.0; CI: 2.9-5.5, P < 0.001), Stanford type A dissections (OR: 2.3; CI: 1.1-4.7; P = 0.020), returning to theater for bleeding/tamponade (OR: 3.2; CI: 2.2-4.6; P < 0.001).

CONCLUSION

The incidence of stroke following surgery is low with many predisposing factors. Nevertheless, identifying patients at increased risk of stroke may enhance informed consent, preoperative planning, and perioperative strategies.

Interpretable machine learning-based predictive modeling of patient outcomes following cardiac surgery

BACKGROUND

The clinical applicability of machine learning predictions of patient outcomes following cardiac surgery remains unclear. We applied machine learning to predict patient outcomes associated with high morbidity and mortality after cardiac surgery and identified the importance of variables to the derived model's performance.

METHODS

We applied machine learning to the Society of Thoracic Surgeons Adult Cardiac Surgery Database to predict postoperative hemorrhage requiring reoperation, venous thromboembolism (VTE), and stroke. We used permutation feature importance to identify variables important to model performance and a misclassification analysis to study the limitations of the model.

RESULTS

The study dataset included 662,772 subjects who underwent cardiac surgery between 2015 and 2017 and 240 variables. Hemorrhage requiring reoperation, VTE, and stroke occurred in 2.9%, 1.2%, and 2.0% of subjects, respectively. The model performed remarkably well at predicting all 3 complications (area under the receiver operating characteristic curve, 0.92-0.97). Preoperative and intraoperative variables were not important to model performance; instead, performance for the prediction of all 3 outcomes was driven primarily by several postoperative variables, including known risk factors for the complications, such as mechanical ventilation and new onset of postoperative arrhythmias. Many of the postoperative variables important to model performance also increased the risk of subject misclassification, indicating internal validity.

CONCLUSIONS

A machine learning model accurately and reliably predicts patient outcomes following cardiac surgery. Postoperative, as opposed to preoperative or intraoperative variables, are important to model performance. Interventions targeting this period, including minimizing the duration of mechanical ventilation and early treatment of new-onset postoperative arrhythmias, may help lower the risk of these complications.

Investigating outcomes of coronary artery bypass graft (CABG) surgery: a single-center retrospective study in Jordan

BACKGROUND

Coronary artery bypass graft (CABG) surgery brings significant cardiac benefits but also risks post-operative complications, including cognitive impairments and infections.

MATERIALS & METHODS

We analyzed 108 patient records between 2011 and 2021 at the Princess Muna Al-Hussein Cardiac Center, Irbid, Jordan. The primary endpoint was the occurrence of postoperative events.

RESULTS

Few patients (8.3%) faced complications like stroke and infections, with age and ICU stay length as significant risk factors. Patients with complications often experienced left ventricular impairments and required inotropic support.

CONCLUSION

The study highlights the need for understanding CABG surgery complications to improve outcomes, emphasizing preventive care and personalized follow-up.

Impact of preoperative computed tomography scan on neurological outcomes in coronary artery bypass grafting patients: A propensity-score analysis

INTRODUCTION

Neurological complications pose significant risks in coronary artery bypass grafting (CABG). This study explores the potential benefits of preoperative chest computed tomography (CT) in optimizing outcomes and reducing neurological events in high-risk CABG patients.

METHODS

From January 2017 to June 2023, a retrospective cohort study of CABG patients categorized groups based on preoperative chest CT use. Multivariate analysis evaluated the associations between CT imaging and patient characteristics, followed by propensity match analysis to balance preoperative features across groups.

RESULTS

The study included 1786 patients, with 435 having undergone preoperative CT and 1351 without. Propensity matching created two well-balanced groups of 413 patients each. At multivariate analysis, CT patients were elderly (71.1 ± 8.9 years; p = 0.03) with a higher incidence of pulmonary disease (19.5%; p < 0.01), peripheral arterial disease (29.2%; p < 0.01), and previous cerebrovascular disease (23.4%; p = 0.02). In the matched CT cohort, the perioperative cerebral stroke rate was 0.7% (vs. 1.9% in without preoperative CT [WCT] cohort; p = 0.223), and the 30-day mortality rate was 0.2% (vs. 1.7% in WCT cohort; p = 0.069). Patients who had a preoperative CT study presented a higher prevalence of porcelain aorta (6.3% vs. 1.5%; p = 0.0003) and required more often a no-touch aorta procedure (20.3% vs. 14.5%; p = 0.035).

CONCLUSIONS

Patients undergoing preoperative chest CT before CABG were typically older and had systemic atherosclerosis and pulmonary disease. Propensity-matched analysis indicated low mortality and perioperative cerebral stroke rates in these high-risk patients. These findings support the integration of chest CT into preoperative evaluations for high-risk patients to develop tailored strategies in coronary artery bypass surgery.

Acute stroke in patients undergoing coronary artery bypass grafting surgery in acute coronary syndrome: Predictors and outcomes

OBJECTIVES

Coronary artery bypass grafting (CABG) surgery in patients with acute coronary syndrome (ACS) remains a high-risk procedure and is associated with adverse outcomes. The risk factors of acute stroke in the above-mentioned patients stay unclear and some appropriate data is lacking in the literature. Thus, we aimed to investigate the predictors of acute stroke in patients undergoing CABG surgery in ACS.

METHODS

The retrospective single-centre cohort analysis was conducted. All patients (n = 1344) who suffered from acute coronary syndrome and underwent CABG procedure at the University hospital Cologne from June 2011 until October 2019 were included in our study. In order to find the risk factors of acute stroke after bypass surgery, patients were divided into two groups (non-stroke group (n = 1297) and stroke group (n = 47)). In order to even above-mentioned groups propensity score matching (PSM) analysis was performed (non-stroke group (n = 46) and stroke group (n = 46).

RESULTS

Duration of cardiopulmonary bypass (p = .015) and cross clamp time (p = .006) were significantly longer in patients who suffered stroke. Perioperative myocardial infarction was significantly higher (p = .030) in the stroke group. Likewise, the duration of intensive care unit stay (p < .001) and in-hospital stay (p < .001) were significantly longer in patients with stroke. However, the mortality rate did not differ significantly (p = .131) between above-mentioned groups. Univariate and multivariate analysis showed cardiogenic shock (p = .003), peripheral vascular disease (PVD, p = .025) and previous stroke (p = .045) as relevant independent predictors for acute stroke after CABG procedure in patients with ACS.

CONCLUSION

Based on our findings, acute stroke after bypass surgery in patients with ACS is associated with increased mortality and adverse outcomes. Cardiogenic shock, peripheral vascular disease and previous stroke were independent predictors of stroke after CABG procedure. Therefore, preoperative evaluation of potential risk factors may be crucial to improve postoperative results.

Anti-inflammatory effect of colchicine on organ damage during the perioperative period of cardiac surgery: a study protocol for a multicentre, randomised, double-blind, placebo-controlled clinical trial

INTRODUCTION

The systemic inflammatory response syndrome during the perioperative period of cardiac surgery can lead to serious postoperative complications and significantly increase the hospital mortality rate. Colchicine, a widely used traditional anti-inflammatory drug, has good clinical value in cardiovascular anti-inflammatory therapy. Our preliminary single-centre study had confirmed the protective value of colchicine in patients undergoing cardiac surgery with cardiopulmonary bypass. For this multicentre investigation, we aim to further validate the anti-inflammatory and organ-protective effects of low-dose colchicine during the perioperative period in a low-risk population.

