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Hacker A, Maggs P, Treanor P, Lilly K, Birjiniuk V. Is cardioplegia system pressure the optimal measure of coronary perfusion during antegrade cardioplegia delivery? A critical review of pressure measurements for optimal antegrade delivery. Perfusion 2023:2676591231206016. [PMID: 37855099 DOI: 10.1177/02676591231206016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
Antegrade cardioplegia is routinely given during cardiac surgery. The delivery of antegrade cardioplegia from the cardiopulmonary bypass machine has many variables. Many perfusionists rely exclusively on cardioplegia system pressure to ensure safe antegrade delivery. Our group reviewed antegrade cardioplegia delivery in 50 patients undergoing coronary artery bypass graft. The data collected included the cardioplegia system pressure and the patient's direct aortic root pressure. The analysis of the data found weak correlation between the two pressures with a large mean difference and a wide standard deviation. The results suggest the direct measurement of aortic root pressure as guidance to antegrade cardioplegia instead of relying solely on cardioplegia system pressure.
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Affiliation(s)
- Allison Hacker
- Department of Cardiovascular Perfusion, Mount Auburn Hospital, Cambridge, MA, USA
| | - Peter Maggs
- Department of Cardiac Surgery, Mount Auburn Hospital, Cambridge, MA, USA
| | - Patrick Treanor
- Department of Cardiovascular Perfusion, Mount Auburn Hospital, Cambridge, MA, USA
| | - Kevin Lilly
- Department of Cardiovascular Perfusion, Mount Auburn Hospital, Cambridge, MA, USA
| | - Vladimir Birjiniuk
- Department of Cardiac Surgery, Mount Auburn Hospital, Cambridge, MA, USA
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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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3
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Roth S, Moss HE, Vajaranant TS, Sweitzer B. Perioperative Care of the Patient with Eye Pathologies Undergoing Nonocular Surgery. Anesthesiology 2022; 137:620-643. [PMID: 36179149 PMCID: PMC9588701 DOI: 10.1097/aln.0000000000004338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Steven Roth
- Department of Anesthesiology, University of Illinois at Chicago, College of Medicine, Chicago, Illinois
| | - Heather E Moss
- Departments of Ophthalmology and Neurology & Neurologic Sciences, Stanford University, Palo Alto, California
| | - Thasarat Sutabutr Vajaranant
- Department of Ophthalmology and Visual Science, University of Illinois at Chicago, College of Medicine, Chicago, Illinois
| | - BobbieJean Sweitzer
- University of Virginia, Charlottesville, Virginia; Perioperative Medicine, Inova Health System, Falls Church, Virginia
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Ramponi F, Seco M, Brereton RJL, Gaudino MFL, Puskas JD, Calafiore AM, Vallely MP. Toward stroke-free coronary surgery: The role of the anaortic off-pump bypass technique. J Card Surg 2021; 36:1499-1510. [PMID: 33502822 DOI: 10.1111/jocs.15372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/06/2021] [Accepted: 01/13/2021] [Indexed: 11/26/2022]
Abstract
Surgical coronary revascularization remains the preferred strategy in a significant portion of patients with coronary artery disease due to superior long-term outcomes. However, there is a significant risk of perioperative neurologic injury that has influenced guideline recommendations. These complications occur in 1%-5% of patients, ranging from overt neurologic deficits with permanent disability, to subtle cerebral defects noted on neuroimaging that may result in slow cognitive and functional decline. The primary mechanism by which these events occur is thromboembolism from manipulation of the ascending aorta. This occurs during cardiopulmonary bypass, aortic cross-clamping, and partial occlusion clamping (side clamp). Elderly patients and patients with aortic atheroma are, therefore, at significantly increased risk. Initial surgical techniques addressed this by aggressively debriding or replacing the ascending aorta during coronary artery bypass grafting (CABG). Strategies then moved toward minimizing aortic manipulation through pump-assisted beating heart surgery and off-pump surgery with partial occlusion clamping or proximal anastomosis devices. Finally, anaortic off-pump CABG aims to avoid all manipulation of the ascending aorta through advanced off-pump grafting techniques combined with in situ and composite grafts. This has been demonstrated to result in the greatest reduction in risk. Establishing successful anaortic off-pump CABG programs requires subspecialization and focused interest groups dedicated to advancing CABG outcomes.
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Affiliation(s)
- Fabio Ramponi
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael Seco
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, New York, USA
| | | | - Michael P Vallely
- Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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5
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Osaka S, Tanaka M. Strategy for Porcelain Ascending Aorta in Cardiac Surgery. Ann Thorac Cardiovasc Surg 2018; 24:57-64. [PMID: 29491196 DOI: 10.5761/atcs.ra.17-00181] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Shunji Osaka
- Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Masashi Tanaka
- Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
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Intraoperative Echocardiography. Echocardiography 2018. [DOI: 10.1007/978-3-319-71617-6_40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Newman MF, Stanley TO, Grocott HP. Strategies to Protect the Brain During Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1053/vc.2000.6499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Despite significant advances in cardiopulmonary by pass (CPB) technology, surgical techniques, and anes thetic management, central nervous system (CNS) com plications remain a common and costly problem after CPB. Stroke is often considered a rare and unprevent able complication of cardiac surgery. Recent studies have shown that through the use of echocardiography and historical risk stratification strategies, we can de fine which patients are at substantially greater risk for CNS injury. Through enhanced understanding of the etiology of stroke and perioperative factors, which are associated with potential for neuroprotection or injury extension, there now exists a greater potential than ever to substantially reduce neurological injury associ ated with cardiac surgery. Strategies and theories of stratifying patients at risk and secondarily reducing that risk are described, as well as consideration for early postoperative assessment to allow treatment when events occur.
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Affiliation(s)
- Mark F. Newman
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC
| | - Timothy O. Stanley
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC
| | - Hilary P. Grocott
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, NC
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Abstract
Patients undergoing coronary artery bypass grafting are at higher risk of neurologic events than demographi cally similar patients undergoing noncardiac surgery. Postoperative stroke has been shown to occur two to three times more frequently than in age-, gender-, and education-matched patients undergoing noncardiac vas cular or thoracic surgery. The incidence of more subtle brain syndromes, giving rise to symptoms of memory loss and cognitive deterioration as documented in up to 79% of coronary bypass patients, varies depending on whether prospective or retrospective data are analyzed, and whether or not serial cognitive testing is used, and is also significantly higher in coronary bypass patients. Various factors have been identified as causative in the genesis of perioperative neurologic injury in these pa tients. Although there is evidence that microgaseous and microparticulate emboli are instrumental in the production of postoperative cognitive impairment, the role of ascending aortic atherosclerosis is increasingly recognized as being the greatest single risk factor for postoperative stroke.
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Affiliation(s)
- Yigal Abramowitz
- From Cedars-Sinai Heart Institute, Los Angeles, California (Y.A., H.J., T.C., R.R.M.); and Department of Cardiovascular Surgery, Heart Hospital Baylor Plano, Baylor Health Care System, Plano, TX (M.J.M.)
| | - Hasan Jilaihawi
- From Cedars-Sinai Heart Institute, Los Angeles, California (Y.A., H.J., T.C., R.R.M.); and Department of Cardiovascular Surgery, Heart Hospital Baylor Plano, Baylor Health Care System, Plano, TX (M.J.M.)
| | - Tarun Chakravarty
- From Cedars-Sinai Heart Institute, Los Angeles, California (Y.A., H.J., T.C., R.R.M.); and Department of Cardiovascular Surgery, Heart Hospital Baylor Plano, Baylor Health Care System, Plano, TX (M.J.M.)
| | - Michael J Mack
- From Cedars-Sinai Heart Institute, Los Angeles, California (Y.A., H.J., T.C., R.R.M.); and Department of Cardiovascular Surgery, Heart Hospital Baylor Plano, Baylor Health Care System, Plano, TX (M.J.M.)
| | - Raj R Makkar
- From Cedars-Sinai Heart Institute, Los Angeles, California (Y.A., H.J., T.C., R.R.M.); and Department of Cardiovascular Surgery, Heart Hospital Baylor Plano, Baylor Health Care System, Plano, TX (M.J.M.).
