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Misra S, Das PK, Srinivasan A. Performance of the transoesophageal echocardiography probe as an oesophageal temperature monitor in patients undergoing cardiac surgery with cardiopulmonary bypass: a prospective observational study. Eur J Cardiothorac Surg 2023; 64:ezad242. [PMID: 37341638 DOI: 10.1093/ejcts/ezad242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/26/2023] [Accepted: 06/20/2023] [Indexed: 06/22/2023] Open
Abstract
OBJECTIVES Core temperature monitoring is critical during cardiopulmonary bypass (CPB). In this prospective observational study, we investigated the performance of the transoesophageal echocardiography (TOE) probe for core (oesophageal) temperature monitoring during CPB. METHODS Thirty adult patients, 18-70 years of either gender, undergoing cardiac surgery with CPB were enrolled. All patients received a reusable nasopharyngeal probe for monitoring core temperatures. In addition, the oesophageal temperatures were monitored with the TOE probe. The arterial outlet temperatures at the membrane oxygenator were also monitored and taken as the reference standard. Monitoring was performed every 5 min until 20 min, and then at 30 min during both the cooling and rewarming periods. RESULTS During cooling, the oesophageal and nasopharyngeal temperatures lagged behind the arterial outlet temperatures. However, the intra-class correlation of the oesophageal temperatures with the arterial outlet temperatures was better (range 0.58-0.74) than the correlation of the nasopharyngeal temperatures with the arterial outlet temperatures (range 0.46-0.62). During rewarming, the performance of the TOE probe was significantly superior to the nasopharyngeal probe. After 15 and 20 min of rewarming, there was a difference of ∼1°C between the oesophageal and nasopharyngeal temperatures. At 30 min of rewarming, the oesophageal and the arterial outlet temperatures were similar, while the nasopharyngeal temperatures still lagged by 0.5°C. Bias was significantly less both during cooling and warming between the oesophageal temperatures and arterial outlet temperatures. CONCLUSIONS Performance of the TOE probe as an oesophageal temperature probe is superior to the nasopharyngeal probe during CPB. CLINICAL TRIAL REGISTRATION NUMBER CTRI no 2020/10/028228; ctri.nic.in.
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Affiliation(s)
- Satyajeet Misra
- Department of Anesthesiology & Critical Care, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Prasanta Kumar Das
- Department of Anesthesiology & Critical Care, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
| | - Anand Srinivasan
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, India
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2
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Role of Transcranial Doppler in Cardiac Surgery Patients. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00483-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Purpose of Review
This review discusses applications of transcranial Doppler (TCD) in cardiac surgery, its efficacy in preventing adverse events such as postoperative cognitive decline and stroke, and its impact on clinical outcomes in these patients.
Recent Findings
TCD alone and in combination with other neuromonitoring modalities has attracted attention as a potential monitoring tool in cardiac surgery patients. TCD allows not only the detection of microemboli and measurement of cerebral blood flow velocity in cerebral arteries but also the assessment of cerebral autoregulation.
Summary
Neuromonitoring is critically important in cardiac surgery as surgical and anesthetic interventions as well as several other factors may increase the risk of cerebral embolization (gaseous and particulate) and cerebral perfusion anomalies, which may lead to adverse neurological events. As an experimental tool, TCD has revealed a possible association of poor neurological outcome with intraoperative cerebral emboli and impaired cerebral perfusion. However, to date, there is no evidence that routine use of transcranial Doppler can improve neurological outcome after cardiac surgery.
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Melnyk V, Fedorko L, Djaiani G. Microemboli on Cardiopulmonary Bypass: Should We Care? J Cardiothorac Vasc Anesth 2020; 34:1504-1505. [PMID: 32173207 DOI: 10.1053/j.jvca.2020.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/13/2020] [Indexed: 11/11/2022]
Affiliation(s)
- V Melnyk
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - L Fedorko
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - G Djaiani
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada.
