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El Shazly J, Gerriets T, Hennig J, Butz M, Kastaun S, Wiedenroth CB, Schoenburg M, Wollenschlaeger M, Bachmann G, Guth S, Juenemann M. Neuroprotective effects of dynamic bubble trap use in patients undergoing pulmonary endarterectomy: a two-arm randomized controlled trial. J Thorac Dis 2021; 13:5807-5817. [PMID: 34795929 PMCID: PMC8575830 DOI: 10.21037/jtd-21-831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/30/2021] [Indexed: 02/04/2023]
Abstract
Background During cardiosurgical procedures that use extracorporeal circulation (ECC), a variety of neurological complications can occur, and postoperative cognitive deficits remain an unsolved problem. Among the sources of these complications are intraoperatively detectable cerebral microemboli, which mainly consist of air. This study's purpose was to assess neuroprotective effects of reducing these gaseous microemboli using a dynamic bubble trap (DBT) in patients undergoing pulmonary endarterectomy (PEA) for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH). Methods Patients undergoing PEA were randomly assigned to receive either a DBT (n=47) or no additional device (controls, n=46) during ECC. Neuropsychological testing was performed before and 3 months after PEA. The primary endpoint was cognitive improvement in the DBT group (n=29) compared with the control group (n=42). As secondary endpoint, ischemic brain micro-lesions were analyzed on postoperative days 6 through 10 using diffusion-weighted magnetic resonance imaging (MRI). Results Analysis of interaction effects revealed improved performance in visual long-term memory (P=0.008, η2=0.099), verbal long-term memory (P=0.030, η2=0.067), verbal short-term memory (P=0.014, η2=0.083), and attention and processing speed (P=0.043, η2=0.056) from pre- to post-testing in the DBT group compared to control group. In MRI, postoperative ischemic micro-lesions could only be detected in one patient; another patient suffered a severe bihemispheric embolic stroke. Conclusions DBT positively influences memory function after PEA. This effect is most likely caused by the reduction of gaseous microemboli. Trial Registration This study is registered in the German Clinical Trials Register, ID: DRKS00021499.
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Affiliation(s)
- Jasmin El Shazly
- Heart and Brain Research Group, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany.,Department of Psychocardiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Tibo Gerriets
- Heart and Brain Research Group, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany.,Department of Neurology, University of Giessen, Giessen, Germany.,Department of Neurology, Health Center Wetterau, Friedberg, Germany
| | - Juergen Hennig
- Division of Personality Psychology and Individual Differences, University of Giessen, Giessen, Germany
| | - Marius Butz
- Heart and Brain Research Group, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany.,Department of Neurology, University of Giessen, Giessen, Germany
| | - Sabrina Kastaun
- Institute of General Practice, Addiction Research and Clinical Epidemiology Unit, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | | | - Markus Schoenburg
- Heart and Brain Research Group, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany.,Department of Cardiac Surgery, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | | | - Georg Bachmann
- Heart and Brain Research Group, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany.,Department of Radiology, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Martin Juenemann
- Heart and Brain Research Group, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany.,Department of Neurology, University of Giessen, Giessen, Germany
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Uysal S, Lin HM, Trinh M, Park CH, Reich DL. Optimizing cerebral oxygenation in cardiac surgery: A randomized controlled trial examining neurocognitive and perioperative outcomes. J Thorac Cardiovasc Surg 2020; 159:943-953.e3. [DOI: 10.1016/j.jtcvs.2019.03.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/01/2019] [Accepted: 03/02/2019] [Indexed: 01/26/2023]
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Decreasing postoperative cognitive deficits after heart surgery: protocol for a randomized controlled trial on cognitive training. Trials 2019; 20:733. [PMID: 31842959 PMCID: PMC6916013 DOI: 10.1186/s13063-019-3799-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/11/2019] [Indexed: 12/04/2022] Open
Abstract