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Hartert M, Abugameh A, Vahl CF. Herausforderung Porzellanaorta. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00398-013-1039-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Pascual I, Avanzas P, Muñoz-García AJ, López-Otero D, Jimenez-Navarro MF, Cid-Alvarez B, del Valle R, Alonso-Briales JH, Ocaranza-Sanchez R, Alfonso F, Hernández JM, Trillo-Nouche R, Morís C. Implante percutáneo de la válvula autoexpandible CoreValve® en pacientes con estenosis aórtica grave y aorta de porcelana: seguimiento a medio plazo. Rev Esp Cardiol 2013. [DOI: 10.1016/j.recesp.2013.03.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Pascual I, Avanzas P, Muñoz-García AJ, López-Otero D, Jimenez-Navarro MF, Cid-Alvarez B, del Valle R, Alonso-Briales JH, Ocaranza-Sanchez R, Alfonso F, Hernández JM, Trillo-Nouche R, Morís C. Percutaneous implantation of the CoreValve® self-expanding valve prosthesis in patients with severe aortic stenosis and porcelain aorta: medium-term follow-up. ACTA ACUST UNITED AC 2013; 66:775-81. [PMID: 24773857 DOI: 10.1016/j.rec.2013.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 03/05/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION AND OBJECTIVES There is little information on the use of transcatheter aortic valve implantation in patients with severe aortic stenosis and porcelain aorta. The primary aim of this study was to analyze death from any cause after CoreValve(®) implantation in patients with severe aortic stenosis, with and without porcelain aorta. METHODS In this multicenter, observational prospective study, carried out in 3 hospitals, percutaneous aortic valves were implanted in 449 patients with severely calcified aortic stenosis. Of these, 36 (8%) met the criteria for porcelain aorta. The primary end-point was death from any cause at 2 years. RESULTS Patients with porcelain aorta more frequently had extracardiac vascular disease (11 [30.6%] vs 49 [11.9%]; P=.002), prior coronary revascularization (15 [41.7%] vs 98 [23.7%]; P=.017), and dyslipidemia (26 [72.2%] vs 186 [45%]; P=.02). In these patients, there was greater use of general anesthesia (15 [41.7%] vs 111 [16.9%]; P=.058) and axillary access (9 [25%] vs 34 [8.2%]; P=.004). The success rate of the procedure (94.4 vs 97.3%; P=.28) and the incidence of complications (7 [19.4%] vs 48 [11.6%]; P=.20) were similar in both groups. There were no statistically significant differences in the primary end point at 24 months of follow-up (8 [22.2%] vs 66 [16%]; P=.33). The only predictive variable for the primary end point was the presence of complications during implantation (hazard ratio=2.6; 95% confidence interval, 1.5-4.5; P=.001). CONCLUSIONS In patients with aortic stenosis and porcelain aorta unsuitable for surgery, percutaneous implantation of the CoreValve(®) self-expanding valve prosthesis is safe and feasible.
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Affiliation(s)
- Isaac Pascual
- Sección de Hemodinámica y Cardiología Intervencionista, Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Pablo Avanzas
- Sección de Hemodinámica y Cardiología Intervencionista, Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | | | - Diego López-Otero
- Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | | | - Belén Cid-Alvarez
- Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Raquel del Valle
- Sección de Hemodinámica y Cardiología Intervencionista, Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Juan H Alonso-Briales
- Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Raimundo Ocaranza-Sanchez
- Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Fernando Alfonso
- Servicio de Cardiología, Hospital Clínico San Carlos, Madrid, Spain
| | - José M Hernández
- Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Ramiro Trillo-Nouche
- Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - César Morís
- Sección de Hemodinámica y Cardiología Intervencionista, Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain.
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Coskun I, Colkesen Y, Demirturk OS, Tunel HA, Giray S, Gulcan O. Pre- and perioperative risk factors predicting neurologic outcomes after coronary artery bypass surgery in patients with pre-existing neurologic events. J Stroke Cerebrovasc Dis 2013; 22:1340-9. [PMID: 23422349 DOI: 10.1016/j.jstrokecerebrovasdis.2013.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Revised: 01/15/2013] [Accepted: 01/20/2013] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND A neurologic event (NE) after coronary artery bypass graft (CABG) surgery is a principal complication affecting morbidity and mortality. We investigated the risk factors predicting postoperative NEs and survival in patients with pre-existing NE undergoing CABG. METHODS Between 2001 and 2012, 3137 patients underwent isolated primary CABG. The data were stored in a computerized database and retrospectively evaluated. Patients were divided into 2 groups based on the existence of preoperative NE (study group; n=126) and without NE (n=3011). Uni- and multivariate logistic regression analyses were performed to evaluate the possible predictors of postoperative NEs. Survival was determined using Kaplan-Meier survival analyses of the study group and propensity score-matched control group. RESULTS The mean age of the 3137 patients was 60±9 years, and 28% (n=885) were female. Postoperative NE was seen in 4 (3.2%) patients with pre-existing NE and in 16 (0.5%) without pre-existing NE. Preoperative NE (odds ratio 4.47; 95% confidence interval 1.32-15.18; P=.01) and age (≥70 years; odds ratio 2.98; 95% confidence interval 1.21-7.33; P=.01) showed strong multivariate associations with postoperative NE. Median CHA2DS2-VASc scores were 4.5 (interquartile range 3-5) and 3 (range 0-4) in patients in the pre-existing and without NE groups, respectively (P=.01). The overall mean follow-up was 4.6±3 years. Overall survival rates (88.1% and 94%, respectively) were different between the 2 groups (P=.02). CONCLUSIONS Preoperative neurologic events and advanced age are significant risk factors predicting postoperative neurologic events. Meticulous management of the ascending aorta and carotid artery are important in diminishing postoperative neurologic events. A pre-existing neurologic event is also predictive for decreased overall survival.
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Affiliation(s)
- Isa Coskun
- Department of Cardiovascular Surgery, Baskent University Medical Center, Adana, Turkey.
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Kurisu K, Hisahara M, Iwai T, Oda S, Wang Y, Ochiai Y. Aortic Valve Replacement in a Porcelain Aorta Using Endo Balloon Occlusion. J Card Surg 2012; 27:689-91. [DOI: 10.1111/jocs.12017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Salenger R, Rodriquez E, Efird JT, Gouge CA, Trubiano P, Lundy EF. Clampless technique during coronary artery bypass grafting for proximal anastomoses in the hostile aorta. J Thorac Cardiovasc Surg 2012; 145:1584-8. [PMID: 22704289 DOI: 10.1016/j.jtcvs.2012.05.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Revised: 04/09/2012] [Accepted: 05/16/2012] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The incidence of stroke in patients undergoing coronary artery bypass grafting increases sharply in the face of significant atherosclerotic disease of the ascending aorta. We use a technique that allows full revascularization for this cohort of patients, while minimizing cerebral embolic risk. METHODS Intraoperative epiaortic ultrasound was used to screen for moderate or severe atherosclerotic disease of the ascending aorta and to precisely identify safe areas for cannulation and proximal anastomoses. By using a mildly hypothermic fibrillating technique, distal revascularization was then performed without clamping the aorta. Proximal anastomoses were accomplished under brief periods of circulatory arrest. RESULTS We routinely use this technique and examined our results in 71 consecutive patients found to have grade 3 or greater atherosclerotic plaque of the ascending aorta. This represented approximately 10.0% of our total population who underwent coronary artery bypass grafting over a 32-month period from January 2007 to September 2009. One patient (1.4%) had a mild stroke that resolved, and there were no other neurologic complications. CONCLUSIONS We have found that clampless fibrillating heart surgery with circulatory arrest for proximal anastomoses is a safe and effective technique for revascularizing patients with significant ascending aortic disease who are at high risk for cerebral embolic complications.