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Listewnik M, Kotfis K, Ślozowski P, Mokrzycki K, Brykczyński M. The influence of carbon dioxide field flooding in mitral valve operations with cardiopulmonary bypass on S100ß level in blood plasma in the aging brain. Clin Interv Aging 2018; 13:1837-1845. [PMID: 30288036 PMCID: PMC6161743 DOI: 10.2147/cia.s177356] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction The risk of air microembolism during cardiopulmonary bypass (CPB) is high and influences the postoperative outcome, especially in elderly patients. The use of carbon dioxide (CO2) atmosphere during cardiac surgery may reduce the risk of cerebral air microembolism. The aim of our study was to assess the influence of CO2 field flooding on microembolism-induced brain damage assessed by the level of S100ß protein, regarded as a marker of brain damage. Materials and methods A group of 100 patients undergoing planned mitral valve operation through median sternotomy using standard CPB was recruited for the study. Echocardiography was performed prior to and after the CPB. CO2 insufflation at 6 L/minute was conducted in the study group. Blood samples for S100ß protein analysis were collected after induction of anesthesia, 2 hours after aorta de-clamping, and 24 hours after operation. Results The S100ß level in blood plasma did not differ significantly between the study and the control group (0.13±0.08 µg/L, 1.12±0.59 µg/L, and 0.26±0.23 µg/L and 0.18±0.19 µg/L, 1.31±0.62 µg/L, and 0.23±0.12 µg/L, P=0.7, 0.14, and 0.78). The mean increase of the S100ß concentration was 13% lower in the group with CO2 protection than in the control group (0.988 µg/L vs 1.125 µg/L), although statistically insignificant. Tricuspid valve annuloplasties (TVAs) had significant impact on the increase in S100ß concentration in the treatment group after 24 hours (TVA [−] 0.21±0.09 vs TVA [+] 0.42±0.42, P=0.05). In patients <60 years, there were significant differences in the S100ß level 2 and 24 hours after the procedure (1.59±0.682 µg/L vs 1.223±0.571 µg/L, P=0.048, and 0.363±0.318 µg/L vs 0.229±0.105 µg/L, P=0.036) as compared with younger patients. Conclusion The increase in S100ß concentration was lower in the group with CO2 protection than in the control group. Age and an addition of TVA significantly influenced the level of S100ß concentration in the tests performed 2 hours after aortic clamp release.
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Affiliation(s)
- Mariusz Listewnik
- Department of Cardiac Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland,
| | - Paweł Ślozowski
- Department of Cardiac Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Krzysztof Mokrzycki
- Department of Cardiac Surgery, Pomeranian Medical University, Szczecin, Poland
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Aggarwal SK, Delahunty RN N, Menezes LJ, Perry R, Wong B, Reinthaler M, Ozkor M, Mullen MJ. Patterns of solid particle embolization during transcatheter aortic valve implantation and correlation with aortic valve calcification. J Interv Cardiol 2018; 31:648-654. [DOI: 10.1111/joic.12526] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/28/2018] [Accepted: 05/15/2018] [Indexed: 11/28/2022] Open
Affiliation(s)
- Suneil K. Aggarwal
- Department of Cardiology; The Heart Hospital; University College London Hospitals; London UK
| | - Nicola Delahunty RN
- Department of Cardiology; The Heart Hospital; University College London Hospitals; London UK
| | - Leon J. Menezes
- Department of Nuclear Medicine; University College London Hospitals; London UK
| | - Richard Perry
- National Hospital for Neurology & Neurosurgery; University College London Hospitals; London UK
| | - Bethany Wong
- Department of Cardiology; The Heart Hospital; University College London Hospitals; London UK
| | - Markus Reinthaler
- Department of Cardiology; The Heart Hospital; University College London Hospitals; London UK
| | - Muhiddin Ozkor
- Department of Cardiology; The Heart Hospital; University College London Hospitals; London UK
| | - Michael J. Mullen
- Department of Cardiology; The Heart Hospital; University College London Hospitals; London UK
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6
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Edmonds HL, Ganzel BL, Austin EH. Cerebral Oximetry for Cardiac and Vascular Surgery. Semin Cardiothorac Vasc Anesth 2017; 8:147-66. [PMID: 15248000 DOI: 10.1177/108925320400800208] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The technology of transcranial near-infrared spectroscopy (NIRS) for the measurement of cerebral oxygen balance was introduced 25 years ago. Until very recently, there has been only occasional interest in its use during surgical monitoring. Now, however, substantial technologic advances and numerous clinical studies have, at least partly, succeeded in overcoming long-standing and widespread misunderstanding and skepticism regarding its value. Our goals are to clarify common misconceptions about near-infrared spectroscopy and acquaint the reader with the substantial literature that now supports cerebral oximetric monitoring in cardiac and major vascular surgery.