Background The occurrence of postoperative cognitive deficits, especially after heart surgery, has been demonstrated in several studies. These deficits can clearly be noticed by the patients and by their close relatives in daily life. Furthermore, postoperative cognitive deficits can decrease quality of life in social functioning and earning capacity. The aim of this study is to investigate whether early postoperative cognitive training can reduce subjective and objective postoperative cognitive deficits. Methods The proposed study is a multicenter, two-arm, randomized controlled trial involving 144 elderly patients undergoing elective heart-valve surgery with extracorporeal circulation. Patients will be assigned to either a training group or a control group. The intervention involves paper-and-pencil-based cognitive training, which is conducted for 36 min over a period of 18 days. The training starts about 1 week after surgery and is carried out during the hospitalized rehabilitation phase. The control group will not receive cognitive training or a placebo intervention. A detailed assessment of psychological functions and health-related quality of life prior to surgery at discharge from rehabilitation and 3 and 12 months after discharge will be performed. The primary outcome of this trial is the training effect on objective cognitive functions at discharge from rehabilitation. Secondary outcomes are the training effect on objective and subjective cognitive functions (3 and 12 months after discharge), depression, health-related quality of life, and the impact of perioperative cerebral ischemia on the training effect. Perioperative cerebral ischemia will be measured with postoperative magnetic resonance imaging including diffusion-weighted sequences. Discussion Should it be shown that our cognitive training can improve postoperative cognitive deficits and quality of life, one possibility could be to integrate this intervention into early rehabilitation. Furthermore, we hope that the investigation of perioperative ischemia by diffusion-weighted magnetic resonance imaging will improve our understanding of neurobiological factors influencing the course of postoperative cognitive plasticity. Trial registration German Clinical Trials Register (DRKS), DRKS00015512. Retrospectively registered on 21 September 2018.
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Abstract
Neurologic abnormality after cardiac surgery is common, and neurologic complications after cardiac surgery are among the most devastating problems that can occur in the postoperative period. Disruption of the blood-brain barrier (BBB) plays an important role in these complications. Assessment of the BBB integrity relies on cognitive testing, MRI, and measurement of brain biomarkers. In applying these methods, up to 50% of cardiac patients show some degree of BBB disruption and most of these abnormalities are short lived. To date there is no single test or measure that can predict BBB disruption in cardiac surgery.
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Cerebral microbleeds are not associated with postoperative delirium and postoperative cognitive dysfunction in older individuals. PLoS One 2019; 14:e0218411. [PMID: 31199858 PMCID: PMC6568413 DOI: 10.1371/journal.pone.0218411] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/31/2019] [Indexed: 11/19/2022] Open
Abstract
Background Cerebral microbleeds (CMB) occur in the context of cerebral small vessel disease. Other brain MRI markers of cerebral small vessel disease are associated with the occurrence of postoperative delirium (POD) and postoperative cognitive dysfunction (POCD), but for CMB this is unknown. We aimed to study the association between CMB and the occurrence of POD and POCD in older individuals. Methods The current study consists of 65 patients (72±5 years) from the BIOCOG study, which is a prospective, observational study of patients who underwent an elective surgery of at least 60 minutes. Patients in the current study received a preoperative cerebral MRI scan including a 3D susceptibility-weighted imaging sequence to detect CMB. The occurrence of POD was screened for twice a day until postoperative day 7 by using the DSM-5, NuDesc, CAM, and CAM-ICU. The occurrence of POCD was determined by the reliable change index model at 7 days after surgery or discharge, respectively, and 3 months after surgery. Statistical analyses consisted of logistic regression adjusted for age and gender. Results A total of 39 CMB were detected in 17 patients (26%) prior to surgery. POD occurred in 14 out of 65 patients (22%). POCD at 7 days after surgery occurred in 11 out of 54 patients (20%) and in 3 out of 40 patients at the 3 month follow-up (8%). Preoperative CMB were not associated with the occurrence of POD (OR (95%-CI): 0.28 (0.05, 1.57); p = 0.147) or POCD at 7 days after surgery (0.76 (0.16, 3.54); p = 0.727) or at 3 months follow-up (0.61 (0.03, 11.64); p = 0.740). Conclusion We did not find an association between preoperative CMB and the occurrence of POD or POCD. Trial registration clinicaltrials.gov (NCT02265263) on 23 September 2014.