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Affiliation(s)
- Rawn Salenger
- Department of Cardiac Surgery, Good Samaritan Regional Medical Center, Suffern, NY 10901, USA.
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Staubach S, Franke J, Gerckens U, Schuler G, Zahn R, Eggebrecht H, Hambrecht R, Sack S, Richardt G, Horack M, Senges J, Steinberg DH, Ledwoch J, Fichtlscherer S, Doss M, Wunderlich N, Sievert H. Impact of aortic valve calcification on the outcome of transcatheter aortic valve implantation: Results from the prospective multicenter German TAVI registry. Catheter Cardiovasc Interv 2012; 81:348-55. [DOI: 10.1002/ccd.24332] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 01/03/2012] [Indexed: 11/06/2022]
Affiliation(s)
- Stephan Staubach
- CardioVascular Center Frankfurt; Sankt Katharinen und Universitätsklinikum Frankfurt; Frankfurt; Germany
| | - Jennifer Franke
- CardioVascular Center Frankfurt; Sankt Katharinen und Universitätsklinikum Frankfurt; Frankfurt; Germany
| | - Ulrich Gerckens
- Klinik für Kardiologie und Angiologie; Helios Klinikum Siegburg; Siegburg; Germany
| | - Gerhard Schuler
- Herzzentrum Leipzig; Klinik für Kardiologie; Leipzig; Germany
| | - Ralf Zahn
- Herzzentrum; Kardiologie; Ludwigshafen; Städtisches Klinikum; Germany
| | - Holger Eggebrecht
- Universitätsklinikum Essen; Westdeutsches Herzzentrum Essen; Klinik für Kardiologie; Essen; Germany
| | - Rainer Hambrecht
- Klinik für Kardiologie und Angiologie; Herzzentrum Bremen; Bremen; Germany
| | - Stefan Sack
- Klinik für Kardiologie; Pneumologie und Internistische Intensivmedizin; Städtisches Klinikum München; München; Germany
| | | | - Martin Horack
- Institut für Herzinfarktforschung Ludwigshafen an der Universität Heidelberg; Ludwigshafen; Germany
| | - Jochen Senges
- Institut für Herzinfarktforschung Ludwigshafen an der Universität Heidelberg; Ludwigshafen; Germany
| | - Daniel H. Steinberg
- CardioVascular Center Frankfurt; Sankt Katharinen und Universitätsklinikum Frankfurt; Frankfurt; Germany
| | - Jakob Ledwoch
- CardioVascular Center Frankfurt; Sankt Katharinen und Universitätsklinikum Frankfurt; Frankfurt; Germany
| | - Stephan Fichtlscherer
- CardioVascular Center Frankfurt; Sankt Katharinen und Universitätsklinikum Frankfurt; Frankfurt; Germany
| | - Mirko Doss
- CardioVascular Center Frankfurt; Sankt Katharinen und Universitätsklinikum Frankfurt; Frankfurt; Germany
| | - Nina Wunderlich
- CardioVascular Center Frankfurt; Sankt Katharinen und Universitätsklinikum Frankfurt; Frankfurt; Germany
| | - Horst Sievert
- CardioVascular Center Frankfurt; Sankt Katharinen und Universitätsklinikum Frankfurt; Frankfurt; Germany
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An unusual origin of proximal coronary bypass anastomosis in a patient with porcelain aorta: how we solved the problem. ACTA ACUST UNITED AC 2011; 64:215-8. [PMID: 21905604 DOI: 10.2298/mpns1104215k] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Severe calcification of the ascending aorta (porcelain aorta) is a very difficult condition in cardiac surgery because of a high embolization potential during the process of cannulation, aortic cross-clamping and a particular difficulty to suture the proximal anastomosis. We described a case of a 68-year-old female referred to our Institute due to unstable angina. Further diagnostics revealed a severe high grade, multilevel fibrolipid symptomatic carotid stenosis and ostial left main coronary artery stenosis and a highly calcified ascending aorta and aortic arch. We performed simultaneous carotid segment replacement with the Dacron prosthesis and revascularisation of the left anterior descending coronary artery. Proximal venous anastomosis was created in the Dacron prosthesis of the right carotid artery. Perfusion of the patient was achieved via the graft sutured at the right subclavian artery due to impossibility of direct aortic cannulation.
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Abe T, Ito T, Sunada M, Yoshizumi T, Kawamura A, Yamana K. Balloon occlusion of the ascending aorta without hypothermic circulatory arrest in valve surgery for patients with a porcelain aorta. Heart Surg Forum 2010; 13:E251-3. [PMID: 20719729 DOI: 10.1532/hsf98.20091015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Severe calcification of the ascending aorta and the aortic arch complicates cardiac surgery. The optimal approach in such patients is unknown. Four valve surgeries were performed with balloon occlusion without hypothermic circulatory arrest. All patients had femoral arterial cannulation, and all 3 patients who required an aortotomy had right axillary artery cannulation as well. A balloon catheter was inserted just proximal to the brachiocephalic artery via a purse-string stitch. Good cardiac arrest was obtained in all cases, and a good bloodless field was obtained in all 3 aortic valve cases. There were no balloon-related complications. The patients all showed good postoperative courses. Balloon occlusion of the ascending aorta without circulatory arrest is effective for performing a rapid and less invasive surgery that is not significantly different from the usual valve surgery.
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Affiliation(s)
- Tomonobu Abe
- Department of Cardiovascular Surgery, Social Insurance Chukyo Hospital, Nagoya, Japan.
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Royse AG, Royse CF. Epiaortic ultrasound assessment of the aorta in cardiac surgery. Best Pract Res Clin Anaesthesiol 2009; 23:335-41. [PMID: 19862892 DOI: 10.1016/j.bpa.2009.02.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The dislodgement of atheroma from the ascending aorta and proximal arch is a major cause of stroke and neurological injury following cardiac surgery. The accurate detection of atheroma prior to aortic manipulation is necessary to facilitate surgical strategies to reduce the risk of embolisation. The traditional method for atheroma detection is manual palpation by the surgeon. This technique misses about half the number of the atheroma lesions, as the soft (non-calcified) lesions offer little resistance to the surgeon's fingers. Trans-oesophageal echocardiography (TOE) is commonly used in cardiac surgery, but the interposition of the bronchus between the aorta and the oesophagus causes an ultrasound 'blind spot' in the ascending aorta and proximal arch, such that it does not offer improved detection compared to manual palpation. Accurate detection of atheroma requires direct ultrasound assessment using epiaortic scanning, with a high-frequency, linear-array probe. This allows the surgeon to correctly assess and localise any atheroma. In this article, a suggested epiaortic examination sequence is described and strategies for surgeons to avoid atheroma are discussed.
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Affiliation(s)
- Alistair George Royse
- Cardiovascular Therapeutics Unit, Department of Surgery and Pharmacology, University of Melbourne, VIC, Australia.
