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Fong KY, Yeo S, Luo H, Kofidis T, Teoh KLK, Kang GS. Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. ANZ J Surg 2024; 94:522-535. [PMID: 38529814 DOI: 10.1111/ans.18947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/15/2023] [Accepted: 03/04/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted. METHODS An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE). RESULTS Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE. CONCLUSION This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Selvie Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Haidong Luo
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Theodoros Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Kristine L K Teoh
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Giap Swee Kang
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
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Jaffar-Karballai M, Kayali F, Botezatu B, Satti DI, Harky A. The Rationalisation of Intra-Operative Imaging During Cardiac Surgery: A Systematic Review. Heart Lung Circ 2023; 32:567-586. [PMID: 36870922 DOI: 10.1016/j.hlc.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 03/05/2023]
Abstract
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.
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Affiliation(s)
| | - Fatima Kayali
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Bianca Botezatu
- Queen's University Belfast, School of Medicine, Dentistry and Biomedical Sciences, Belfast, Northern Ireland
| | - Danish Iltaf Satti
- Shifa College of Medicine, Shifa Tameer-e-millat University, Islamabad, Pakistan
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.
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Kulkarni S, Szeto WY, Jha S. Preoperative Computed Tomography in the Adult Cardiac Surgery Patient. Curr Probl Diagn Radiol 2020; 51:121-129. [PMID: 33414038 DOI: 10.1067/j.cpradiol.2020.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 11/22/2022]
Abstract
Increasingly, computed tomography is requested for preoperative planning prior to cardiac surgery. Common pathologies, such as aortic and mitral annular calcification, can influence the choice of surgical technique or approach. In this article, we present a case-based review of primary and reoperative sternotomies that focuses on the clinical relevance of the common pathologies and findings in pre-operative computed tomography images, with respect to surgical decision-making and management.
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Affiliation(s)
- Sagar Kulkarni
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Saurabh Jha
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA
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Composite endpoints: What were the odds of that? Med Hypotheses 2020; 143:110092. [DOI: 10.1016/j.mehy.2020.110092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/22/2020] [Accepted: 07/06/2020] [Indexed: 11/23/2022]
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Krause M, Morabito JE, Mackensen GB, Perry TE, Bartels K. Current Neurologic Assessment and Neuroprotective Strategies in Cardiac Anesthesia: A Survey to the Membership of the Society of Cardiovascular Anesthesiologists. Anesth Analg 2020; 131:518-526. [PMID: 31880633 DOI: 10.1213/ane.0000000000004601] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Neurologic injury and cognitive disorder after cardiac surgery are associated with morbidity and mortality. Variability in the application of neuroprotective strategies likely exists during cardiac surgery. The Society of Cardiovascular Anesthesiologists (SCA) conducted a survey among its members on common perioperative neuroprotective strategies: assessment of aortic atheromatous burden, management of intraoperative blood pressure, and use of cerebral oximetry. METHODS A 15-item survey was developed by 3 members of the SCA Continuous Practice Improvement - Cerebral Protection Working Group. The questionnaire was then circulated among all working group members, adapted, and tested for face validity. On March 26, 2018, the survey was sent to members of the SCA via e-mail using the Research Electronic Data Capture system. Responses were recorded until April 16, 2018. RESULTS Of the 3645 surveys e-mailed, 526 members responded (14.4%). Most responders worked in academic institutions (58.3%), followed by private practices (38.7%). Epiaortic ultrasound for the assessment of aortic atheromatous burden was most commonly utilized at the surgeon's request (46.5%). Cerebral oximetry was most commonly used in patients with increased perioperative risk of cerebral injury (41.4%). Epiaortic ultrasound (1.9%) and cerebral oximetry (5.2%) were rarely part of a standardized monitoring approach. A majority of respondents (52.0%) reported no standardized management strategies for neuroprotection during cardiac surgery at their institution. A total of 55.3% stated that no standardized institutional guidelines were in place for managing a patient's blood pressure intraoperatively or during cardiopulmonary bypass. When asked about patients at risk for postoperative cerebral injury, 41.3% targeted a blood pressure goal >65 mmHg during cardiopulmonary bypass. The majority of responders (60.4%) who had access to institutional rates of postoperative stroke/cerebral injury had standard neuroprotective strategies in place. CONCLUSIONS Our data indicate that approximately half of the respondents to this SCA survey do not use standardized guidelines/standard operating procedures for perioperative cerebral protection. The lack of standardized neuroprotective strategies during cardiac surgery may impact postoperative neurologic outcomes. Further investigations are warranted and should assess the association of standardized neuroprotective approaches and postoperative neurological outcomes.