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6
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Hasani Z, Keunen RWM, Tavy DLJ, Mosch A, Mook-Kanamori BB, De Bruijn SFTM, Keyhan-Falsafi AM, Hoohenkerk GJF, Stephens G, Teeuws E, van Alphen J, van Overhagen H, Treurniet FEE, van Dijk L, van Kampen PM. Safety and effectiveness of selective carotid angioplasty prior to cardiac surgery: a single-centre matched case-control study. Interact Cardiovasc Thorac Surg 2018; 26:834-839. [PMID: 29309707 DOI: 10.1093/icvts/ivx415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 11/12/2017] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Reducing the rate of postoperative stroke after cardiac surgery remains challenging, especially in patients with occlusive cerebrovascular disease. Angioplasty in all patients with high-grade carotid artery stenosis has not been shown to be effective in reducing the post-surgical stroke rate. In this study, we present the initial results of a different approach using selective carotid angioplasty only in patients with poor intracranial collaterals. METHODS We conducted a single-centre study to assess the safety of this procedure. The postangioplasty complication rate of the study group was compared to that of patients who were scheduled for symptomatic carotid artery angioplasty. To determine the effectiveness of this procedure, the post-cardiac surgery complication rate of the study group was compared with that of the matched case controls. RESULTS Twenty-two patients were treated with selective carotid angioplasty without developing persistent major neurological complications. All patients except 1 patient subsequently underwent surgery without developing persistent major neurological disabilities. Two patients died of cardiogenic shock within 30 days. CONCLUSIONS Selective carotid angioplasty prior to cardiac surgery in patients with a presumed high risk of stroke was relatively safe and effective in this study group. Although this strategy does not prevent stroke in these high-risk patients, data suggest that this approach shifts the postoperative type of stroke from a severe haemodynamic stroke towards a minor embolic stroke with favourable neurological outcomes. Larger studies are needed to determine whether this strategy can effectively eliminate the occurrence of haemodynamic stroke after cardiac surgery.
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Affiliation(s)
- Zahra Hasani
- Department of Neurology and Clinical Neurophysiology, Haga Teaching Hospitals, The Hague, Netherlands
| | - Rudolf W M Keunen
- Department of Neurology and Clinical Neurophysiology, Haga Teaching Hospitals, The Hague, Netherlands
| | - Dénes L J Tavy
- Department of Neurology and Clinical Neurophysiology, Haga Teaching Hospitals, The Hague, Netherlands
| | - Arne Mosch
- Department of Neurology and Clinical Neurophysiology, Haga Teaching Hospitals, The Hague, Netherlands
| | - Barry B Mook-Kanamori
- Department of Neurology and Clinical Neurophysiology, Haga Teaching Hospitals, The Hague, Netherlands
| | | | | | | | - Gayleen Stephens
- Department of Cardiosurgery, Haga Teaching Hospitals, The Hague, Netherlands
| | - Eric Teeuws
- Department of Cardiosurgery, Haga Teaching Hospitals, The Hague, Netherlands
| | - Jan van Alphen
- Department of Cardioanaesthesiology, Haga Teaching Hospitals, The Hague, Netherlands
| | - Hans van Overhagen
- Department of Intervention Radiology, Haga Teaching Hospitals, The Hague, Netherlands
| | - Frank E E Treurniet
- Department of Intervention Radiology, Haga Teaching Hospitals, The Hague, Netherlands
| | - Lucas van Dijk
- Department of Intervention Radiology, Haga Teaching Hospitals, The Hague, Netherlands
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Browndyke JN, Berger M, Smith PJ, Harshbarger TB, Monge ZA, Panchal V, Bisanar TL, Glower DD, Alexander JH, Cabeza R, Welsh-Bohmer K, Newman MF, Mathew JP. Task-related changes in degree centrality and local coherence of the posterior cingulate cortex after major cardiac surgery in older adults. Hum Brain Mapp 2017; 39:985-1003. [PMID: 29164774 DOI: 10.1002/hbm.23898] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 10/24/2017] [Accepted: 11/13/2017] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES Older adults often display postoperative cognitive decline (POCD) after surgery, yet it is unclear to what extent functional connectivity (FC) alterations may underlie these deficits. We examined for postoperative voxel-wise FC changes in response to increased working memory load demands in cardiac surgery patients and nonsurgical controls. EXPERIMENTAL DESIGN Older cardiac surgery patients (n = 25) completed a verbal N-back working memory task during MRI scanning and cognitive testing before and 6 weeks after surgery; nonsurgical controls with cardiac disease (n = 26) underwent these assessments at identical time intervals. We measured postoperative changes in degree centrality, the number of edges attached to a brain node, and local coherence, the temporal homogeneity of regional functional correlations, using voxel-wise graph theory-based FC metrics. Group × time differences were evaluated in these FC metrics associated with increased N-back working memory load (2-back > 1-back), using a two-stage partitioned variance, mixed ANCOVA. PRINCIPAL OBSERVATIONS Cardiac surgery patients demonstrated postoperative working memory load-related degree centrality increases in the left dorsal posterior cingulate cortex (dPCC; p < .001, cluster p-FWE < .05). The dPCC also showed a postoperative increase in working memory load-associated local coherence (p < .001, cluster p-FWE < .05). dPCC degree centrality and local coherence increases were inversely associated with global cognitive change in surgery patients (p < .01), but not in controls. CONCLUSIONS Cardiac surgery patients showed postoperative increases in working memory load-associated degree centrality and local coherence of the dPCC that were inversely associated with postoperative global cognitive outcomes and independent of perioperative cerebrovascular damage.