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20
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Stewart WJ, Savage RM. Intraoperative Echocardiography. Echocardiography 2009. [DOI: 10.1007/978-1-84882-293-1_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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21
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van der Linden J, Bergman P, Hadjinikolaou L. The topography of aortic atherosclerosis enhances its precision as a predictor of stroke. Ann Thorac Surg 2007; 83:2087-92. [PMID: 17532403 DOI: 10.1016/j.athoracsur.2007.02.020] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2005] [Revised: 02/06/2007] [Accepted: 02/07/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND Atherosclerosis of the thoracic aorta is an independent risk factor for stroke after cardiac surgery. No attention had so far been paid to its topography. The relationship between the topography of aortic atherosclerosis and stroke was studied in patients admitted for coronary surgery. METHODS The extent and location of atherosclerosis in the ascending aorta and arch was assessed intraoperatively with epiaortic ultrasound and transesophageal echocardiography in 611 consecutive patients. They were followed for 5.5 +/- 1.7 years (mean +/- SE), amounting to 3,358 patient-years. RESULTS The incidence of early postoperative (<30-day) stroke was 6.4% in patients with atherosclerosis of the ascending aorta and 1.5% in those without (p = 0.004). The five-year stroke-free survival rates (>30 days after the operation) for patients without aortic disease, with less than 50%, and with greater than 50% of the ascending aorta affected, were 95.3 +/- 0.9%, 91.8 +/- 2.1%, and 65.0 +/- 14.6%, respectively (p < 0.0001). CONCLUSIONS Atherosclerosis of the ascending aorta stands out as a predictor of late stroke. High risk is predominantly linked to atheromas in its distal part and lesser curvature.
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Affiliation(s)
- Jan van der Linden
- Karolinska Institute, Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden.
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22
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Lilly KJ, Balaguer JM, Pirundini PA, Smith MA, Connelly G, Campbell LJ, Philie PC, McAdams M, Riley W, Dekkers R, Fitzgerald D, Cohn LH, Rizzo RJ. Early results of a comprehensive operative and perfusion strategy to attenuate the incidence of adverse neurological outcomes in on-pump coronary artery bypass grafting (CABG) patients. Perfusion 2007; 21:311-7. [PMID: 17312854 DOI: 10.1177/0267659106073986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Adverse neurological events, both focal (Type I) and non-focal (Type II), have been appreciated in postoperative on-pump coronary artery bypass grafting (CABG) patients for many years. Advanced age is a significant risk factor for adverse neurological events following CABG surgery. With full knowledge that our elderly population of patients was at high risk for these untoward neurological events, we adopted a comprehensive operative and perfusion strategy in an attempt to attenuate the incidence of these complications. Our strategy included efforts to minimise the number of emboli generated during the operation, avoid cerebral hypoperfusion, and attenuate the systemic inflammatory response. From 15 August 2002 to 31 December 2005, we performed 355 on-pump CABG operations. The incidence of Type I focal injury was 0/355 (0%), the incidence of Type II non-focal injury was 9/355 (2.5%), and postoperative mortality was 2/355 (0.6%). These results compared favorably to the results predicted by the Society of Thoracic Surgeons' (STS) model, and may suggest efficacy.
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Affiliation(s)
- Kevin J Lilly
- Division of Cardiac Surgery, Brigham & Women's Hospital/Cape Cod Hospital, Harvard Medical School, Boston, MA, USA.
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23
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Lockowandt U. Apicoaortic valved conduit: Potential for progress? J Thorac Cardiovasc Surg 2006; 132:796-801. [PMID: 17000290 DOI: 10.1016/j.jtcvs.2006.07.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2006] [Revised: 06/24/2006] [Accepted: 07/07/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The number of elderly patients who require aortic valve replacement is growing, as is the increase of complicating factors, such as previous coronary bypass grafting and atherosclerotic disease of the ascending aorta. An uncommon surgical option to aortic valve replacement is the apicoaortic valved conduit. In this article the techniques and outcomes of 13 cases of apicoaortic valved conduit insertions in high-risk patients are described. METHODS From 2002 through 2005, 13 patients (mean age, 75 +/- 8.7 years; 8 men) with severe calcific aortic stenosis had insertions of an apicoaortic valved conduit because of a porcelain aorta (n = 4), previous coronary bypass grafting (n = 6), or both (n = 3). The off-pump technique was used in 9 patients, and a heparinized miniextracorporeal circulation system was used in 4 patients. Follow-up time was 6 to 33 months. RESULTS Mean intensive care stay was 2 +/- 2.7 days, and mean hospital stay was 12 +/- 8 days. The 30-day mortality was 15% (2 patients; postoperative days 3 and 28, both caused by myocardial infarction). Mortality later than 30 days postoperatively was 23% (3 patients; postoperative day 45 caused by bilateral pulmonary bleeding because of pneumonia, postoperative day 56 caused by myocardial infarction, and postoperative day 81 caused by pneumonia). The remaining 8 patients were doing well, all in New York Heart Association class I or II at follow-up, with echocardiography showing a low gradient over the valved conduit. CONCLUSIONS The apicoaortic valved conduit in high-risk patients undergoing aortic valve replacement remains a feasible option, with a substantial potential for technical development and progress.
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Affiliation(s)
- Ulf Lockowandt
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden.
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Hamman BL, White CH, Fontes M, Labiche L. Clampless Anastomosis: Novel Device for Clampless Proximal Vein Anastomosis in OPCAB Surgery--The Initial Spyder Experience. Heart Surg Forum 2005; 8:E443-6. [PMID: 16283982 DOI: 10.1532/hsf98.20041161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The Spyder is a novel device that enables the attachment of a vein to the aorta by compliant, interrupted anastomosis; this minimizes aortic manipulation during off pump-coronary artery bypass (OPCAB) surgery. Its use may reduce transcranial Doppler signals recorded during CABG. We performed 250 anastomoses in 160 OPCAB cases in many centers and recorded efficiency and efficacy data. There were no adverse events noted during the operative period. In a subset of patients in one center, flow (n = 48) and transcranial Doppler signals (n = 22) were measured. We found the device to be a useful adjunct for minimally invasive CABG surgery.
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Affiliation(s)
- Baron L Hamman
- Clinical Cardiology Research Center, Baylor University Medical Center, Dallas, Texas 75246, USA
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Girardi LN, Krieger KH, Mack CA, Isom OW. No-Clamp Technique for Valve Repair or Replacement in Patients With a Porcelain Aorta. Ann Thorac Surg 2005; 80:1688-92. [PMID: 16242439 DOI: 10.1016/j.athoracsur.2005.04.044] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2005] [Revised: 04/25/2005] [Accepted: 04/25/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patients requiring valvular heart surgery may have circumferential calcification of the ascending aorta. A variety of creative procedures have been described for managing this "porcelain aorta." We describe a technique based on replacement of the ascending aorta and proximal arch under profound hypothermic circulatory arrest, followed by the valve procedure. METHODS Twenty-five consecutive patients with a porcelain aorta were referred for heart valve surgery. In every case the aorta was replaced under circulatory arrest before the valve procedure. Postoperative morbidity, mortality, and univariate risk factors for death were calculated. Fisher's exact test defined significant perioperative variables with a p value less than 0.05. RESULTS Of 25 patients, 23 (92%) survived the surgery to hospital discharge. One patient had a stroke (4%) and 2 patients (8%) required reexploration for bleeding. Risk factors for perioperative death by univariate analysis included age more than 78 years (p < 0.009), cardiopulmonary bypass time longer than 200 minutes (p < 0.0001), reexploration for bleeding (p < 0.02), need for intra-aortic balloon pump support (p < 0.001), and postoperative gastrointestinal complications (p < 0.001). CONCLUSIONS Valve replacement or repair in the patient with a porcelain aorta can be safely accomplished with a technique based on aortic replacement under circulatory arrest. Elderly patients requiring extensive procedures and prolonged periods on bypass have a substantially increased risk for postoperative complications and death.
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Affiliation(s)
- Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Medical College of Cornell University, New York, New York 10021, USA.