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Affiliation(s)
- Harvey L Edmonds
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, Louisville, Kentucky 40202-3619, USA.
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Rodriguez RA, Belway D. Comparison of two different extracorporeal circuits on cerebral embolization during cardiopulmonary bypass in children. Perfusion 2016; 21:247-53. [PMID: 17201077 DOI: 10.1177/0267659106074764] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To compare the effect of two different extra-corporeal circuits on the counts of high-intensity transient signals (HITS) during pediatric cardiopulmonary bypass (CPB). Methods: Transcranial Doppler was used to detect HITS associated with extracorporeal sources during the period of aortic crossclamping in the middle cerebral artery of children undergoing CPB. Based on body size, children were assigned one of two extracorporeal circuits (A or B). Circuit A included a D-705 oxygenator and associated reservoir, and circuit B included a Lilliput oxygenator and reservoir. Patients were further classified into two groups according to the complexity of surgical repair: single simple lesions or multiple complex lesions. Results: We studied 109 pediatric patients. Surgery for multiple complex lesions was associated with longer periods of aortic crossclamping and CPB (p <0.0001). The median count of extra-corporeal HITS was 12 (25th, 75th percentiles: 3, 51). The type of extracorporeal circuit (p=0.012) and the complexity of surgical repair (p <0.0001) had an effect on the HITS counts. The use of circuit A was associated with higher HITS counts during surgery for multiple complex lesions compared to single simple lesions (p <0.0001). Conversely, no differences were found with the use of circuit B between these two surgical groups (p >0.25). During surgery for multiple complex lesions, patients treated with circuit A showed higher HITS counts than those with circuit B (p <0.01), but there were no circuit-related differences in HITS counts (p=0.30) during single simple lesions. Conclusion: Variations in the design characteristics of extracorporeal circuits can increase cerebral emboli during CPB in children. This may be related to the reduced ability of some circuits to remove emboli during long periods of CPB for complex congenital heart-surgery.
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MESH Headings
- Aorta
- Cardiopulmonary Bypass/instrumentation
- Cardiopulmonary Bypass/methods
- Child
- Child, Preschool
- Constriction
- Embolism, Air/diagnostic imaging
- Embolism, Air/etiology
- Embolism, Fat/diagnostic imaging
- Embolism, Fat/etiology
- Equipment Design
- Extracorporeal Circulation/instrumentation
- Extracorporeal Circulation/methods
- Head-Down Tilt
- Heart Defects, Congenital/surgery
- Humans
- Incidence
- Infarction, Middle Cerebral Artery/diagnostic imaging
- Infarction, Middle Cerebral Artery/epidemiology
- Infarction, Middle Cerebral Artery/etiology
- Nervous System Diseases/epidemiology
- Nervous System Diseases/etiology
- Postoperative Complications/etiology
- Postoperative Complications/mortality
- Randomized Controlled Trials as Topic/statistics & numerical data
- Retrospective Studies
- Ultrasonography, Doppler, Transcranial
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Affiliation(s)
- Rosendo A Rodriguez
- Department of Surgery, Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada.
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8
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Rodriguez RA, Williams KA, Babaev A, Rubens F, Nathan HJ. Effect of perfusionist technique on cerebral embolization during cardiopulmonary bypass. Perfusion 2016; 20:3-10. [PMID: 15751664 DOI: 10.1191/0267659105pf778oa] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To determine the association between high-intensity transient signals (HITS) and perfusionist interventions, purging techniques, pump flows and venous reservoir blood volume levels during cardiopulmonary bypass. Methods: Transcranial Doppler was used to detect HITS in the middle cerebral artery during the period of aortic crossclamping in patients undergoing coronary artery bypass grafting. Perfusionist-related interventions were recorded and included blood sampling (including the number of times that the oxygenator sampling manifold was purged), drug bolus injections and infusions (vasopressors, crystalloid and mannitol). Pump flows and venous reservoir volume levels were also documented. Results: There were 534 interventions in 90 patients [median number of interventions per patient: 6 (quartiles: 4, 8)]. The median total HITS count from all interventions was 17 (5, 37). This represented 38% of the total HITS counts during aortic crossclamping. Factors contributing to differences in the HITS count included type of intervention ( p<0.0001) and perfusionist (p=0.0012). Blood sampling ( p<0.001) and drug bolus injections (p=0.06) had higher HITS counts per patient than infusions. Repetitive purging significantly increased HITS counts (r=0.74; p<0.001). Purging perfusionists (purging: 1 - 10 times) had higher HITS counts per patient [5 HITS (1, 15) than nonpurgers [0 HITS (0, 1) p<0.0001]. HITS counts were significantly correlated with reservoir volumes (r=-0.20, p=0.017) and pump flow rates (r=0.21, p=0.008). Reservoir volume levels ≤ 800 mL were associated with higher HITS counts per intervention [11 HITS (2, 27)] during blood sampling compared with higher volume levels [3 HITS (1, 10), p=0.001]. Conclusions: Cerebral emboli associated with perfusionist interventions can be minimized by not purging the sampling manifold, using continuous infusions rather than bolus injections, and maintaining high blood-volume levels (>800 mL) in the venous reservoir.