METHODS AND ANALYSIS

This study is a multicentre, randomised, double-blind, placebo-controlled clinical trial. A total of 768 patients undergoing elective cardiac surgery will be enrolled from eight heart centres in China. The participants will be randomly assigned to two groups: the colchicine group will receive low-dose colchicine (0.5 mg once-a-day dosing regimen (QD) orally for 3 days before the surgery and 0.5 mg dosing frequency of every other day (QOD) continuously for 10 days after the surgery), whereas the placebo group will be given starch tablets for the same time and dosage. Primary endpoints are the occurrence of postoperative inflammatory diseases, including postoperative atrial fibrillation, acute respiratory distress syndrome, preoperative myocardial injury and post-pericardiotomy syndrome. Secondary endpoints included laboratory tests on postoperative days 1, 3, 5, 7 and 10, intensive care unit data, APACHE II score, Murray lung injury score, medication-related gastrointestinal reactions, 30-day and 90-day all-cause mortality, surgical data, chest radiograph on postoperative days 1, 2 and 3, and chest CT within 14 days after surgery.

ETHICS AND DISSEMINATION

This research has received approval from the Medical Ethics Committee of Affiliated Nanjing Drum Tower Hospital, Nanjing University Medical College (approval number 2023-366-01). The study findings will be made available by publishing them in an open access journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT06118034).

Clinical outcomes of on-pump versus off-pump coronary-artery bypass surgery: a meta-analysis

BACKGROUND

The ongoing debate regarding off-pump coronary artery bypass grafting (CABG) and on-pump CABG has endured for over three decades. Although numerous randomized controlled trials (RCTs) and meta-analyses have been reported, new evidence has emerged. Therefore, an updated and comprehensive meta-analysis to guide clinical practice is essential.

MATERIALS AND METHODS

A comprehensive search for eligible articles published after 2000, reporting RCTs involving at least 100 patients and comparing off-pump CABG with on-pump CABG, was performed throughout the databases including Embase, Ovid Medline, and Web of Science. The primary interested outcomes included the short-term incidence of stroke and long-term mortality. The primary analysis utilized fixed-effect model with the inverse variance method. The Grade of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the certainty of evidence.

RESULTS

After thorough screening, 39 articles were included, consisting of 28 RCTs and involving a total of 16 090 patients. Off-pump CABG significantly reduced the incidence of short-term stroke (1.27 vs. 1.78%, OR: 0.74, P =0.03, high certainty). However, it was observed to be associated with increased mid-term coronary reintervention (2.77 vs. 1.85%, RR: 1.49, P <0.01, high certainty) and long-term mortality (21.8 vs. 21.0%, RR: 1.09, P =0.02, moderate certainty).

CONCLUSIONS

Off-pump CABG significantly reduces the short-term incidence of stroke, but it also increases the incidence of mid-term coronary reintervention. Moreover, it may increase long-term mortality.

Role of Intraoperative Electroencephalography in Predicting Postoperative Delirium in Patients Undergoing Cardiovascular Surgeries

OBJECTIVE

To determine the utility of electroencephalography (EEG) in predicting postoperative delirium (POD) in patients who underwent cardiovascular surgeries with EEG monitoring.

METHODS

A total of 1161 patients who underwent cardiovascular surgeries with EEG monitoring were included in the study, and their data were retrospectively reviewed. POD assessment was done utilizing Intensive Care Delirium Screening Checklist (ICDSC). Patients with a score of > 4 on ICDSC were diagnosed with POD.

RESULTS

Of 1161 patients, 131 patients had EEG changes and 56 (42.74%) of 131 patients experienced POD. Of 1030 patients without EEG changes, 219 (21.26%) experienced POD. EEG showed specificity of 91.5% and negative predictive value of 78.7% in detecting POD. On multivariable analysis, EEG changes showed a strong association with POD (ORadj 1.97 CI (1.30-2.99), p = 0.001) with persistent EEG changes showing even a higher risk of developing POD (ORadj 2.65 (1.43-4.92), p = 0.002).

CONCLUSION

EEG change has specificity of 91.5% emphasizing the need for its implementation as a diagnostic tool for predicting POD. Patients with POD are two times more likely to experience significant EEG changes, especially persistent EEG changes when undergoing cardiovascular surgeries.

SIGNIFICANCE

Intraoperative EEG can detect POD, and EEG changes based therapeutic interventions can mitigate POD.

Perioperative and Long-Term Outcomes in Patients Undergoing Synchronous Carotid Endarterectomy and Coronary Artery Bypass Grafting: A Single-Center Experience

INTRODUCTION

Patients requiring coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) can be managed with staged (CEA before CABG), reverse staged (CABG before CEA) or synchronous treatment. This single-center retrospective study evaluated the outcomes in patients undergoing planned synchronous CEA and CABG.

METHODS

Between 2000 and 2020 a total of 185 patients with symptomatic triple-vessel or left main coronary artery disease associated with 70-99% asymptomatic or 50-99% symptomatic uni- or bilateral internal carotid artery (ICA) stenosis underwent synchronous CEA and CABG at our institution. Study endpoints were defined as mortality, stroke and myocardial infarction at 30 days. Additionally, the composite endpoint of these events was investigated.

RESULTS

At 30 days, mortality, stroke and myocardial infarction rates were 5.9%, 8.1% (permanent [unresolved deficit at discharge] 5.4%) and 3.8%, respectively, and the composite endpoint was reached in 13.0% of patients. Patients suffering from a stroke more frequently had a contralateral 70-99% ICA stenosis (60.0% vs. 17.3%; p < 0.001), peripheral artery disease (73.3% vs. 38.9%; p = 0.013) and prolonged cardiopulmonary bypass time (mean 119 ± 62 min vs. 84 ± 29 min; p = 0.012). Multivariate logistic regression analysis revealed the duration of cardiopulmonary bypass (odds ratio [OR] 1.024; 95% confidence interval [CI] 1.002-1.046; p = 0.034), a history of type 2 diabetes mellitus (OR 5.097; 95% CI 1.161-22.367; p = 0.031) and peripheral artery disease (OR 5.814; 95% CI 1.231-27.457; p = 0.026) as independent risk factors for reaching the composite endpoint.

CONCLUSION

Patients undergoing synchronous CEA and CABG face an elevated risk of perioperative cardiovascular events, particularly an increased stroke risk in patients with symptomatic and bilateral ICA stenosis. Graphical Abstract available for this article.

Cognitive Training for Reduction of Delirium in Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial

IMPORTANCE

Postoperative delirium is a common and impactful neuropsychiatric complication in patients undergoing coronary artery bypass grafting surgery. Cognitive training may enhance cognitive reserve, thereby reducing postoperative delirium.

OBJECTIVE

To determine whether preoperative cognitive training reduces the incidence of delirium in patients undergoing coronary artery bypass grafting.

DESIGN, SETTING, and PARTICIPANTS

This prospective, single-blind, randomized clinical trial was conducted at 3 university teaching hospitals in southeastern China with enrollment between April 2022 and May 2023. Eligible participants included those scheduled for elective coronary artery bypass grafting who consented and enrolled at least 10 days before surgery.

INTERVENTIONS

Participating patients were randomly assigned 1:1, stratified by site, to either routine care or cognitive training, which included substantial practice with online tasks designed to enhance cognitive functions including memory, imagination, reasoning, reaction time, attention, and processing speed.

MAIN OUTCOMES AND MEASURES

The primary outcome was occurrence of delirium during postoperative days 1 to 7 or until hospital discharge, diagnosed using the Confusion Assessment Method or the Confusion Assessment Method for Intensive Care Units. Secondary outcomes were postoperative cognitive dysfunction, delirium characteristics, and all-cause mortality within 30 days following the operation.

RESULTS

A total of 218 patients were randomized and 208 (median [IQR] age, 66 [58-70] years; 64 female [30.8%] and 144 male [69.2%]) were included in final analysis, with 102 randomized to cognitive training and 106 randomized to routine care. Of all participants, 95 (45.7%) had only a primary school education and 54 (26.0%) had finished high school. In the cognitive training group, 28 participants (27.5%) developed delirium compared with 46 participants (43.4%) randomized to routine care. Those receiving cognitive training were 57% less likely to develop delirium compared with those receiving routine care (adjusted odds ratio [aOR] 0.43; 95% CI, 0.23-0.77; P = .007). Significant differences were observed in the incidence of severe delirium (aOR, 0.46; 95% CI, 0.25-0.82; P = .01), median (IQR) duration of delirium (0 [0-1] days for cognitive training vs 0 [0-2] days for routine care; P = .008), and median (IQR) number of delirium-positive days (0 [0-1] days for cognitive training vs 0 [0-2] days for routine care; P = .007). No other secondary outcomes differed significantly.