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Svensson LG, Blackstone EH, Rajeswaran J, Sabik JF, Lytle BW, Gonzalez-Stawinski G, Varvitsiotis P, Banbury MK, McCarthy PM, Pettersson GB, Cosgrove DM. Does the arterial cannulation site for circulatory arrest influence stroke risk? Ann Thorac Surg 2005; 78:1274-84; discussion 1274-84. [PMID: 15464485 DOI: 10.1016/j.athoracsur.2004.04.063] [Citation(s) in RCA: 209] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2004] [Indexed: 02/07/2023]
Abstract
BACKGROUND We investigated whether axillary/subclavian artery inflow with a side graft decreases the risk of stroke versus cannulation at other sites during hypothermic circulatory arrest. METHODS Between January 1993 and May 2003, 1,352 operations with circulatory arrest were performed for complex adult cardiac problems. A single arterial inflow cannulation site was used in 1,336 operations, and these formed the basis for comparative analyses. Cannulation sites were axillary plus graft in 299 operations, direct cannulation of the aorta in 471, femoral in 375, innominate in 24, and axillary or subclavian without a side graft in 167. Retrograde brain perfusion was used in 933 (69%). A total of 272 (20%) were for emergencies, 432 (32%) were reoperations, and 439 (32%) were for dissections. A total of 617 (46%) had aortic valve replacement and 1,160 (87%) ascending, 415 arch (31%), and 248 descending (18%) aortic replacements. Indications also included arteriosclerosis (n = 301) and calcified aorta (n = 278). Primary comparisons were made by using propensity matching, and, secondarily, risk factors for stroke or hospital mortality were identified by multivariable logistic regression. RESULTS Stroke occurred in 6.1% of patients (81/1,336): 4.0% (12/299) of those had axillary plus graft and 6.7% who had direct cannulation (69/1,037; p = 0.09; p = 0.05 among propensity-matched pairs). Operative variables associated with stroke included direct aortic cannulation, aortic arteriosclerosis, descending aorta repair, and mitral valve replacement. The risk of hospital mortality was higher (11%; 42/375) for patients who had femoral cannulation than axillary plus graft (7.0%; 21/299; p = 0.06; p = 0.02 among propensity-matched pairs). CONCLUSIONS Axillary inflow plus graft reduces stroke and is our method of choice for complex cardiac and cardioaortic operations that necessitate circulatory arrest. Retrograde or antegrade perfusion is used selectively.
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Affiliation(s)
- Lars G Svensson
- Department of Thoracic Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Bergman P, van der Linden J. Atherosclerosis of the ascending aorta as a major determinant of the outcome of cardiac surgery. ACTA ACUST UNITED AC 2005; 2:246-51; quiz 269. [PMID: 16265508 DOI: 10.1038/ncpcardio0192] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2004] [Accepted: 03/21/2005] [Indexed: 11/09/2022]
Abstract
Epiaortic ultrasonography has high sensitivity for the detection of atherosclerosis. In several studies, the technique has identified atherosclerosis of the ascending aorta as the major risk factor for stroke after cardiac surgery. The level of risk depends on the presence, location and extent of disease when the ascending aorta is surgically manipulated. This knowledge enables clinicians to focus on the diagnostic and surgical technique and to consider the various options. Routine use of intraoperative epiaortic ultrasonography should be applied so that surgical manipulation of the ascending aorta can be reduced or, if possible, avoided in patients with atherosclerosis of the ascending aorta. Alternatively, if major manipulation such as clamping must be performed in the presence of severe atherosclerosis, the use of intra-aortic filters could be considered.
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Affiliation(s)
- Per Bergman
- Department of Cardiothoracic Surgery & Anesthesiology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden.
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Staples JR, Tanaka KA, Shanewise JS, Glas KE, Merlino JD, Cooper WA, Puskas JD, Lattouf OM. The use of the SonoSite ultrasound device for intraoperative evaluation of the aorta. J Cardiothorac Vasc Anesth 2005; 18:715-8. [PMID: 15650979 DOI: 10.1053/j.jvca.2004.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Neurologic complications remain a significant cause of morbidity and mortality in cardiac surgery. Risk factors for neurologic injuries include the presence of atheromatous disease in the aorta. Epiaortic ultrasound has been shown to be superior in detecting the extent and location of atheromatous disease. The SonoSite Corporation (Bothell, WA) has recently introduced an affordable, portable, high-resolution ultrasound device. This new device was compared with the Hewlett-Packard Sonos 5550 ultrasound device (currently manufactured by Philips, Andover, MA) to determine suitability for this purpose. DESIGN Prospective, serial comparison of 2 devices. SETTING University hospital. PARTICIPANTS Fifty consecutive cardiac surgery patients. INTERVENTIONS Intraoperative epiaortic ultrasound images were obtained using a SonoSite 180 Plus ultrasound device and a Hewlett-Packard Sonos 5500 ultrasound device. Three observers graded recorded images based on extent of atheromatous disease. MEASUREMENTS AND MAIN RESULTS Two patients were excluded because of errors in recording images. For the 48 remaining patients, consensus (median) grades had an observed agreement of 93.6% compared with a chance agreement of 67.7%. This correlates to a kappa value of 0.80 or near-excellent agreement. CONCLUSIONS The near-excellent agreement of the 2 devices is acceptable, thus providing a unique opportunity to expand the use of epiaortic ultrasound imaging.
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Affiliation(s)
- James R Staples
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, Emory University School of Medicine, Atlanta, GA 30306, USA.
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Ozatik MA, Göl MK, Fansa I, Uncu H, Küçüker SA, Küçükaksu S, Bayazit M, Sener E, Taşdemir O. Risk Factors for Stroke Following Coronary Artery Bypass Operations. J Card Surg 2005; 20:52-7. [PMID: 15673410 DOI: 10.1111/j.0886-0440.2005.200384.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although the overall complication rates have been decreased significantly in recent years, stroke rates still remain high in patients undergoing coronary bypass operations. This study is designed to evaluate the risk factors for stroke in patients who had undergone coronary artery bypass surgery in an 8-year period in our clinic. METHODS Between 1995 and 2003, 8547 coronary artery operations under cardiopulmonary bypass were performed. Retrospective analysis of the patient files revealed that 75 (0.9%) patients had stroke in the early postoperative period. RESULTS Mean age of these patients was 62.3 +/- 9.5 years, and 54 (72%) were males. Stroke rate was 1.2% between 1995 and 1998 and this was significantly higher from the stroke rate (0.7%) of the period 1998 to 2003 (p = 0.03). Major technical differences between these two periods were the routine application of preoperative carotid arteries Doppler evaluation and intraoperative epiaortic echocardiography after 1998. Higher age (p = 0.000), female sex (p = 0.005), smoking (p = 0.03), presence of diabetes mellitus (p = 0.01), hypertension (p = 0.008), and left main coronary artery disease (p = 0.001), carotid surgery (p = 0.000), and peripheral vascular disease (p = 0.049) were identified as important risk factors in univariate analysis for stroke development. Higher age (p = 0.000; OR = 21.38), left main coronary artery disease (p = 0.007; OR = 7.26), peripheral vascular disease (p = 0.050; OR = 3.08), and operation date before 1998 (p = 0.012; OR = 6.33) were identified as important risk factors in logistic regression analysis. According to intraoperative epiaortic ultrasonography, operative strategy was changed in 9% of patients. Thirty-seven (49.3%) of the stroke patients died. Female sex (p = 0.023; OR = 5.18) and preoperative hypertension (p = 0.045; OR = 4.03) were observed as significant risk factors for mortality after stroke. CONCLUSION Development of stroke is one of the major reasons of mortality after coronary artery bypass operations. It is essential to take all the measures to prevent this complication, especially in patients with known risk factors. Evaluation of carotid arteries prior to operation and application of routine intraoperative epiaortic echocardiography may in part eliminate stroke.
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Affiliation(s)
- Mehmet Ali Ozatik
- Türkiye Yüksek Ihtisas Eğitim ve Araştirma Hospital, Cardiovascular Surgery Clinic, Ankara, Turkey.
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Murkin JM, Boyd WD, Ganapathy S, Adams SJ, Peterson RC, Morgan J, Lok P. Neuroprotection During CPB: From Mechanisms to Interventions. Semin Cardiothorac Vasc Anesth 2002. [DOI: 10.1177/108925320200600103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The incidence and etiology of brain dysfunction after conventional coronary artery bypass surgery using cardiopulmonary bypass are reviewed. Stroke rates and incidences of cognitive dysfunction from various studies are considered. Mechanisms of injury including cerebral embolization as detected by transcranial Doppler and evidence for postoperative cerebral edema are discussed. Evidence for lower overall postoperative morbidity, and for a lower incidence of cognitive dysfunction specifically, after nonpump coronary revascularization is presented.