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Affiliation(s)
- Martin Krause
- From the Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado
| | - Joseph E Morabito
- From the Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado
| | - G Burkhard Mackensen
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - Tjörvi E Perry
- Department of Anesthesiology, University of Minnesota, Medical School, Minneapolis, Minnesota
| | - Karsten Bartels
- From the Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado
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Neurological Complications in Cardiac Surgery. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00344-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Vranken NPA, Weerwind PW. Non-Invasive Tissue Oximetry-An Integral Puzzle Piece. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2019; 51:41-45. [PMID: 30936588 PMCID: PMC6436175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 01/25/2019] [Indexed: 06/09/2023]
Abstract
Non-invasive tissue oximetry is a monitoring method for continuous assessment of tissue oxygenation, which may aid in detection of hemodynamic instability and otherwise unnoticed hypoxia. Numerous studies focused on using non-invasive tissue oximetry intraoperatively, proposing its predictive value in relation to clinical outcome. Tissue oximetry may be part of standard monitoring practice for brain monitoring during cardiac surgery in many clinical centers; however, the monitoring method can be deployed in numerous clinical settings. This succinct overview aims to determine the role of non-invasive tissue oximetry in current clinical practice.
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Affiliation(s)
- Nousjka P A Vranken
- Department of Cardiothoracic Surgery and Cardiovascular Research Institute - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Patrick W Weerwind
- Department of Cardiothoracic Surgery and Cardiovascular Research Institute - CARIM, Maastricht University Medical Center, Maastricht, The Netherlands
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Sun LY, Chung AM, Farkouh ME, van Diepen S, Weinberger J, Bourke M, Ruel M. Defining an Intraoperative Hypotension Threshold in Association with Stroke in Cardiac Surgery. Anesthesiology 2019; 129:440-447. [PMID: 29889106 DOI: 10.1097/aln.0000000000002298] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Stroke is a leading cause of morbidity, mortality, and disability in patients undergoing cardiac surgery. Identifying modifiable perioperative stroke risk factors may lead to improved patient outcomes. The association between the severity and duration of intraoperative hypotension and postoperative stroke in patients undergoing cardiac surgery was evaluated. METHODS A retrospective cohort study was conducted of adult patients who underwent cardiac surgery requiring cardiopulmonary bypass at a tertiary center between November 1, 2009, and March 31, 2015. The primary outcome was postoperative ischemic stroke. Intraoperative hypotension was defined as the number of minutes spent within mean arterial pressure bands of less than 55, 55 to 64, and 65 to 74 mmHg before, during, and after cardiopulmonary bypass. The association between stroke and hypotension was examined by using logistic regression with propensity score adjustment. RESULTS Among the 7,457 patients included in this analysis, 111 (1.5%) had a confirmed postoperative diagnosis of stroke. Stroke was strongly associated with sustained mean arterial pressure of less than 64 mmHg during cardiopulmonary bypass (adjusted odds ratio 1.13; 95% CI, 1.05 to 1.21 for every 10 min of mean arterial pressure between 55 and 64 mmHg; adjusted odds ratio 1.16; 95% CI, 1.08 to 1.23 for every 10 min of mean arterial pressure less than 55 mmHg). Other factors that were independently associated with stroke were older age, hypertension, combined coronary artery bypass graft/valve surgery, emergent operative status, prolonged cardiopulmonary bypass duration, and postoperative new-onset atrial fibrillation. CONCLUSIONS Hypotension is a potentially modifiable risk factor for perioperative stroke. The study's findings suggest that mean arterial pressure may be an important intraoperative therapeutic hemodynamic target to reduce the incidence of stroke in patients undergoing cardiopulmonary bypass.
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Affiliation(s)
- Louise Y Sun
- From the Division of Cardiac Anesthesiology (L.Y.S., A.M.C., M.B.) the Division of Cardiac Surgery (M.R.) University of Ottawa Heart Institute, Ottawa, Ontario, Canada; the School of Epidemiology and Public Health (L.Y.S.) University of Ottawa, Ottawa, Ontario, Canada; Cardiovascular Research Program, Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada (L.Y.S.) Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada (M.E.F.) the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada (M.E.F.) the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada (S.v.D.) the Department of Neurology, The Icahn School of Medicine at Mount Sinai, New York, New York (J.W.)
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Engelman RM, Engelman DT. Strategies and Devices to Minimize Stroke in Adult Cardiac Surgery. Semin Thorac Cardiovasc Surg 2015; 27:24-9. [DOI: 10.1053/j.semtcvs.2015.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2015] [Indexed: 01/04/2023]
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