CONCLUSIONS AND RELEVANCE

In this randomized trial of 208 patients undergoing coronary artery bypass grafting, preoperative cognitive training reduced the incidence of postoperative delirium. However, our primary analysis was based on fewer than 75 events and should therefore be considered exploratory and a basis for future larger trials.

Trial Registration

Chinese Clinical Trial Registry Identifier: ChiCTR2200058243.

Integrative proteomics and metabolomics data analysis exploring the mechanism of brain injury after cardiac surgery in chronic stress rats

OBJECTIVE

Preoperative chronic stress (CS) is associated with postoperative brain injury in patients undergoing open heart cardiac surgery. This research is to explore the potential molecular biological mechanisms of brain damage following cardiac surgery in preoperative CS rats by the analyses combining proteomics and metabolomics.

METHODS

We constructed the chronic unpredictable stress (CUS) and cardiac surgery models in adult rats. We proved the brain injury in CUS cardiac surgery rats by Hematoxylin-Eosin (H&E) staining, followed by separating the hippocampal tissue and investigating the potential mechanisms of brain injury by the methods of data-independent acquisition proteomics and untargeted metabolomics.

RESULTS

The signaling pathways of glycoproteins and metabolism of amino acids were the main possible mechanisms of brain injury in CUS rats following cardiac surgery according to the proteomics and metabolomics. In addition, the pathways of animo acids metabolism such as the pathways of lysine degradation and β-alanine metabolism may be the main mechanism of cardiac surgery related brain injury in preoperative CUS rats.

CONCLUSIONS

The pathways of animo acids metabolism such as lysine degradation and β-alanine metabolism may be the potential mechanisms of brain injury in CUS rats following cardiac surgery. We should focus on the varieties of bioproteins and metabolites in these pathways, and related changes in other signaling pathways induced by the two pathways.

Transesophageal echocardiography: A bibliometric analysis from 1979 to 2022

OBJECTIVE

Heart disease poses a significant global health challenge. Transesophageal echocardiography (TEE) has gained prominence in clinical practice because of advancements in visual medicine. The present bibliometric analysis provides an overview of TEE research, identifies trends, and highlights emerging topics.

METHODS

A comprehensive search of TEE-related literature from the establishment of the Web of Science Core Collection (WOSCC) until 2022 was conducted. Utilizing the CiteSpace software, we performed an in-depth analysis of the literature data encompassing disciplines, publication years, countries, institutions, authors, journals, cited references, and keywords.

RESULTS

A total of 17 032 TEE-related articles were included in this study. The most active disciplines in TEE research were Cardiac & Cardiovascular Systems, Anesthesiology, and Respiratory System. The number of publications displayed a consistent upward trajectory over the years. Notably, research contributions predominantly originated from developed countries, mainly Europe and North America, with the United States, Germany, Italy, and Japan leading the way. Analysis of institutions, authors, and journals revealed the United States' significant role in TEE research. Furthermore, the analysis of cited references and keywords identified the treatment of patent foramen ovale and its association with stroke as emerging hot topics in recent years.

CONCLUSIONS

This study highlights that TEE remains a research hotspot, with the United States at the forefront. Future research should investigate the relationship between heart disease and brain function.

[History of anti-embolic protection in cardiac surgery]

The review is devoted to history of anti-embolic protection system, in particular protection against cerebral embolism, in cardiac surgery and endovascular surgery. Cerebral embolism is a common and dangerous complication in cardiovascular surgery, leading to disability of patients and significantly impairing treatment outcomes. Prevention of embolic complications is an urgent task in correction of heart valve disease in cardiac and endovascular surgery.

Incidence Rate of Post Coronary Artery Shunt Complications; Age Dependent!

BACKGROUND

Numerous complications, such as postoperative arrhythmia and stroke, have been observed following coronary artery bypass graft (CABG) surgery.

AIMS

This study sought to examine the impact of aging on the incidence of post-coronary artery shunt complications.

OBJECTIVES

Aging is a physiological process experienced by every living cell, beginning early in development. Age plays a crucial role in determining postoperative complications, including those related to CABG.

MATERIALS AND METHODS

A retrospective analysis was conducted on 290 patients who underwent CABG at the Mordovian Republic Hospital between 2017 and 2021. The sample was divided into two age-based groups: the first group comprised 126 patients (mean age range: 55.21-60.00), and the second group included 163 patients (mean age range: 66.11-80.00). Statistical analyses employed in this study encompassed descriptive statistics, Chi-square test, T-test, one-way ANOVA test, ROC analysis, and Pearson correlation using Statistica 12 software.

RESULTS

Elderly patients in the second group demonstrated a higher incidence of post-CABG arrhythmia (p < 0.012528). Moreover, the second group experienced markedly longer ICU and total hospitalization days following CABG, with p-values of less than 0.000000 and 0.000072, respectively. Notably, elderly individuals in the second group faced an increased risk of developing psychosis after CABG surgery (p < 0.007379). Furthermore, psychosis was found to be significantly associated with longer ICU hospitalization (p < 0.000140). Postoperative stroke occurred more frequently among the elderly (second group) with a p-value of less than 0.037736. Consequently, postoperative stroke was associated with extended ICU hospitalization (p < 0.000747). The usage of internal thoracic arteries (ITAs) was lower among the elderly (second group), with a p-value of less than 0.016145. Regarding correlations, a direct association was observed between age and ICU days, total hospitalization days, and the number of complications, with correlation coefficients (r) of 0.189046, 0.141415, and 0.138565, respectively.

CONCLUSION

Elderly individuals in the second group who undergo CABG face a greater risk of developing psychosis, arrhythmia, prolonged total and ICU hospitalization, and stroke. The presence of arrhythmia, which is commonly observed in patients aged 63 years and older, significantly affects total hospitalization days. The number of complications is influenced by age, cardiopulmonary bypass (CPB) time, aortic cross-clamp time, ICU hospitalization, and total hospitalization duration.

Early mortality of emergency surgery for acute type A aortic dissection in octogenarians and nonagenarians: A multi-center retrospective study

OBJECTIVES

The clinical data on postoperative mortality and central nervous system (CNS) complications in older adults who underwent acute type A aortic dissection are limited. Thus, in this study we aimed to evaluate the association between age and early postoperative mortality and occurrence of CNS complications.

METHODS

This multicentric retrospective cohort study included 5 tertiary hospitals in Japan. All patients who underwent emergency surgery for acute type A aortic dissection between October 1998 and December 2019 were enrolled. The multilevel Cox proportional hazards model, which considered years as level 1, institutions as level 2, and surgeons as level 3, was used to evaluate the association between age and early postoperative hospital mortality and occurrence of CNS complications.

RESULTS

Of the 1037 patients, 227 (21.9%) were ≥80 years old and 810 (78.1%) were <80 years old. Overall, 134 patients (12.9%) died within 30 days postoperatively; among them, 42/227 (18.5%) and 92/810 (11.4%) were aged ≥80 and <80 years, respectively (hazard ratio [HR], 1.63; P = .0046). CNS complications within 30 days postoperatively occurred in 140/1037 (13.5%) patients; among them, 42/227 (18.5%) and 98/810 (12.1%) were aged ≥80 and <80 years, respectively (HR, 1.63; P = .011). In multivariate analysis, age ≥80 years was associated with mortality within 30 days postoperatively (adjusted HR, 2.37; 95% CI, 1.23-4.57; P = .01) but not with CNS complications (adjusted HR, 1.58; 95% CI, 0.93-2.69; P = .091).

CONCLUSIONS

The early postoperative mortality in older patients was approximately 50% higher than in the younger population. A thorough discussion regarding the surgical indications should be done.