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Affiliation(s)
- Rosendo A Rodriguez
- Department of Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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9
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Riley W, FitzGerald D, Cohn L. Single, percutaneous, femoral venous cannulation for cardiopulmonary bypass. Perfusion 2016; 22:211-5. [DOI: 10.1177/0267659107083021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Percutaneous femoral venous cannulation for cardiopulmonary bypass has emerged as an indispensable technique in the management of cardiac surgical procedures requiring cardiopulmonary bypass. A review of cases at Brigham and Women's Hospital (Boston, MA, USA) relying solely on percutaneous femoral venous cannulation for venous return to the heart-lung machine demonstrated achievable blood flow and complexity of case-load. Operations performed in this manner include, but are not limited to, coronary artery bypass grafting (CABG), valve, CABG/valve, and aortic procedures. Minimally invasive procedures and re-operations comprise a portion of each group. Complications of cardiopulmonary bypass and site-related complications were considered. Percutaneous femoral venous cannulation is a safe method to provide most patients with adequate venous return to perform any cardiac surgery. Patients demanding greater flow than this method will provide, may require a second venous cannula at some time during cardiopulmonary bypass. Perfusion (2007) 22, 211—215.
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10
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Whitaker DC, Stygall J, Hope-Wynne C, Walesby RK, Harrison MJG, Newman SP. A prospective clinical study of cerebral microemboli and neuropsychological outcome comparing vent-line and auto-venting arterial line filters: both filters are equally safe. Perfusion 2016; 21:83-6. [PMID: 16615684 DOI: 10.1191/0267659106pf852oa] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Introduction: Microemboli are the main implicated cause of neuropsychological (NP) impairment after cardiac surgery. This prospective clinical trial compared the effect of an auto-venting arterial line filter on intraoperative cerebral microemboli and NP outcome compared to an arterial line filter with a vent line, in patients undergoing elective coronary artery bypass graft (CABG) surgery. Methods: One hundred and ten patients received either an Avecor Affinity ( n = 73) or Pall AV-6 ( n = 37) control filter. Cerebral microemboli during cardiopulmonary bypass were recorded by transcranial Doppler monitoring of the right middle cerebral artery. Evidence of cerebral impairment was obtained by comparing patients’ performance in a NP test battery (nine tests) administered 6-8 weeks postoperatively with their pre-operative scores. Results: During cardiopulmonary bypass, the median number and range of microemboli were 67 (5-846) and 55 (2-773) for the Avecor and AV-6 groups, respectively ( p = 0.47). There was no difference in NP outcome. Conclusion: There is no difference in the filtering ability of vent-line and auto-vent filters as assessed by cerebral microemboli. This, together with the similar NP outcome, suggests that both types of filter are equally safe for clinical use.