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Affiliation(s)
- Jeffrey N Browndyke
- Geriatric Behavioral Health Division, Department of Psychiatry & Behavioral Sciences, Duke University Health System, Durham, North Carolina.,Duke Institute for Brain Sciences, Duke University, Durham, North Carolina.,Duke Brain Imaging and Analysis Center, Duke University, Durham, North Carolina
| | - Miles Berger
- Division of Neuroanesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Patrick J Smith
- Behavioral Medicine Division, Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Todd B Harshbarger
- Duke Brain Imaging and Analysis Center, Duke University, Durham, North Carolina.,Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Zachary A Monge
- Center for Cognitive Neuroscience, Duke University, Durham, North Carolina
| | - Viral Panchal
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Tiffany L Bisanar
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Donald D Glower
- Cardiovascular & Thoracic Division, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Roberto Cabeza
- Duke Institute for Brain Sciences, Duke University, Durham, North Carolina.,Duke Brain Imaging and Analysis Center, Duke University, Durham, North Carolina.,Center for Cognitive Neuroscience, Duke University, Durham, North Carolina
| | - Kathleen Welsh-Bohmer
- Geriatric Behavioral Health Division, Department of Psychiatry & Behavioral Sciences, Duke University Health System, Durham, North Carolina.,Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Mark F Newman
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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MRI Markers of Neurodegenerative and Neurovascular Changes in Relation to Postoperative Delirium and Postoperative Cognitive Decline. Am J Geriatr Psychiatry 2017; 25:1048-1061. [PMID: 28760515 DOI: 10.1016/j.jagp.2017.06.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 06/08/2017] [Accepted: 06/20/2017] [Indexed: 12/17/2022]
Abstract
Postoperative delirium (POD) and postoperative cognitive decline (POCD) are common in elderly patients. The aim of the present review was to explore the association of neurodegenerative and neurovascular changes with the occurrence of POD and POCD. Fifteen MRI studies were identified by combining multiple search terms for POD, POCD, and brain imaging. These studies described a total of 1,422 patients and were all observational in design. Neurodegenerative changes (global and regional brain volumes) did not show a consistent association with the occurrence of POD (four studies) or POCD (two studies). In contrast, neurovascular changes (white matter hyperintensities and cerebral infarcts) were more consistently associated with the occurrence of POD (seven studies) and POCD (five studies). In conclusion, neurovascular changes appear to be consistently associated with the occurrence of POD and POCD, and may identify patients at increased risk of these conditions. Larger prospective studies are needed to study the consistency of these findings and to unravel the underlying pathophysiological mechanisms.