Predictive factors of rehabilitation outcomes of perioperative stroke after surgery of the coronary artery and aorta: A pilot study

BACKGROUND

Perioperative stroke is a devastating complication of coronary artery and aortic surgery, resulting in significantly increased mortality and morbidity rates. As such, predicting rehabilitation outcomes after perioperative stroke would be valuable in establishing rehabilitation plans.

OBJECTIVE

To identify prognostic factors of rehabilitation outcomes in perioperative stroke after surgery of the aorta and coronary arteries.

METHODS

This study included patients who experienced perioperative stroke after coronary artery bypass grafting and aortic surgery, and underwent 3-weeks of rehabilitation. Demographic data included age, sex, diagnosis, brain lesions, and Charlson Comorbidity Index (CCI). To identify prognostic factors and the effectiveness of rehabilitation, the Modified Barthel Index (MBI), National Institutes of Health Stroke Scale (NIHSS), Medical Research Council (MRC) sum score, modified Rankin Scale (mRS) score, and Mini-Mental State Examination (MMSE) scores were investigated before and after a three-week rehabilitation period. Spearman rank correlation analyses were performed.

RESULTS

Statistically significant improvements were observed in NIHSS, MBI, and MMSE scores after rehabilitation. Spearman rank correlation analysis revealed a significant correlation between sex, stroke type, and improvement in MRC sum score.

CONCLUSION

The most crucial factors influencing the prognosis of perioperative stroke occurring after coronary artery or aortic surgery included sex and stroke type.

The role of carotid artery stenosis in predicting stroke after coronary artery bypass grafting in a Chinese cohort study

Current guidelines give priority to surgical treatment of carotid artery stenosis (CAS) before coronary artery bypass grafting (CABG), especially in symptomatic patients. Carotid artery stenting is an alternative treatment for narrowing of the carotid arteries. This study sought to demonstrate the role of severe CAS in predicting stroke after CABG and assess the efficacy of carotid artery stenting in preventing postoperative stroke in a Chinese cohort. From 2015 to 2021, 1799 consecutive patients undergoing isolated CABG surgery were retrospectively recruited in a Chinese cohort. The predictive value of severe CAS in postoperative stroke and carotid stenting in preventing postoperative stroke was statistically analyzed. The incidence of postoperative stroke was 1.67%. The incidence of CAS with stenosis ≥ 50% and ≥ 70% was 19.2% and 6.9%. After propensity matching, the incidence of stroke was 8.0% in the severe CAS group and 0% in the non-severe CAS group. We successfully established an optimal predictive nomogram for predicting severe CAS in patients undergoing CABG. Carotid artery stenting was found ineffective in preventing postoperative stroke. The present study provides the incidence of CAS and postoperative stroke in a Chinese cohort, identifies severe CAS as an independent risk factor for postoperative stroke after CABG, constructs a nomogram predicting the incidence of severe CAS, and evaluates the effectiveness of carotid artery stenting in preventing postoperative stroke after CABG.

Risk Factors for Stroke Development After Thoracic Aortic Surgery

OBJECTIVES

Stroke after thoracic aortic surgery is a complication that is associated with poor outcomes. The aim is to characterize the intraoperative risk factors for stroke development.

DESIGN

A retrospective analysis.

SETTING

Tertiary, high-volume cardiac surgery center.

PARTICIPANTS

Patients who had surgical repair of thoracic aortic diseases from January 1, 2017, through December 31, 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 704 patients were included, of whom 533 had ascending aortic aneurysms, and 171 had type A aortic dissection. The incidence of postoperative stroke was 4.5% (95% CI 2.9%-6.6%) for ascending aortic aneurysms compared with 12.3% (95% CI 7.8%-18.16%) in type-A aortic dissections. Patients who developed postoperative strokes had significantly lower intraoperative hemoglobin median (7.5 gm/dL [IQR 6.8-8.6] v 8.55 gm/dL [IQR 7.3-10.0]; p < 0.001). The median cardiopulmonary bypass time was 185 minutes (IQR 136-328) in the stroke group versus 156 minutes (IQR 113-206) in the nonstroke group (p = 0.014). Circulatory arrest was used in 57.8% versus 38.5% of the nonstroke patients (p = 0.017). The initial temperature after leaving the operating room was lower, with a median of 35.0°C (IQR 34-35.92) in the stroke group versus 35.5°C (IQR 35-36) in the nonstroke cohort (p = 0.021).

CONCLUSIONS

This single-center study highlighted the potential importance of intra-operative factors in preventing stroke. Lower hemoglobin, longer duration of cardiopulmonary bypass, deep hypothermic circulatory arrest, and postoperative hypothermia are potential risk factors for postoperative stroke. Further studies are needed to prevent this significant complication in patients with thoracic aortic diseases.

Impact of Pulse Pressure on Acute Brain Injury in Venoarterial ECMO Patients with Cardiogenic Shock During the First 24 Hours of ECMO Cannulation: Analysis of the Extracorporeal Life Support Organization Registry

Background

Low pulse pressure (PP) in venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is a marker of cardiac dysfunction and has been associated with acute brain injury (ABI) as continuous-flow centrifugal pump may lead to endothelial dysregulation.

Methods

We retrospectively analyzed adults (≥18 years) on "peripheral" VA-ECMO support for cardiogenic shock in the Extracorporeal Life Support Organization Registry (1/2018-7/2023). Cubic splines were used to establish a threshold (PP≤10 mmHg at 24 hours of ECMO support) for "early low" PP. ABI included central nervous system (CNS) ischemia, intracranial hemorrhage, brain death, and seizures. Multivariable logistic regressions were performed to examine whether PP≤10 mmHg was associated with ABI. Covariates included age, sex, body mass index, pre-ECMO variables (temporary mechanical support, vasopressors, cardiac arrest), on-ECMO variables (pH, PaO2, PaCO2), and on-ECMO complications (hemolysis, arrhythmia, renal replacement therapy).

Results

Of 9,807 peripheral VA-ECMO patients (median age=57.4 years, 67% male), 8,294 (85%) had PP>10 mmHg vs. 1,513 (15%) had PP≤10 mmHg. Patients with PP≤10 mmHg experienced ABI more frequently vs. PP>10 mmHg (15% vs. 11%, p<0.001). After adjustment, PP≤10 mmHg was independently associated with ABI (adjusted odds ratio [aOR]=1.25, 95% confidence interval [CI]=1.06-1.48, p=0.01). CNS ischemia and brain death were more common in patients with PP≤10 mmHg vs. PP>10 mmHg (8% vs. 6%, p=0.008; 3% vs. 1%, p<0.001). PP≤10 mmHg was associated with CNS ischemia (aOR=1.26, 95%CI=1.02-1.56, p=0.03) but not intracranial hemorrhage (aOR=1.14, 95%CI=0.85-1.54, p=0.38).

Conclusions

Early low PP (≤10 mmHg) at 24 hours of ECMO support was associated with ABI, particularly CNS ischemia, in peripheral VA-ECMO patients.

Neurologic complications after cardiopulmonary bypass - A narrative review

Neurologic complications, associated with cardiac surgery and cardiopulmonary bypass (CPB) in adults, are common and can be devastating in some cases. This comprehensive review will not only consider the broad categories of stroke and neurocognitive dysfunction, but it also summarises other neurological complications associated with CPB, and it provides an update about risks, prevention and treatment. Where appropriate, we consider the impact of off-pump techniques upon our understanding of the contribution of CPB to adverse outcomes.

Heart surgery and simultaneous carotid endarterectomy - 10-years single-center experience

BACKGROUND

Patients with coronary artery heart disease frequently suffer concomitant carotid vascular disease and are at high perioperative risk for neurological adverse events. Several concepts regarding the timing and modality of carotid revascularization are controversially discussed in patients with heart disease. Current guidelines recommendations on myocardial revascularization recommend a concomitant carotid endarterectomy (CEA) in patients with a history of stroke/transient ischemic attack (TIA) or 50-99% grade of the carotid stenosis. Our study aimed to analyze early outcome parameters of patients undergoing coronary artery bypass grafting (CABG), but also including concomitant heart valve surgery and simultaneous CEA.