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Affiliation(s)
- Donald C Whitaker
- Centre for Behavioural and Social Sciences in Medicine, University College London, UK
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11
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Alpha-stat, beach chair, cerebral autoregulation… But who is at risk? Can J Anaesth 2016; 63:513-8. [DOI: 10.1007/s12630-016-0605-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/14/2015] [Accepted: 01/27/2016] [Indexed: 11/27/2022] Open
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12
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Koutsogiannidis CPC, Ananiadou OG, Ampatzidou FC, Savvas IP, Mytilinaios DG, Nikolopoulou EN, Troupis TG, Charchanti AV, Drossos GE, Johnson EO. Decreased DNA Disruption in the Porcine Neocortex with Erythromycin Preconditioning during Prolonged Hypothermic Circulatory Arrest: Evidence for Neuroprotection. J Card Surg 2015; 30:525-31. [DOI: 10.1111/jocs.12544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Charilaos-Panagiotis C. Koutsogiannidis
- Cardiothoracic Surgery Department; General Hospital “G. Papanikolaou”; Thessaloniki Greece
- Department of Anatomy-Histology-Embryology; University of Ioannina Medical School; Ioannina Greece
| | - Olga G. Ananiadou
- Cardiothoracic Surgery Department; General Hospital “G. Papanikolaou”; Thessaloniki Greece
| | - Fotini C. Ampatzidou
- Cardiothoracic Surgery Department; General Hospital “G. Papanikolaou”; Thessaloniki Greece
| | - Ioannis P. Savvas
- Faculty of Veterinary Medicine; Companion Animal Clinic; Thessaloniki Greece
| | | | | | | | - Antonia V. Charchanti
- Department of Anatomy-Histology-Embryology; University of Ioannina Medical School; Ioannina Greece
| | - George E. Drossos
- Cardiothoracic Surgery Department; General Hospital “G. Papanikolaou”; Thessaloniki Greece
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DENEKE THOMAS, JAIS PIERRE, SCAGLIONE MARCO, SCHMITT RAINER, DI BIASE LUIGI, CHRISTOPOULOS GEORGIOS, SCHADE ANJA, MÜGGE ANDREAS, BANSMANN MARTIN, NENTWICH KARIN, MÜLLER PATRICK, KRUG JOACHIM, ROOS MARKUS, HALBFASS PHILLIP, NATALE ANDREA, GAITA FIORENZO, HAINES DAVID. Silent Cerebral Events/Lesions Related to Atrial Fibrillation Ablation: A Clinical Review. J Cardiovasc Electrophysiol 2015; 26:455-463. [DOI: 10.1111/jce.12608] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 12/11/2014] [Indexed: 11/30/2022]
Affiliation(s)
- THOMAS DENEKE
- Heart Center Bad Neustadt; Bad Neustadt Germany
- Ruhr-University Bochum; Bochum Germany
| | | | - MARCO SCAGLIONE
- Cardiology Division; Cardinal Guglielmo Massaia Hospital; Asti Italy
| | - RAINER SCHMITT
- Department of Radiology; Heart Center Bad Neustadt; Bad Neustadt Germany
| | - LUIGI DI BIASE
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
- Department of Biomedical Engineering; University of Texas; Austin Texas USA
- Department of Cardiology; University of Foggia; Foggia Italy
- Albert Einstein College of Medicine at Montefiore Hospital New York; New York USA
| | | | - ANJA SCHADE
- Heart Center Bad Neustadt; Bad Neustadt Germany
| | | | - MARTIN BANSMANN
- Institute for Diagnostic and Interventional Radiology; Hospital Cologne-Porz; Germany
| | | | - PATRICK MÜLLER
- Heart Center Bad Neustadt; Bad Neustadt Germany
- Ruhr-University Bochum; Bochum Germany
| | | | - MARKUS ROOS
- Heart Center Bad Neustadt; Bad Neustadt Germany
| | | | - ANDREA NATALE
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
- Ruhr-University Bochum; Bochum Germany
| | - FIORENZO GAITA
- Division of Cardiology; Department of Medical Sciences; University of Turin; Italy
| | - DAVID HAINES
- Department of Cardiovascular Medicine; Oakland University William Beaumont School of Medicine; Royal Oak Michigan USA
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14
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Cognitive dysfunction after on-pump operations: neuropsychological characteristics and optimal core battery of tests. Stroke Res Treat 2014; 2014:302824. [PMID: 24955279 PMCID: PMC4021688 DOI: 10.1155/2014/302824] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 04/04/2014] [Accepted: 04/08/2014] [Indexed: 01/05/2023] Open
Abstract
Postoperative cognitive dysfunction (POCD) is a mild form of perioperative ischemic brain injury, which emerges as memory decline, decreased attention, and decreased concentration during several months, or even years, after surgery. Here we present results of our three neuropsychological studies, which overall included 145 patients after on-pump operations. We found that the auditory memory span test (digit span) was more effective as a tool for registration of POCD, in comparison with the word-list learning and story-learning tests. Nonverbal memory or visuoconstruction tests were sensitive to POCD in patients after intraoperative opening of cardiac chambers with increased cerebral air embolism. Psychomotor speed tests (digit symbol, or TMT A) registered POCD, which was characteristic for elderly atherosclerotic patients. Finally, we observed that there were significant effects of the order of position of a test on the performance on this test. For example, the postoperative performance on the core tests (digit span and digit symbol) showed minimal impairment when either of these tests was administered at the beginning of testing. Overall, our data shows that the selection of tests, and the order of which these tests are administered, may considerably influence the results of studies of POCD.