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Affiliation(s)
- John M. Murkin
- Department of Anesthesia, University Hospital Campus-London Health Sciences Center, University of Western Ontario, London, Ontario, Canada; Department of Anesthesiology and Perioperative Medicine, University Hospital Campus-LHSC, 339 Windermere Rd., London, Ontario, Canada N6A 5A5
| | - W. Douglas Boyd
- Department of Surgery, University Hospital Campus-London Health Sciences Center, University of Western Ontario, London, Ontario, Canada
| | | | | | | | | | - Peter Lok
- Department of Anesthesia, University Hospital Campus-London Health Sciences Center, University of Western Ontario, London, Ontario, Canada
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Zacharias A, Schwann TA, Riordan CJ, Clark PM, Martinez B, Durham SJ, Engoren M, Habib RH. Operative and 5-year outcomes of combined carotid and coronary revascularization: review of a large contemporary experience. Ann Thorac Surg 2002; 73:491-7; discussion 497-8. [PMID: 11845864 DOI: 10.1016/s0003-4975(01)03401-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Surgical treatment of concomitant coronary and carotid disease is controversial. Studies comparing staged versus combined coronary artery bypass grafting and carotid endarterectomy (CABG/CEA) report varying and often conflicting operative results. Also, few studies have investigated the long-term outcomes of combined surgery. METHODS We reviewed the operative outcome and 5-year survival results of 189 consecutive patients (69+/-9 years old, 66 [35%] female patients) who underwent combined CABG/CEA between 1994 and 1999. Survival follow-up was conducted in February 2001 and the incidence of late stroke, carotid surgery, and myocardial infarction was investigated in all surviving patients by mail survey. A phone interview was done by a surgeon of patients with late strokes or repeated CEA. RESULTS Operative death occurred in 5 of 189 patients (2.65%) 4 of which were in-hospital deaths. A total of 5 (2 permanent, 3 transient [2.65%]) perioperative strokes were documented in these patients, and 1 of the perioperative strokes patients died in the hospital. In all, 156 of 189 patients (82.5%) were alive at the time of the study and completed surveys were collected from 153 of 156 patients (98%). Of these 153 patients, 4 reported a late stroke (2.6%), 5 suffered a myocardial infarction (3.3%), and 16 (10.5%) underwent subsequent CEA (7 ipsilateral to original CEA). Angioplasty (3 of 153, 2.0%) and redo surgery (1 of 153, 0.66%) occurred infrequently. Median survival follow-up was 51 months (range 12 to 84), and the corresponding 5-year Kaplan-Meier survival was 79.4%. This survival was similar to that of age-matched isolated CABG patients (n = 532) with documented history of cerebrovascular disease but no surgical carotid lesions. CONCLUSIONS Our results suggest that combined CABG/ CEA is safe and may in fact reduce the risk of adverse outcomes in the intermediate term compared with age and risk-matched patients. We speculate the latter may be attributable to a cerebrovascular protective effect of CABG/CEA pending verification by randomized trials. An economic benefit of CABG/CEA may also be inferred from avoiding separate coronary and carotid operations and reduction in the high costs of perioperative stroke.
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Affiliation(s)
- Anoar Zacharias
- Department of Cardiovascular Surgery, St. Vincent Mercy Medical Center, Toledo, Ohio 43608, USA
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Abstract
Cerebral injury is a major cause of mortality and morbidity of coronary artery bypass grafting. Stroke occurs in 3% of patients and is largely caused by embolization of atheromatous debris during manipulation of the diseased aorta. Cognitive impairment, which is predominantly caused by microembolization of gaseous and particulate matter, mainly generated by cardiotomy suction, is more common. Demonstration of similar cognitive impairment in patients operated on without cardiopulmonary bypass indicates that other pathophysiological mechanisms, such as anaesthesia and hypoperfusion, are also involved. Advances in medical, anesthetic, and surgical management have resulted in a reduction in the incidence of neurological injury in CABG patients over the past decade. On the other hand, an increasingly elderly population with more severe comorbidity, who are more prone to cerebral injury, are increasingly being referred for CABG. Possible mechanisms to reduce overt and subtle cerebral injury are discussed. The use of composite arterial grafts performed on the beating heart may be the most effective way of minimizing the risk of cerebral injury associated with CABG.
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Affiliation(s)
- D P Taggart
- Oxford Heart Centre, John Radcliffe Hospital, Oxford OX3 9DU, England.
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Iglesias I, Murkin JM. Beating heart surgery or conventional CABG: are neurologic outcomes different? Semin Thorac Cardiovasc Surg 2001; 13:158-69. [PMID: 11494207 DOI: 10.1053/stcs.2001.24076] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although there has been much debate about the causes of neurologic complications associated with coronary artery bypass grafting (CABG), there is good evidence linking such complications with some of the pathophysiologic changes associated with use of conventional cardiopulmonary bypass (CPB). Several studies indicate that it is possible to significantly lower risk of stroke and other central nervous system (CNS) morbidity in patients undergoing CPB for CABG by application of selected techniques and equipment modifications. The resurgence of interest in coronary revascularization by using beating heart surgery (BHS) offers a unique opportunity to evaluate neurologic outcome independent of CPB. Currently, BHS would appear to significantly reduce morbidity in the elderly and to decrease the costs and resource use in coronary revascularization patients. It is hoped that by understanding the mechanisms of CNS injury associated with CABG, techniques can be developed to decrease the risk of neurologic injury associated with coronary revascularization, whether or not CPB is used. Definitive conclusions regarding outcomes after best practice CPB or BHS await large-scale, risk-stratisfied multicenter trials.
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Affiliation(s)
- I Iglesias
- Department of Cardiac Anesthesiology, University Hospital Campus-LHSC, University of Western Ontario, London, Ontario, Canada
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Vaage J, Jensen U, Ericsson A. Neurologic injury in cardiac surgery: aortic atherosclerosis emerges as the single most important risk factor. SCAND CARDIOVASC J 2000; 34:550-7. [PMID: 11214006 DOI: 10.1080/140174300750064468] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
With older and sicker patients undergoing cardiac surgery, neurologic injury has emerged as an increasingly important cause of rising costs, morbidity and mortality. Several studies investigating the relationship between atherosclerotic aortic disease and subsequent adverse clinical outcomes have demonstrated that the single most important risk factor for neurologic injury following cardiac surgery is the presence of aortic atheromatous disease. The results of these studies suggest that atheroemboli are correlated with neurologic injury following cardiac surgery. Surgical techniques to avoid and prevent particulate debris during cardiac surgery may be a major step in preventing severe neurologic injury.
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Affiliation(s)
- J Vaage
- Department of Thoracic Surgery, Karolinska Hospital, Stockholm, Sweden.