METHODS

This study retrospectively analyzed a cohort of 111 patients from our institutional database undergoing heart surgery with CABG or heart-valve surgery between 2010 and 2020 with concomitant carotid surgery due to significant carotid stenosis.

RESULTS

Patients undergoing heart and simultaneous carotid surgery were 77 ± 8.0 years of age with a body mass index of 28 ± 1.7 kg/m2 and a mean EuroSCORE II of 6.5 ± 2.3. Most patients (61%) had a smoking history and arterial hypertension (97%). The preoperative mean grade of internal carotid stenosis was 87 ± 4.2%, 13% of patients suffered from internal carotid artery stenosis on both sites. In total, 4.5% of patients had previously undergone internal carotid artery intervention before and 6.3% had a history of stroke with a persistent neurologic disorder in 1.8%, 8.9% of cases had prior TIA. Thirty-day all-cause mortality was 6.3% and postoperative neurologic events occurred with 7.2% TIA and 4.5% of disabling stroke.

CONCLUSION

Within the reported patient population of coronary artery heart disease and significant internal carotid stenosis, a one-time approach with CABG or heart-valve surgery and CEA is safe and feasible as justified by clinical and neurological postoperative outcomes.

The effect of intravenous lidocaine on postoperative cognitive dysfunction: a systematic review and meta-analysis

BACKGROUND

Postoperative cognitive dysfunction (POCD) has been reported as a significant complication in elderly patients. Various methods have been proposed for reducing the incidence and severity of POCD. Intravenous lidocaine administration has been reported in the literature to reduce POCD, but the effect of lidocaine remains controversial.

METHODS

We screened Medline, Embase, Cochrane Library, and China National Knowledge Infrastructure (up to April 2022) databases following a search strategy for intravenous lidocaine on POCD. We also screened related bibliographies on lidocaine for POCD. Ten articles comprising 1517 patients were selected and analyzed. We divided the postoperative follow-up period as follows: short term (<30 days), medium term (30-90 days), and long term (>90 days).

OUTCOMES

We found that lidocaine could attenuate the overall incidence of POCD, especially in the short term. There were no differences between lidocaine and placebo on the overall severity of POCD.

CONCLUSION

Lidocaine administered intravenously could attenuate the overall incidence of POCD and its severity in the short term.

Acute Myocardial Infarction and Risk of Cognitive Impairment and Dementia: A Review

Cognitive impairment (CI) shares common cardiovascular risk factors with acute myocardial infarction (AMI), and is increasingly prevalent in our ageing population. Whilst AMI is associated with increased rates of CI, CI remains underreported and infrequently identified in patients with AMI. In this review, we discuss the evidence surrounding AMI and its links to dementia and CI, including pathophysiology, risk factors, management and interventions. Vascular dysregulation plays a major role in CI, with atherosclerosis, platelet activation, microinfarcts and perivascular inflammation resulting in neurovascular unit dysfunction, disordered homeostasis and a dysfunctional neurohormonal response. This subsequently affects perfusion pressure, resulting in enlarged periventricular spaces and hippocampal sclerosis. The increased platelet activation seen in coronary artery disease (CAD) can also result in inflammation and amyloid-β protein deposition which is associated with Alzheimer's Dementia. Post-AMI, reduced blood pressure and reduced left ventricular ejection fraction can cause chronic cerebral hypoperfusion, cerebral infarction and failure of normal circulatory autoregulatory mechanisms. Patients who undergo coronary revascularization (percutaneous coronary intervention or bypass surgery) are at increased risk for post-procedure cognitive impairment, though whether this is related to the intervention itself or underlying cardiovascular risk factors is debated. Mortality rates are higher in dementia patients with AMI, and post-AMI CI is more prevalent in the elderly and in patients with post-AMI heart failure. Medical management (antiplatelet, statin, renin-angiotensin system inhibitors, cardiac rehabilitation) can reduce the risk of post-AMI CI; however, beta-blockers may be associated with functional decline in patients with existing CI. The early identification of those with dementia or CI who present with AMI is important, as subsequent tailoring of management strategies can potentially improve outcomes as well as guide prognosis.

Major Adverse Cardiac and Cerebrovascular Events in Patients Undergoing Simultaneous Heart Surgery and Carotid Endarterectomy

BACKGROUND

Patients with simultaneous relevant internal carotid artery stenosis and coronary artery heart or valve disease represent a high-risk collective with respect to cerebral or cardiovascular severe events when undergoing surgery. There exist several concepts regarding the timing and modality of carotid revascularization, which are controversially discussed in patients with heart disease. More data regarding outcome predictors and measures are needed to gain a better understanding of the best treatment option of the discussed patient collective.

METHODS

This single-center study retrospectively analyzed n = 111 patients undergoing heart surgery with coronary artery bypass grafting or heart-valve surgery and concomitant carotid surgery due to significant internal carotid artery stenosis. In order to do so, patients were divided into two groups with respect to postoperative major adverse cardiac and cerebrovascular events (MACCE) with thirty-day all-cause mortality, valve related mortality, myocardial infarction, stroke and transitory ischemic attack.

RESULTS

Preoperative patient's characteristic in the no-MACCE and MACCE group were mainly balanced, other than higher rates of chronic obstructive pulmonary disease, chronic kidney disease, instable angina pectoris and prior transitory ischemic attack in the MACCE cohort. The analysis of intraoperative characteristics revealed a higher number of intra-aortic balloon pump implantation, which is in line for a higher number of postoperative supports. Besides MACCE, patients suffered significantly more often from postoperative bleeding events and re-thoracotomy, cardiopulmonary reanimation, new onset postoperative dialysis and prolonged intensive care unit stay related complications.

CONCLUSIONS

Within the reported patient population suffering from MACCE after a simultaneous carotid endarterectomy and heart surgery, a preoperative history of transitory ischemic attack and kidney disease might account for worse outcomes, as severe events were not only neurologically driven but also associated with postoperative cardiovascular complications following heart surgical procedures.

Patterns of cytokine release and association with new onset of post-cardiac surgery atrial fibrillation

Introduction

Postoperative Atrial Fibrillation (POAF) is a common complication of cardiac surgery, associated with increased mortality, stroke risk, cardiac failure and prolonged hospital stay. Our study aimed to assess the patterns of release of systemic cytokines in patients with and without POAF.

Methods

A post-hoc analysis of the Remote Ischemic Preconditioning (RIPC) trial, including 121 patients (93 males and 28 females, mean age of 68 years old) who underwent isolated coronary artery bypass grafting (CABG) and aortic valve replacement (AVR). Mixed-effect models were used to analyze patterns of release of cytokines in POAF and non-AF patients. A logistic regression model was used to assess the effect of peak cytokine concentration (6 h after the aortic cross-clamp release) alongside other clinical predictors on the development of POAF.

Results

We found no significant difference in the patterns of release of IL-6 (p = 0.52), IL-10 (p = 0.39), IL-8 (p = 0.20) and TNF-α (p = 0.55) between POAF and non-AF patients. Also, we found no significant predictive value in peak concentrations of IL-6 (p = 0.2), IL-8 (p = >0.9), IL-10 (p = >0.9) and Tumour Necrosis Factor Alpha (TNF-α)(p = 0.6), however age and aortic cross-clamp time were significant predictors of POAF development across all models.

Conclusions

Our study suggests no significant association exists between cytokine release patterns and the development of POAF. Age and Aortic Cross-clamp time were found to be significant predictors of POAF.

Acute clinical and financial outcomes of on- versus off-pump coronary artery bypass grafting in octogenarians

BACKGROUND

Coronary artery bypass surgery in octogenarians is associated with increased postoperative morbidity. Off-pump coronary artery bypass surgery eliminates potential complications of cardiopulmonary bypass, but its use remains controversial. This study aimed to evaluate the clinical and financial impact of off-pump coronary artery bypass surgery compared to conventional coronary artery bypass surgery among this high-risk population.