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Mack MJ, Acker MA, Gelijns AC, Overbey JR, Parides MK, Browndyke JN, Groh MA, Moskowitz AJ, Jeffries NO, Ailawadi G, Thourani VH, Moquete EG, Iribarne A, Voisine P, Perrault LP, Bowdish ME, Bilello M, Davatzikos C, Mangusan RF, Winkle RA, Smith PK, Michler RE, Miller MA, O’Sullivan KL, Taddei-Peters WC, Rose EA, Weisel RD, Furie KL, Bagiella E, Moy CS, O’Gara PT, Messé SR. Effect of Cerebral Embolic Protection Devices on CNS Infarction in Surgical Aortic Valve Replacement: A Randomized Clinical Trial. JAMA 2017; 318:536-547. [PMID: 28787505 PMCID: PMC5808875 DOI: 10.1001/jama.2017.9479] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Stroke is a major complication of surgical aortic valve replacement (SAVR). OBJECTIVE To determine the efficacy and adverse effects of cerebral embolic protection devices in reducing ischemic central nervous system (CNS) injury during SAVR. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial of patients with calcific aortic stenosis undergoing SAVR at 18 North American centers between March 2015 and July 2016. The end of follow-up was December 2016. INTERVENTIONS Use of 1 of 2 cerebral embolic protection devices (n = 118 for suction-based extraction and n = 133 for intra-aortic filtration device) vs a standard aortic cannula (control; n = 132) at the time of SAVR. MAIN OUTCOMES AND MEASURES The primary end point was freedom from clinical or radiographic CNS infarction at 7 days (± 3 days) after the procedure. Secondary end points included a composite of mortality, clinical ischemic stroke, and acute kidney injury within 30 days after surgery; delirium; mortality; serious adverse events; and neurocognition. RESULTS Among 383 randomized patients (mean age, 73.9 years; 38.4% women; 368 [96.1%] completed the trial), the rate of freedom from CNS infarction at 7 days was 32.0% with suction-based extraction vs 33.3% with control (between-group difference, -1.3%; 95% CI, -13.8% to 11.2%) and 25.6% with intra-aortic filtration vs 32.4% with control (between-group difference, -6.9%; 95% CI, -17.9% to 4.2%). The 30-day composite end point was not significantly different between suction-based extraction and control (21.4% vs 24.2%, respectively; between-group difference, -2.8% [95% CI, -13.5% to 7.9%]) nor between intra-aortic filtration and control (33.3% vs 23.7%; between-group difference, 9.7% [95% CI, -1.2% to 20.5%]). There were no significant differences in mortality (3.4% for suction-based extraction vs 1.7% for control; and 2.3% for intra-aortic filtration vs 1.5% for control) or clinical stroke (5.1% for suction-based extraction vs 5.8% for control; and 8.3% for intra-aortic filtration vs 6.1% for control). Delirium at postoperative day 7 was 6.3% for suction-based extraction vs 15.3% for control (between-group difference, -9.1%; 95% CI, -17.1% to -1.0%) and 8.1% for intra-aortic filtration vs 15.6% for control (between-group difference, -7.4%; 95% CI, -15.5% to 0.6%). Mortality and overall serious adverse events at 90 days were not significantly different across groups. Patients in the intra-aortic filtration group vs patients in the control group experienced significantly more acute kidney injury events (14 vs 4, respectively; P = .02) and cardiac arrhythmias (57 vs 30; P = .004). CONCLUSIONS AND RELEVANCE Among patients undergoing SAVR, cerebral embolic protection devices compared with a standard aortic cannula did not significantly reduce the risk of CNS infarction at 7 days. Potential benefits for reduction in delirium, cognition, and symptomatic stroke merit larger trials with longer follow-up. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02389894.