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15
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Nagy-Baló E, Tint D, Clemens M, Beke I, Kovács KR, Csiba L, Édes I, Csanádi Z. Transcranial Measurement of Cerebral Microembolic Signals During Pulmonary Vein Isolation. Circ Arrhythm Electrophysiol 2013; 6:473-80. [DOI: 10.1161/circep.112.971747] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Edina Nagy-Baló
- From the Institute of Cardiology (E.N.-B., D.T., M.C., I.B., I.E., Z.C.), and Department of Neurology (K.R.K., L.C.), University of Debrecen, Debrecen, Hungary
| | - Diana Tint
- From the Institute of Cardiology (E.N.-B., D.T., M.C., I.B., I.E., Z.C.), and Department of Neurology (K.R.K., L.C.), University of Debrecen, Debrecen, Hungary
| | - Marcell Clemens
- From the Institute of Cardiology (E.N.-B., D.T., M.C., I.B., I.E., Z.C.), and Department of Neurology (K.R.K., L.C.), University of Debrecen, Debrecen, Hungary
| | - Ildikó Beke
- From the Institute of Cardiology (E.N.-B., D.T., M.C., I.B., I.E., Z.C.), and Department of Neurology (K.R.K., L.C.), University of Debrecen, Debrecen, Hungary
| | - Katalin Réka Kovács
- From the Institute of Cardiology (E.N.-B., D.T., M.C., I.B., I.E., Z.C.), and Department of Neurology (K.R.K., L.C.), University of Debrecen, Debrecen, Hungary
| | - László Csiba
- From the Institute of Cardiology (E.N.-B., D.T., M.C., I.B., I.E., Z.C.), and Department of Neurology (K.R.K., L.C.), University of Debrecen, Debrecen, Hungary
| | - István Édes
- From the Institute of Cardiology (E.N.-B., D.T., M.C., I.B., I.E., Z.C.), and Department of Neurology (K.R.K., L.C.), University of Debrecen, Debrecen, Hungary
| | - Zoltán Csanádi
- From the Institute of Cardiology (E.N.-B., D.T., M.C., I.B., I.E., Z.C.), and Department of Neurology (K.R.K., L.C.), University of Debrecen, Debrecen, Hungary
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Abstract
Transexamic acid (TXA) is an antifibrinolytic that has been used successfully to prevent blood loss during major surgery. However, as its usage has increased, there have been growing reports of postsurgical seizure events in cardiac surgery patients. In this issue of the JCI, Lecker et al. explore this connection and suggest that TXA-mediated inhibition of glycine receptors may underlie the effect. This finding prompted the authors to explore the preclinical efficacy of common anesthetics that function by reducing the TXA-mediated inhibition to prevent or modify postsurgical seizures.
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Affiliation(s)
- Debra A Schwinn
- Department of Anesthesiology, Pharmacology, and Biochemistry, Roy J. and Lucille A. Carver College of Medicine, The University of Iowa, Iowa City, Iowa 52242-1101, USA.
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17
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Dabrowski W, Rzecki Z, Czajkowski M, Pilat J. Magnesium reduces matrix metalloproteinase-9, but not glial fibrillary acidic protein, in cardiac surgery patients. FUTURE NEUROLOGY 2012. [DOI: 10.2217/fnl.12.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Magnesium (Mg) is one of the most important ions in the brain. Its supplementation decreases intracellular disorders and improves final outcomes following traumatic brain injury. Aim: The aim of the study was to analyze the effects of magnesium supplementation on arteriovenous differences in plasma magnesium concentration in brain circulation (a–vMg), plasma matrix metalloproteinase-9 (MMP-9) and glial fibrillary acidic protein (GFAP) concentrations in cardiac surgery patients. Methods: A total of 92 adult patients were enrolled. Patients were allocated into three groups: A, receiving 6.66 mg of MgSO4 per min intravenously; B, receiving 10 mg of MgSO4; and C, receiving 13.33 mg of MgSO4. Results: In all groups, GFAP and MMP-9 increased after extracorporeal circulation and immediately after surgery. Sequentially higher concentrations of MMP-9 and a–vMg were noted in groups A, B and C. Plasma GFAP concentrations were similar in all groups. Conclusion: Magnesium supplementation reduces plasma MMP-9 and a-vMg in brain circulation but does not affect plasma GFAP.