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Gillinov AM, Lytle BW, Hoang V, Cosgrove DM, Banbury MK, McCarthy PM, Sabik JF, Pettersson GB, Smedira NG, Blackstone EH. The atherosclerotic aorta at aortic valve replacement: surgical strategies and results. J Thorac Cardiovasc Surg 2000; 120:957-63. [PMID: 11044322 DOI: 10.1067/mtc.2000.110191] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Aortic valve replacement in patients with severe atherosclerosis of the ascending aorta poses technical challenges. The purpose of this study was to examine operative strategies and results of aortic valve replacement in patients with a severely atherosclerotic ascending aorta that could not be safely crossclamped. PATIENTS AND METHODS From January 1990 to December 1998, 4983 patients had aortic valve surgery; of these, 62 (1.2%) patients had a severely atherosclerotic ascending aorta and required hypothermic circulatory arrest to facilitate aortic valve replacement. They form the study group. RESULTS All patients had hypothermic circulatory arrest, but several different strategies were used to manage the ascending aorta. These techniques included aortic valve replacement with the use of hypothermic circulatory arrest (39%), ascending aortic endarterectomy (26%), ascending aortic replacement (19%), aortic inspection and crossclamping during hypothermic circulatory arrest (10%), and balloon occlusion of the ascending aorta (6%). Duration of hypothermic circulatory arrest was substantially longer for patients having aortic valve replacement with hypothermic circulatory arrest than for all other strategies. Hospital mortality was 14%, and 10% of patients had strokes. Increasing New York Heart Association functional class and impaired left ventricular function were risk factors for hospital mortality. Choice of operative technique did not influence patient outcome; however, no patient who underwent replacement of the ascending aorta had a stroke. CONCLUSIONS Aortic valve replacement in patients with severe atherosclerosis of the ascending aorta is associated with increased operative morbidity and mortality. Complete aortic valve replacement during hypothermic circulatory arrest, the "no-touch" technique, requires a prolonged period of circulatory arrest. Ascending aortic replacement is a preferred technique, as it requires a short period of hypothermic circulatory arrest and results in comparable mortality with a low risk of stroke.
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Affiliation(s)
- A M Gillinov
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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Gaudino M, Glieca F, Alessandrini F, Luciani N, Cellini C, Pragliola C, Possati G. The unclampable ascending aorta in coronary artery bypass patients: A surgical challenge of increasing frequency. Circulation 2000; 102:1497-502. [PMID: 11004139 DOI: 10.1161/01.cir.102.13.1497] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The unclampable ascending aorta (UAA) is a condition increasingly encountered during CABG procedures. We report our experience with CABG patients with UAA and place particular emphasis on the preoperative diagnosis and surgical management. METHODS AND RESULTS UAA was diagnosed in 211 of 4812 consecutive CABG patients (4.3%). On the basis of the chest radiograph, echocardiogram, and coronary angiograph, a preoperative diagnosis was achieved in only 58 patients (27.4%). An age of >70 years, diabetes, smoking, unstable angina, diffuse coronaropathy, and peripheral vasculopathy were all predictors of UAA. Patients were treated with hypothermic ventricular fibrillation (no-touch technique n=129) or beating heart revascularization (no-pump technique n=82) depending on the possibility of founding an arterial cannulation site. The overall in-hospital mortality rate was 2.8% (6 of 211) with no differences between the 2 surgical strategies. The no-touch technique was associated with a greater incidence of neurological complications (stroke and transient ischemic attack), renal insufficiency, and stay in the intensive care unit and hospital. However, at midterm follow-up, more patients of the no-pump group had ischemia recurrence. CONCLUSIONS A preoperative diagnosis of UAA is achievable only in a minority of patients, which highlights the necessity revising the current diagnostic protocols. The use of the no-touch technique is associated with an high perioperative risk but a superior possibility of complete revascularization, whereas adoption of the no-pump strategy ensures a smoother postoperative course at the expense of an higher incidence of ischemia recurrence.
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Affiliation(s)
- M Gaudino
- Department of Cardiac Surgery, Catholic University, Rome, Italy.
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Hagl C, Ergin MA, Galla JD, Spielvogel D, Lansman S, Squitieri RP, Griepp RB. Delayed chronic type A dissection following CABG: implications for evolving techniques of revascularization. J Card Surg 2000; 15:362-7. [PMID: 11599830 DOI: 10.1111/j.1540-8191.2000.tb00472.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative dissection in some patients is related to manipulation of the aorta and accounts for 3% to 5% of deaths after cardiac surgery. METHODS Between 1987 and 1999, 109 patients with previous cardiac operations were treated for chronic type A dissection. In 31 of the patients, the etiology was related to aortic manipulation. Twenty-one patients (17 men, 4 women; 67+/-13 years of age) had isolated coronary artery bypass grafting (CABG) as their first operation and were reviewed. The interval between operations was 52.9+/-47.3 months. RESULTS Reoperation was elective in 11 patients, urgent in 10 patients. Median maximal aortic diameter was 6.8+/-2.1 cm; 9 patients had major aortic insufficiency. The intimal tear was at the partial occlusion clamp site in 12 patients (57.1%), at the cross-clamping site in 4 patients (19.1%), and at the proximal anastomosis in 1 patient (4.8%); 4 patients (19.1%) had multiple tears at several sites. Cystic media necrosis was present in 9.5% of the patients, severe atherosclerosis in 47.6% of the patients, and 42.9% of the patients had both. Nine patients (42.9%) underwent a modified Bentall procedure, 12 patients (57.1%) underwent a supracoronary anastomosis, and all had open distal anastomosis. There were two (9.5%) hospital deaths and three (14.3%) postoperative strokes. Freedom from cardiac or aorta-related mortality was 85.7% at a mean follow-up of 49.3 months. CONCLUSIONS In patients who develop type A dissection of the aorta after previous CABG, the intimal tear most often is at partial occlusion clamp site. This complication is associated with morbidity and mortality. It remains to be seen whether the use of partial occlusion clamps on the pulsating and often diseased aorta during off-pump coronary artery bypass (OPCAB) will increase the risk of delayed iatrogenic dissections.
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Affiliation(s)
- C Hagl
- Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, New York 10029, USA.
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Abstract
The average age of patients undergoing cardiac surgery and the number of comorbidities they possess will continue to increase as surgical technology advances. Toxic/metabolic encephalopathy, hemispheric strokes, hypoxic injury, and peripheral nerve lesions all can occur as a result of cardiac surgery. Therefore, an understanding of the neurologic risk, recognizable syndromes, and preventative measures will continue to be important. Careful preoperative assessment, operative risk factor reduction, and careful postoperative assessments and management may reduce the neurologic risk for cardiac surgery.
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Affiliation(s)
- R Llinas
- Department of Neurology, Beth Israel-Deaconess Medical Center, Harvard University, Boston, MA, USA
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Royse AG, Royse CF, Ajani AE, Symes E, Maruff P, Karagiannis S, Gerraty RP, Grigg LE, Davis SM. Reduced neuropsychological dysfunction using epiaortic echocardiography and the exclusive Y graft. Ann Thorac Surg 2000; 69:1431-8. [PMID: 10881818 DOI: 10.1016/s0003-4975(00)01173-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND To examine the effect of screening the aorta for atheroma before aortic manipulation and use of exclusive Y graft revascularization on the incidence of neuropsychological dysfunction after coronary artery bypass. METHODS Aortic atheroma was detected using epiaortic and transesophageal echocardiography. Atheroma avoidance was facilitated by use of the exclusive Y graft technique, which has no aortic coronary anastomoses. In the control group aortic atheroma was assessed by manual palpation, and we attempted to avoid any atheroma detected. In this group we also used aorta-coronary grafts. Transcranial Doppler imaging of the right middle cerebral artery was used to detect cerebral microemboli. Neuropsychological dysfunction was defined as a 20% or more decline in score for at least 20% of a neuropsychometric battery of ten tests for each patient. RESULTS Late dysfunction at 57 +/- 2 days postoperatively in the control group was 38.1% and in the echo/Y group was 3.8% (p' = 0.012). Microemboli detected by transcranial Doppler imaging during periods of aortic manipulation was greater for those with late dysfunction (5.2 +/- 3.0 compared with 0.5 +/- 0.2) (p' = 0.018). No clinical strokes occurred in either group. CONCLUSIONS The combined techniques of epiaortic screening and exclusive Y graft for coronary artery bypass operations resulted in a low incidence of late neuropsychological dysfunction.
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Affiliation(s)
- A G Royse
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Victoria, Australia.