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Affiliation(s)
- Michael J. Mack
- Department of Cardiothoracic Surgery, Baylor Research Institute, Baylor Scott & White Health, Plano, Texas
| | - Michael A. Acker
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
| | - Annetine C. Gelijns
- International Center for Health Outcomes and Innovation Research, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jessica R. Overbey
- International Center for Health Outcomes and Innovation Research, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael K. Parides
- International Center for Health Outcomes and Innovation Research, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeffrey N. Browndyke
- Division of Geriatric Behavioral Health, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Mark A. Groh
- Cardiovascular and Thoracic Surgery, Mission Health and Hospitals, Asheville, North Carolina
| | - Alan J. Moskowitz
- International Center for Health Outcomes and Innovation Research, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Neal O. Jeffries
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville
| | - Vinod H. Thourani
- Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Ellen G. Moquete
- International Center for Health Outcomes and Innovation Research, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alexander Iribarne
- Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Pierre Voisine
- Institut Universitaire de Cardiologie de Québec, Hôpital Laval, Quebec, Quebec, Canada
| | - Louis P. Perrault
- Montréal Heart Institute, University of Montréal, Montreal, Quebec, Canada
| | - Michael E. Bowdish
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| | - Michel Bilello
- Department of Radiology, University of Pennsylvania, Philadelphia
| | | | - Ralph F. Mangusan
- Cardiovascular and Thoracic Surgery, Mission Health and Hospitals, Asheville, North Carolina
| | - Rachelle A. Winkle
- Department of Cardiothoracic Surgery, Baylor Research Institute, Baylor Scott & White Health, Plano, Texas
| | - Peter K. Smith
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Robert E. Michler
- Department of Cardiothoracic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York
| | - Marissa A. Miller
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Karen L. O’Sullivan
- International Center for Health Outcomes and Innovation Research, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Wendy C. Taddei-Peters
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Eric A. Rose
- Department of Cardiac Surgery, Mount Sinai Health System, New York, New York
| | - Richard D. Weisel
- Peter Munk Cardiac Centre and Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network and the Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Karen L. Furie
- Department of Neurology, Rhode Island Hospital, Miriam Hospital and Bradley Hospital, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Emilia Bagiella
- International Center for Health Outcomes and Innovation Research, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Claudia Scala Moy
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Patrick T. O’Gara
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Steven R. Messé
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia
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Knipp SC, Weimar C, Schlamann M, Schweter S, Wendt D, Thielmann M, Benedik J, Jakob H. Early and long-term cognitive outcome after conventional cardiac valve surgery. Interact Cardiovasc Thorac Surg 2017; 24:534-540. [PMID: 28104728 DOI: 10.1093/icvts/ivw421] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 11/29/2016] [Indexed: 11/12/2022] Open
Abstract
Objectives Adverse cognitive outcome is well recognized after coronary artery bypass grafting (CABG) while little is known about the extent and duration of decline after cardiac valve surgery. We investigated changes in cognitive function following conventional cardiac valve surgery over up to 4 years. Methods Among 36 patients (65.2 ± 9.2 years, 36% women) who received valve surgery, we assessed serial cognitive function with a battery of 11 standardized tests across 3-4 years. Cognitive function was analysed to identify: (1) cognitive decline (i.e. within-patient changes in test scores) and (2) cognitive deficit (i.e. drop of score ≥1 SD in ≥3 tests). Diffusion-weighted magnetic resonance imaging (DW-MRI) was applied pre- and post-procedure to detect ischaemic brain injury. Data were compared to a historical cohort of 39 patients undergoing CABG. Results After both valve surgery and CABG, a significant decline at discharge was detected in 7 of 11 cognitive tests. The rate of patients with a cognitive deficit after valve surgery vs CABG was 39% vs 56% at discharge, 14% vs 23% at 3 months, and 16% vs 26% at 3-4 years (not significant, [n.s.]). After valve surgery, DW-MRI identified 19 (53%) patients with evidence of 50 new focal ischaemic lesions (CABG: 20 [51%] patients with 42 lesions, n.s.). Cumulative cerebral ischaemic load per patient was not significantly different between the valve surgery group and CABG group (503 ± 485 mm 3 vs 415 ± 234 mm 3 ). After correction for multiple potential risk factors in both groups, reduced verbal memory at discharge could be identified as a predictor of long-term cognitive impairment in CABG patients only ( P = 0.04). For both the valve surgery and CABG group, no association between cognitive impairment and new ischaemic cerebral lesions was found. Conclusions The course of cognitive performance after valve surgery and CABG was similar with early postoperative decline followed by subsequent recovery. Although silent small brain infarcts were present in about half of all patients, they did not impact cognitive performance neither at early nor during long-term follow-up.
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Affiliation(s)
- Stephan C Knipp
- Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Essen, Germany
| | - Christian Weimar
- Department of NeurologyUniversity Hospital Essen, Essen, Germany
| | - Marc Schlamann
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Sebastian Schweter
- Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Essen, Germany
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Essen, Germany
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Essen, Germany
| | - Jaroslav Benedik
- Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Essen, Germany
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Essen, Germany
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