METHODS

Patients ≥80 years undergoing first-time, isolated, elective coronary artery bypass surgery were identified using the 2010-2019 Nationwide Readmissions Database. Patients were grouped into off-pump or conventional coronary artery bypass surgery cohorts. Multivariable models were developed to assess the independent associations between off-pump coronary artery bypass surgery and key outcomes.

RESULTS

Of ∼56,158 patients, 13,940 (24.8%) underwent off-pump coronary artery bypass surgery. On average, the off-pump cohort was more likely to undergo single-vessel bypass (37.3 vs 19.7%, P < .001). After adjustment, undergoing off-pump coronary artery bypass surgery was associated with similar odds of in-hospital mortality (adjusted odds ratio 0.90, 95% confidence interval 0.73-1.12) relative to conventional bypass. Additionally, the off-pump and conventional coronary artery bypass surgery groups were comparable in odds of postoperative stroke (adjusted odds ratio 1.03, 95% confidence interval 0.78-1.35), cardiac arrest (adjusted odds ratio 0.99, 95% confidence interval 0.71-1.37), ventricular fibrillation (adjusted odds ratio 0.89, 95% confidence interval 0.60-1.31), tamponade (adjusted odds ratio 1.21, 95% confidence interval 0.74-1.97), and cardiogenic shock (adjusted odds ratio 0.94, 95% confidence interval 0.75-1.17). However, the off-pump coronary artery bypass surgery cohort was linked with an increased likelihood of ventricular tachycardia (adjusted odds ratio 1.23, 95% confidence interval 1.01-1.49) and myocardial infarction (adjusted odds ratio 1.34, 95% confidence interval 1.16-1.55). Furthermore, those undergoing off-pump coronary artery bypass surgery demonstrated reduced odds of non-home discharge (adjusted odds ratio 0.91, 95% confidence interval 0.83-0.99) and a decrement in hospitalization expenditures ($-1,290, 95% confidence interval -$2,370 to $200).

CONCLUSION

Off-pump coronary artery bypass surgery was linked with increased odds of ventricular tachycardia and myocardial infarction, but no difference in mortality. Our findings point to the safety of conventional coronary artery bypass surgery in octogenarians. Yet, future work is needed to consider long-term outcomes in this complex surgical cohort.

Timing of Postoperative Stroke and Risk of Mortality After Noncardiac Surgery: A Cohort Study

Background

Postoperative stroke is a devastating complication of surgery, given its association with severe long-term disability and mortality. Previous investigators have confirmed the association of stroke with postoperative mortality. However, limited data exist regarding the relationship between the timing of stroke and survival. Addressing this knowledge gap will help clinicians develop tailored perioperative strategies to reduce the incidence, severity, and mortality associated with perioperative stroke. Therefore, our objective was to determine whether the timing of postoperative stroke influenced mortality risk.

Methods

We performed a retrospective cohort study of patients > 18 years who underwent noncardiac surgery and developed postoperative stroke during the first 30 days of surgery (National Surgical Quality Improvement Program Pediatrics 2010 - 2021). Our primary outcome was 30-day mortality following the occurrence of postoperative stroke. We subdivided patients into two mutually exclusive groups: early and delayed stroke. Early stroke was defined as the occurrence within 7 days following surgery, consistent with a previous study.

Results

We identified 16,750 patients who underwent noncardiac surgery and developed stroke within 30 days of surgery. Of these, 11,173 (66.7%) had an early postoperative stroke (≤ 7 days). Perioperative physiological status, operative characteristics, and preoperative comorbidities were generally comparable between patients with early and delayed postoperative stroke. Despite the comparability in these clinical characteristics, the mortality risk was 24.9% for early and 19.4% for delayed stroke. After adjusting for perioperative physiological status, operative characteristics, and preoperative comorbidities, early stroke was associated with an increased mortality risk (adjusted odds ratio: 1.39, confidence interval: 1.29 - 1.52, P-value < 0.001). In patients with an early postoperative stroke, the most common preceding complications were bleeding requiring transfusion (24.3%), followed by pneumonia (13.2%) and renal insufficiency (11.3%).

Conclusions

Postoperative stroke tends to occur within 7 days following noncardiac surgery. Such timing of postoperative stroke carries a higher mortality risk, suggesting that targeted efforts to prevent stroke should focus on the first week following surgery to reduce the incidence and mortality associated with this complication. Our findings contribute to the growing understanding of stroke after noncardiac surgery and may help clinicians develop tailored perioperative neuroprotective strategies to prevent or improve treatment and outcomes of postoperative stroke.

The Rationalisation of Intra-Operative Imaging During Cardiac Surgery: A Systematic Review

INTRODUCTION

One critical complication of cardiac surgery is cerebrovascular accidents (CVAs). Ascending aorta atherosclerosis poses a significant risk of embolisation to distal vessels and to cerebral arteries. Epi-aortic ultrasonography (EUS) is thought to offer a safe, high-quality accurate visualisation of the diseased aorta to guide the surgeon on the best surgical approach to the planned procedure and potentially improve neurological outcomes post-cardiac surgery.

METHOD

The authors conducted a comprehensive search of PubMed, Scopus and Embase. Studies that reported on epi-aortic ultrasound use in cardiac surgery were included. Major exclusion criteria were: (1) abstracts, conference presentations, editorials, literature reviews; (2) case series with <5 participants; (3) epi-aortic ultrasound in trauma or other surgeries.

RESULTS

A total of 59 studies and 48,255 patients were included in this review. Out of the studies that reported patient co-morbidities prior to cardiac surgery, 31.6% had diabetes, 59.5% had hyperlipidaemia and 66.1% had a diagnosis of hypertension. Of those that reported significant ascending aorta atherosclerosis found on EUS, this ranged from 8.3% of patients to 95.2% with a mean percentage of 37.8%. Hospital mortality ranged from 7% to 13%; four studies reported zero deaths. Long-term mortality and stroke rate varied significantly with hospital duration.

CONCLUSION

Current data have shown EUS to have superiority over manual palpation and transoesophageal echocardiography in the prevention of CVAs following cardiac surgery. Yet, EUS has not been implemented as a routine standard of care. Extensive adoption of EUS in clinical practice is warranted to aid large, randomised trials before making prospective conclusions on the efficacy of this screening method.

Predictors and Outcomes of Stroke After Isolated Coronary Artery Bypass Grafting. A Single-Center Experience in 20,582 Patients

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.

Cerebral oxygenation and autoregulation during rewarming on cardiopulmonary bypass

BACKGROUND

Rewarming on cardiopulmonary bypass (CPB) is associated with increased metabolic demands; however, it remains unclear whether cerebral autoregulation is affected during this phase. This RCT aims to describe the effects of 20% supranormal, compared to normal CPB flow, on monitoring signs of inadequate perfusion, oxygenation, and disturbed cerebral autoregulation, during the rewarming phase of CPB.

METHOD

Thirty two patients scheduled for coronary artery bypass grafting were allocated to a Control group (n = 16) receiving a CPB pump flow corresponding to preoperatively measured cardiac output, and an Intervention group (n = 16) receiving the corresponding CPB pump flow increased by 20% during rewarming. Cerebral Oximetry Index (COx) was calculated with the aid of Near Infrared Spectroscopy.

RESULTS

Twenty five patients were included in the data. Results show a median COx value of 0.0 (IQR -0.33-0.5) (Control) and 0.0 (IQR -0.15-0.25) (Intervention), respectively; p = .85 with individual variations within groups. The median cerebral perfusion pressure (CPP) was 55 (52-58) (Control) and 61 (54-66) mmHg (Intervention); p = .08. No significant difference in rSO2 values was observed between the groups (58.5% (50-61) versus 64% (58-68); p = .06).

CONCLUSION

The present study showed no difference between increased and normal CPB pump flow with respect to cerebral autoregulation during rewarming. Large variations in cerebral autoregulation were seen at individual level.