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Affiliation(s)
- A M Grigore
- Department of Anesthesiology, Duke Heart Center, Duke University Medical Center, Durham, NC 27710, USA
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Bonatti J, Hangler H, Oturanlar D, Posch L, Müller LC, Voelckel W, Schwarz B, Bodner G. Beating heart axillocoronary bypass for management of the untouchable ascending aorta in coronary artery bypass grafting. Eur J Cardiothorac Surg 1999. [DOI: 10.1093/ejcts/16.supplement_2.s18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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BONATTI J. Beating heart axillocoronary bypass for management of the untouchable ascending aorta in coronary artery bypass grafting*1. Eur J Cardiothorac Surg 1999. [DOI: 10.1016/s1010-7940(99)00264-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Eagle KA, Guyton RA, Davidoff R, Ewy GA, Fonger J, Gardner TJ, Gott JP, Herrmann HC, Marlow RA, Nugent WC, O'Connor GT, Orszulak TA, Rieselbach RE, Winters WL, Yusuf S, Gibbons RJ, Alpert JS, Eagle KA, Garson A, Gregoratos G, Russell RO, Smith SC. ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery). American College of Cardiology/American Heart Association. J Am Coll Cardiol 1999; 34:1262-347. [PMID: 10520819 DOI: 10.1016/s0735-1097(99)00389-7] [Citation(s) in RCA: 329] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Hogue CW, Murphy SF, Schechtman KB, Dávila-Román VG. Risk factors for early or delayed stroke after cardiac surgery. Circulation 1999; 100:642-7. [PMID: 10441102 DOI: 10.1161/01.cir.100.6.642] [Citation(s) in RCA: 326] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke after cardiac surgery is a devastating complication that leads to excess mortality and health resource utilization. The purpose of this study was to identify risk factors for perioperative stroke, including strokes detected early after cardiac surgery or postoperatively. METHODS AND RESULTS Data were obtained from 2972 patients undergoing coronary artery bypass graft and/or valve surgery. Patients >/=65 years old and those with a history of symptomatic neurological disease underwent preoperative carotid artery ultrasound scanning. Intraoperative epiaortic ultrasound to assess for ascending aorta atherosclerosis was performed in all patients. New strokes were considered as a single end point and were categorized with respect to whether they were detected immediately after surgery (early stroke) or after an initial, uneventful neurological recovery from surgery (delayed stroke). Strokes occurred in 48 patients (1.6%); 31 (65%) were delayed strokes. By multivariate analysis, prior neurological event, aortic atherosclerosis, and duration of cardiopulmonary bypass were independently associated with early stroke, whereas predictors of delayed stroke were prior neurological event, diabetes, aortic atherosclerosis, and the combined end points of low cardiac output and atrial fibrillation. Female sex was associated with a 6.9-fold increased risk of early stroke and a 1.7-fold increased risk of delayed stroke. In-hospital mortality of patients with early (41%) and delayed (13%) strokes was higher than that of other patients (3%, P=0.0001). CONCLUSIONS Most strokes after cardiac surgery occurred after initial uneventful recovery from surgery. Women were at higher risk to suffer early and delayed perioperative strokes. Atrial fibrillation had no impact on postoperative stroke rate unless it was accompanied by low cardiac output syndrome.
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Affiliation(s)
- C W Hogue
- Department of Anesthesiology, Washington University School of Medicine,St. Louis, MO, USA
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Ergin MA, Spielvogel D, Apaydin A, Lansman SL, McCullough JN, Galla JD, Griepp RB. Surgical treatment of the dilated ascending aorta: when and how? Ann Thorac Surg 1999; 67:1834-9; discussion 1853-6. [PMID: 10391320 DOI: 10.1016/s0003-4975(99)00439-7] [Citation(s) in RCA: 154] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aorta is considered pathologically dilated if the diameters of the ascending aorta and the aortic root exceed the norms for a given age and body size. A 50% increase over the normal diameter is considered aneurysmal dilatation. Such dilatation of the ascending aorta frequently leads to significant aortic valvular insufficiency, even in the presence of an otherwise normal valve. The dilated or aneurysmal ascending aorta is at risk for spontaneous rupture or dissection. The magnitude of this risk is closely related to the size of the aorta and the underlying pathology of the aortic wall. The occurrence of rupture or dissection adversely alters natural history and survival even after successful emergency surgical treatment. METHODS In recommending elective surgery for the dilated ascending aorta, the patient's age, the relative size of the aorta, the structure and function of the aortic valve, and the pathology of the aortic wall have to be considered. The indications for replacement of the ascending aorta in patients with Marfan's syndrome, acute dissection, intramural hematoma, and endocarditis with annular destruction are supported by solid clinical information. Surgical guidelines for intervening in degenerative dilatation of the ascending aorta, however, especially when its discovery is incidental to other cardiac operations, remain mostly empiric because of lack of natural history studies. The association of a bicuspid aortic valve with ascending aortic dilatation requires special attention. RESULTS There are a number of current techniques for surgical restoration of the functional and anatomical integrity of the aortic root. The choice of procedure is influenced by careful consideration of multiple factors, such as the patient's age and anticipated survival time; underlying aortic pathology; anatomical considerations related to the aortic valve leaflets, annulus, sinuses, and the sino-tubular ridge; the condition of the distal aorta; the likelihood of future distal operation; the risk of anticoagulation; and, of course, the surgeon's experience with the technique. Currently, elective root replacement with an appropriately chosen technique should not carry an operative risk much higher than that of routine aortic valve replacement. Composite replacement of the aortic valve and the ascending aorta, as originally described by Bentall, DeBono and Edwards (classic Bentall), or modified by Kouchoukos (button Bentall), remains the most versatile and widely applied method. Since 1989, the button modification of the Bentall procedure has been used in 250 patients at Mount Sinai Medical Center, with a hospital mortality of 4% and excellent long-term survival. In this group, age was the only predictor of operative risk (age > 60 years, mortality 7.3% [9/124] compared with age < 60, mortality 0.8% [1/126], p = 0.02). CONCLUSIONS This modification of the Bentall procedure has set a standard for evaluating the more recently introduced methods of aortic root repair.
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Affiliation(s)
- M A Ergin
- Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, New York 10029, USA
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Hogue CW, Sundt TM, Goldberg M, Barner H, Dávila-Román VG. Neurological complications of cardiac surgery: the need for new paradigms in prevention and treatment. Semin Thorac Cardiovasc Surg 1999; 11:105-15. [PMID: 10378854 DOI: 10.1016/s1043-0679(99)70003-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Neurological injury is a devastating complication of cardiac surgery that results in a longer duration of hospitalization, increased costs, and increased likelihood of death. Such injury can affect any level of the central nervous system, and its manifestations are broad, ranging from neurocognitive dysfunction to frank stroke. Many variables have been found to be indicative or risk for perioperative neurological injury, but the predictive models are more useful for stroke risk than for neurocognitive dysfunction. Strategies aimed at reducing neurological injury during cardiac surgery have focused, for the most part, on the technical aspects of cardiopulmonary bypass. The concomitant performance of carotid endarterectomy and cardiac surgery continues to be controversial, although the management of patients with symptomatic carotid stenosis is better defined. Cerebral embolism, including atheroembolism from the ascending aorta, has an important role in the pathogenesis of neurological injury of all types. Epiaortic ultrasound imaging of the aorta is a sensitive technique for the identification of atherosclerosis of the ascending aorta at the time of surgery, which can allow it to be avoided and therefore reduce the risk for atheroembolism. Results of laboratory investigations have provided insight into the mechanisms of ischemic neuronal injury and a basis for the development of neuroprotective drugs. Neuroprotection may best be accomplished during cardiac surgery because, in contrast to nonsurgical situations, potential agents can be administered before the neurological insult occurs. Reducing the incidence of perioperative stroke will require a multidisciplinary approach that includes novel diagnostic and therapeutic strategies.
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Affiliation(s)
- C W Hogue
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO 63110, USA
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