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Affiliation(s)
- Wojciech Dabrowski
- Department of Anaesthesiology & Intensive Therapy, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
| | - Ziemowit Rzecki
- Department of Anaesthesiology & Intensive Therapy, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
| | - Marek Czajkowski
- Department of Anaesthesiology & Intensive Therapy, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
| | - Jacek Pilat
- Department of Anaesthesiology & Intensive Therapy, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
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18
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Zanatta P, Benvenuti SM, Valfrè C, Baldanzi F, Palomba D. The role of asymmetry and the nature of microembolization in cognitive decline after heart valve surgery: a pilot study. Perfusion 2012; 27:199-206. [DOI: 10.1177/0267659112437776] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Our objective was to determine the role of asymmetry and the nature of microembolization on postoperative cognitive decline in patients who had undergone heart valve surgery. Continuous transcranial Doppler ultrasound was intraoperatively used for both middle cerebral arteries in 13 right-handed heart valve surgery patients to detect microembolization. The Trail Making Test A and B, Memory with 10/30 s interference, the Digit Span Test and Phonemic Fluency were performed preoperatively, at discharge and three months after surgery. Our data suggest that early and late postoperative psychomotor and executive functions may be sensitive to microemboli in the left, but not in the right middle cerebral artery. Moreover, solid and gaseous microemboli are both similarly associated with early postoperative cognitive decline while, surprisingly, late postoperative cognitive decline is more likely to be associated with gaseous than solid microemboli.
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Affiliation(s)
- P Zanatta
- Anesthesia and Intensive Care Department, Treviso Regional Hospital, Italy
| | | | - C Valfrè
- Cardiovascular Disease Department, Treviso Regional Hospital, Italy
| | - F Baldanzi
- Regional project for the reduction of neurodysfunction after cardiac surgery and neurosurgery, and the improvement of multimodality neuromonitoring, Regione Veneto, Italy
| | - D Palomba
- Department of General Psychology, University of Padova, Italy
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19
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Generation, detection and prevention of gaseous microemboli during cardiopulmonary bypass procedure. Int J Artif Organs 2012; 34:1039-51. [PMID: 22183517 DOI: 10.5301/ijao.5000010] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2011] [Indexed: 11/20/2022]
Abstract
Neuropsychological injury after cardiopulmonary bypass (CPB) is one of the most serious and costly complications arising from the procedure. Gaseous microemboli (GME) have long been implicated as one of the principal causes. There are two major sources of GME: surgical and manual manipulation of the heart and arteries; and the components of the extracorporeal circuit, including the type of pump, different perfusion modes, the design of the oxygenator and reservoir, and the use of vacuum assisted venous drainage (VAVD), all of which have a great impact on the delivery of existing GME to the patients. Transcranial cranial Doppler (TCD) has been used for more than two decades to assess and monitor the quality of extracorporeal perfusion with regard to the blood flow velocity of the middle cerebral arteries (MCA) and emboli detection, contributing to the achievement of better perfusion results. The Emboli Detection and Classification (EDAC) Quantifier has been able to detect and track microemboli in CPB circuits up to 1,000 microemboli per second at flow rates ranging from 0.2 L/min to 6.0 L/min. The deleterious effects of GME are multiple, including damage to the cerebral vascular endothelium, disruption of the blood-brain barrier, complement activation, leukocyte aggregation, increased platelet adherence, and fibrin deposition in the micro-vasculature. Improvements in perfusion equipment and in perfusion and surgical techniques have led to a dramatic reduction in the occurrence of GME during cardiac surgery. Although the clinical relevance of cerebral air embolization in causing neurological damage is unclear, every single person involved in perfusion and surgical technology should be aware of the risk of embolization and strictly regulate clinical behavior. Related research should also be done to improve the design of circuit components and clinical practice with a view to eliminating air bubbles during CPB procedure.