Comparison of bubble removal performances of five membrane oxygenators with and without a pre-filter

When employing minimal invasive extracorporeal circulation (MiECC), the removal of bubbles in the circuit is important to prevent air embolism. We investigated the bubble removal performance of the FHP oxygenator with a pre-filter and compared it with that of four oxygenators, including the Fusion oxygenator, Quadrox oxygenator, Inspire oxygenator, and FX oxygenator. A closed test circuit filled with an aqueous glycerin solution was used. Air injection (10 mL) was performed prior to the oxygenator, and the number and volume of the bubbles were measured at the inlet and outlet of each oxygenator. At the inlet of the five oxygenators, there were no significant differences in the total number of bubbles detected. At the outlet, bubbles were classified into two groups according to the bubble size: ≥100 μm and <100 μm. Tests were performed at pump flow rates of 4 and 5 L/min. For bubbles ≥100 μm, which are considered clinically detrimental, the FHP was the lowest number and volume of bubbles at both pump flow rates compared to the other oxygenators. Regarding the bubbles <100 μm, the number of bubbles was higher in the FHP than those in others; however, the volume of bubbles was significantly lower at 4 L/min and tended to be lower at 5 L/min. The use of the FHP with the pre-filter removed more bubbles ≥100 μm in the circuit than that by the other oxygenators.

Microvascular dysfunction following cardiopulmonary bypass plays a central role in postoperative organ dysfunction

Despite significant advances in surgical technique and strategies for tissue/organ protection, cardiac surgery involving cardiopulmonary bypass is a profound stressor on the human body and is associated with numerous intraoperative and postoperative collateral effects across different tissues and organ systems. Of note, cardiopulmonary bypass has been shown to induce significant alterations in microvascular reactivity. This involves altered myogenic tone, altered microvascular responsiveness to many endogenous vasoactive agonists, and generalized endothelial dysfunction across multiple vascular beds. This review begins with a survey of in vitro studies that examine the cellular mechanisms of microvascular dysfunction following cardiac surgery involving cardiopulmonary bypass, with a focus on endothelial activation, weakened barrier integrity, altered cell surface receptor expression, and changes in the balance between vasoconstrictive and vasodilatory mediators. Microvascular dysfunction in turn influences postoperative organ dysfunction in complex, poorly understood ways. Hence the second part of this review will highlight in vivo studies examining the effects of cardiac surgery on critical organ systems, notably the heart, brain, renal system, and skin/peripheral tissue vasculature. Clinical implications and possible areas for intervention will be discussed throughout the review.

Perioperative Care of the Patient with Eye Pathologies Undergoing Nonocular Surgery

The authors reviewed perioperative ocular complications and implications of ocular diseases during nonocular surgeries. Exposure keratopathy, the most common perioperative eye injury, is preventable. Ischemic optic neuropathy, the leading cause of perioperative blindness, has well-defined risk factors. The incidence of ischemic optic neuropathy after spine fusion, but not cardiac surgery, has been decreasing. Central retinal artery occlusion during spine fusion surgery can be prevented by protecting eyes from compression. Perioperative acute angle closure glaucoma is a vision-threatening emergency that can be successfully treated by rapid reduction of elevated intraocular pressure. Differential diagnoses of visual dysfunction in the perioperative period and treatments are detailed. Although glaucoma is increasingly prevalent and often questions arise concerning perioperative anesthetic management, evidence-based recommendations to guide safe anesthesia care in patients with glaucoma are currently lacking. Patients with low vision present challenges to the anesthesia provider that are becoming more common as the population ages.

One-stage hybrid coronary revascularization for the treatment of multivessel coronary artery disease— Periprocedural and long-term results from the “HYBRID-COR” feasibility study

Background

The constant growth of interest in hybrid coronary artery revascularization (HCR) is apparent. Yet, few studies report outcomes of the one-stage HCR. Consequently, the status of such procedures is not adequately supported in clinical guidelines. The aim of this study was to report the safety, feasibility, and long term-outcomes of the one-stage HCR.

Methods and results

Patients were enrolled in the prospective one-stage hybrid coronary revascularization program (HYBRID-COR). They underwent a one-stage hybrid revascularization procedure while on double antiplatelet therapy (DAPT) with Ticagrelor: endoscopic atraumatic coronary artery bypass grafting (EACAB) for revascularization of the left anterior descending (LAD) artery and percutaneous intervention in non-LAD arteries with contemporary drug-eluting stents. The composite primary endpoint included MACCE (major adverse cardiac and cerebrovascular events: death, myocardial infarction, stroke, and repeated revascularization) in long-term observation. The study cohort consisted of 30 patients (68% male) with stable coronary artery disease (26.7%) and unstable angina (73.3%). Procedural success was 100%. No death, myocardial infarction (MI), or stroke were observed in the perioperative period. One patient (3.3%) required chest revision and blood transfusion due to surgical bleeding. Kidney injury was noted in two patients (6.6%). In a long-term follow-up (median; IQR: 4.25; 2.62–4.69 years), two patients (6.6%) underwent repeated revascularization and one patient (3.3%) died due to MI. The overall primary endpoint rate was 9.9%.

Conclusion

One-stage hybrid revascularization, on DAPT, is a feasible, safe, and efficient way of achieving complete revascularization in selected patients. The complication rate is low and acceptable. Further randomized trials are required.

Neuroprotective effect of remote ischemic preconditioning in patients undergoing cardiac surgery: A randomized controlled trial

Background

The neuroprotective effect of remote ischemic preconditioning (RIPC) in patients undergoing elective cardiopulmonary bypass (CPB)-assisted coronary artery bypass graft (CABG) or valvular cardiac surgery remains unclear.

Methods

A randomized, double-blind, placebo-controlled superior clinical trial was conducted in patients undergoing elective on-pump coronary artery bypass surgery or valve surgery. Before anesthesia induction, patients were randomly assigned to RIPC (three 5-min cycles of inflation and deflation of blood pressure cuff on the upper limb) or the control group. The primary endpoint was the changes in S-100 calcium-binding protein β (S100-β) levels at 6 h postoperatively. Secondary endpoints included changes in Neuron-specific enolase (NSE), Mini-mental State Examination (MMSE), and Montreal Cognitive Assessment (MoCA) levels.

Results

A total of 120 patients [mean age, 48.7 years; 36 women (34.3%)] were randomized at three cardiac surgery centers in China. One hundred and five patients were included in the modified intent-to-treat analysis (52 in the RIPC group and 53 in the control group). The primary result demonstrated that at 6 h after surgery, S100-β levels were lower in the RIPC group than in the control group (50.75; 95% confidence interval, 67.08 to 64.40 pg/ml vs. 70.48; 95% CI, 56.84 to 84.10 pg/ml, P = 0.036). Compared to the control group, the concentrations of S100-β at 24 h and 72 h and the concentration of NSE at 6 h, 24 h, and 72 h postoperatively were significantly lower in the RIPC group. However, neither the MMSE nor the MoCA revealed significant between-group differences in postoperative cognitive performance at 7 days, 3 months, and 6 months after surgery.

Conclusion

In patients undergoing CPB-assisted cardiac surgery, RIPC attenuated brain damage as indicated with the decreased release of brain damage biomarker S100-β and NSE.

Clinical trial registration

[ClinicalTrials.gov], identifier [NCT01231789].

"This looks like a movie": a case report of post-surgical amnesia

A 52-year-old male patient with a background of adaptive personality disorder was admitted for mitral valve repair and cardiac ablation for atrial fibrillation. He suffered intraoperative complications with severe mitral insufficiency that suffered ischemia.. Post-operatively, he demonstrated acute loss of retrograde autobiographical memory, prosopagnosia and a loss of public semantic memory. His CT scan was normal and MRI was not possible due to intra-cardiac leads. An initial diagnosis of hypoxic-ischemic encephalopathy was considered. A neuropsychological examination undertaken 20 days after his surgery showed a severe alteration of retrograde autobiographical memory, marked alteration of semantic knowledge and prosopagnosia. He demonstrated an average performance in tasks measuring constructional praxis, visuospatial ability, and executive functions. 34 days after surgery, and after a short nap, the patient "returns" to the day before admission and consequently recovers his memory. Repeat neuropsychological assessment demonstrated performance within the normal range across all previously tested domains. This sudden recovery of memory, together with a normal MRI, led to a rethinking of the diagnosis of dissociative amnesia. This case illustrates the long-standing discussion about the organic or functional origin of some memory disorders, in which, despite advances in neuroimaging techniques, it is still difficult to know their etiology    .

Mortality Reduction After a Preincision Safety Check Before Cardiac Surgery: Is It the Aorta?

OBJECTIVES

The introduction and use of a preincision safety check were associated with lower mortality after mixed adult cardiac surgery; however, an explanatory mechanism is lacking. Stroke, one of the most severe complications after cardiac surgery, with high mortality, may be reduced by adapting the surgical handling of the ascending aorta. This study assessed the prevalence and predictors of this adaptation after a preincision safety check and the subsequent effect on outcome.

DESIGN

A prospective, single-center, observational study comparing adaptation with no-adaptation. The primary outcome measure was 30-day mortality. Multivariate analyses were performed to determine independent predictors of adaptation. To study the effect of adaptation on outcome, a propensity score-matched cohort was constructed in a 1:3 intervention:control ratio.

SETTING

At Isala Zwolle (NL), a large, nonacademic teaching hospital.

PARTICIPANTS

All consecutive cardiac surgery procedures from 2012 until 2015, including 4,752 surgeries.

INTERVENTIONS

The adaptation of surgical handling of the ascending aorta.

MEASUREMENTS AND MAIN RESULTS

In 283 cardiac surgeries (5.9%), adaptation was indicated. The most important independent predictors for adaptation were extracardiac atherosclerosis, current smoking, and increasing age. In the propensity score-matched cohort consisting of 1,069 procedures, there were no significant differences in outcome. After correction for propensity score, the hazard ratio of adaptation for 30-day mortality was 1.8 (0.85-3.79).

CONCLUSIONS

The adaptation of aortic surgical handling after a preincision safety check was necessary for 5.9% of cardiac surgeries, with extracardiac atherosclerosis as the strongest predictor. Outcome was not significantly different between patients with and without adaptation. Although promising, it remains unclear whether adaptation may fully explain mortality reduction after the use of a preincision safety check.

Prediction of stroke reconvalescence after coronary bypass surgery indicated by CT scan parameters

BACKGROUND

Stroke in the postoperative time course after heart surgery remains a serious risk. Cranial computer tomography (CCT) is the first line option to detect severe intracranial damage. However, only few data are available to predict neurological outcome. Using visual rating scales (VRSs), this study addresses reliability and effectivity to indicate neurological status and likelyhood of improvement.

METHODS

In a single-center retrospective evaluation, 3719 patients underwent coronary bypass surgery. Because of a delayed recovery phase and neurologic deficits after cardiac surgery 109 patients had a cranial CT scan in the early postoperative period. The incidence of clinically relevant findings within the imaging was rated by an experienced neuroradiologist using two VRS, that is, the age-related white matter changes (ARWMCs) and the Mendes-Ribeiro visual rating scale (MRVRS). Both are computer-assisted measurement schemes to detect stroke-related intracranial damage. Follow-up was investigated with regard to clinical outcome and patient-related risk profiles.

RESULTS

Of 109 patients with postoperative cranial CT scans due to prolonged recovery phases or proven neurological damage 44.5% had one cerebral defect in CCT imaging scans only. The others showed multiple defects. During hospital stay, 92.3% experienced neurological improvement exposing reduced ARWMC, while 7.1% had no improvement and correlating high scores. Of both scales, the ARWMC-VRS demonstrated superior accuracy and discrimination. The preoperative ejection fraction (EF), arteriosclerotic degeneration of carotid arteries, and reduced glomerular filtration rate were found to have a high correlation (r = 0.0005) with the latter group. In-hospital mortality of this cohort was 8.18%.

CONCLUSION

Both the ARWMC and MRVRS were found to be appropriate. They reliably discriminate the groups of stroke patients after coronary artery bypass grafting (CABG)  in the analysis of CCT images. When applied at the onset of neurological symptoms both scales are able to predict neurological reconvalescence upon hospital dismission. The ARWMC scale appeared superior as it demonstrated better accuracy and discrimination. The use of both VRS in patients with suspected stroke after CABG surgery can give insightful information toward a progression of neurological dysfunction or postoperative improvement.

Mitigation of perioperative neurocognitive disorders: A holistic approach

William Morton introduced the world to ether anesthesia for use during surgery in the Bullfinch Building of the Massachusetts General Hospital on October 16, 1846. For nearly two centuries, the prevailing wisdom had been that the effects of general anesthetics were rapidly and fully reversible, with no apparent long-term adverse sequelae. Despite occasional concerns of a possible association between surgery and anesthesia with dementia since 1887 (Savage, 1887), our initial belief was robustly punctured following the publication in 1998 of the International Study of Post-Operative Cognitive Dysfunction [ISPOCD 1] study by Moller et al. (1998) in The Lancet, in which they demonstrated in a prospective fashion that there were in fact persistent adverse effects on neurocognitive function up to 3 months following surgery and that these effects were common. Since the publication of that landmark study, significant strides have been made in redefining the terminology describing cognitive dysfunction, identifying those patients most at risk, and establishing the underlying etiology of the condition, particularly with respect to the relative contributions of anesthesia and surgery. In 2018, the International Nomenclature Consensus Working Group proposed new nomenclature to standardize identification of and classify perioperative cognitive changes under the umbrella of perioperative neurocognitive disorders (PND) (Evered et al., 2018a). Since then, the new nomenclature has tried to describe post-surgical cognitive derangements within a unifying framework and has brought to light the need to standardize methodology in clinical studies and motivate such studies with hypotheses of PND pathogenesis. In this narrative review, we highlight the relevant literature regarding recent key developments in PND identification and management throughout the perioperative period. We provide an overview of the new nomenclature and its implications for interpreting risk factors identified by clinical association studies. We then describe current hypotheses for PND development, using data from clinical association studies and neurophysiologic data where appropriate. Finally, we offer broad clinical guidelines for mitigating PND in the perioperative period, highlighting the role of Brain Enhanced Recovery After Surgery (Brain-ERAS) protocols.

Silent Brain Infarction, Delirium, and Cognition in Three Invasive Cardiovascular Procedures: a Systematic Review

Silent brain infarctions (SBIs) are brain lesions noted on neuroimaging that are not associated with clinical symptoms. SBIs are associated with a number of vascular risk factors and are common following invasive cardiovascular procedures such as atrial fibrillation (AF) ablation, coronary artery bypass graft (CABG), and transcatheter aortic valve replacement (TAVR). Although not eliciting signs of clinical stroke, SBIs are associated with increased frailty, and motor and mood features. Less is known, however, about the relationship between SBI, cognition, and delirium following invasive cardiac procedures and most investigations into these relationships have been reported in large-scale epidemiological studies. In the current paper, we conducted a systematic review to evaluate evidence of a relationship between SBI, delirium, and cognitive decline following CABG, AF ablation, and TAVR. Twenty studies met inclusion criteria. In general, our review identified conflicting results for each cardiac procedure, with some studies suggesting a relationship between SBI, cognitive impairment, and delirium, whereas others showed no relationship between SBI, cognitive impairment, and delirium. Potential reasons for this discrepancy as well as suggestions for future research are discussed.

Nose-shaped mass in the ascending aorta

A 79‐year‐old man was referred for urgent coronary artery bypass grafting. Contrast‐enhanced computed tomography revealed an atypically nose‐shaped contrast defect, which intraoperatively turned out to be an atheromatous plaque. Its preoperative detection allowed us to prevent an adverse cerebral event. This case highlights that a thorough preoperative work‐up should ideally include a CT angiography, in patients where atherosclerotic changes are to be expected.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.