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20
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Golukhova EZ, Polunina AG, Lefterova NP, Begachev AV. Electroencephalography as a tool for assessment of brain ischemic alterations after open heart operations. Stroke Res Treat 2011; 2011:980873. [PMID: 21776370 PMCID: PMC3138153 DOI: 10.4061/2011/980873] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 03/31/2011] [Accepted: 03/31/2011] [Indexed: 11/24/2022] Open
Abstract
Cardiac surgery is commonly associated with brain ischemia. Few studies addressed brain electric activity changes after on-pump operations. Eyes closed EEG was performed in 22 patients (mean age: 45.2 ± 11.2) before and two weeks after valve replacement. Spouses of patients were invited to participate as controls. Generalized increase of beta power most prominent in beta-1 band was an unambiguous pathological sign of postoperative cortex dysfunction, probably, manifesting due to gamma-activity slowing (“beta buzz” symptom). Generalized postoperative increase of delta-1 mean frequency along with increase of slow-wave activity in right posterior region may be hypothesized to be a consequence of intraoperative ischemia as well. At the same time, significant changes of alpha activity were observed in both patient and control groups, and, therefore, may be considered as physiological. Unexpectedly, controls showed prominent increase of electric activity in left temporal region whereas patients were deficient in left hemisphere activity in comparison with controls at postoperative followup. Further research is needed in order to determine the true neurological meaning of the EEG findings after on-pump operations.
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Affiliation(s)
- Elena Z Golukhova
- Bakulev Scientific Center of Cardiovascular Surgery, Russian Academy of Medical Sciences, Leninsky Prospekt 156-368, Moscow 119571, Russia
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21
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Chaudhuri K, Marasco SF. The effect of carbon dioxide insufflation on cognitive function during cardiac surgery. J Card Surg 2011; 26:189-96. [PMID: 21395683 DOI: 10.1111/j.1540-8191.2011.01217.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of carbon dioxide (CO(2)) insufflation into the pericardial well has become widespread, and in some units routine. The rationale behind this practice is the fact that CO(2) is more soluble than air leading to fewer gaseous microemboli entering the bloodstream and being transferred to the brain or heart. However, the evidence that this reduces postoperative neurocognitive decline is scant. Although CO(2) insufflation is generally a safe procedure there are case reports of significant complications. The aim of this systematic review is to analyze the current evidence for this practice.
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22
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Rodriguez RA, Rubens FD, Wozny D, Nathan HJ. Cerebral Emboli Detected by Transcranial Doppler During Cardiopulmonary Bypass Are Not Correlated With Postoperative Cognitive Deficits. Stroke 2010; 41:2229-35. [DOI: 10.1161/strokeaha.110.590513] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
High-intensity transient signals (HITS) are the transcranial Doppler representation of both air and solid cerebral emboli. We studied the frequency of HITS associated with different surgical maneuvers during cardiopulmonary bypass for coronary artery bypass graft surgery and their association with postoperative cognitive dysfunction (POCD).
Methods—
We combined 356 patients undergoing coronary artery bypass graft from 2 clinical trials who had both neuropsychological testing (before, 1 week and 3 months after surgery) and transcranial Doppler during cardiopulmonary bypass. HITS were grouped into periods that included: cannulation, cardiopulmonary bypass onset, aortic crossclamp-on, aortic crossclamp-off, side clamp-on, side clamp-off, and decannulation. POCD was defined by a decreased combined Z-score of at least 2.0 or reduction in Z-scores of at least 2.0 in 20% of the individual tests.
Results—
Incidence of POCD was 47.3% and 6.3% at 1 week and 3 months after surgery. There was no association between cardiopulmonary bypass counts of HITS and POCD at 1 week (
P
=0.617) and 3 months (
P
=0.110). No differences in HITS counts were identified at any of the surgical periods between patients with and without POCD. Factors affecting HITS counts were surgical period (
P
<0.0001), blood flow velocity (
P
=0.012), cardiopulmonary bypass duration (
P
=0.040), and clinical study (
P
=0.048).
Conclusions—
Although cerebral microemboli have been implicated in the pathogenesis of POCD, in this study that included low-risk patients undergoing coronary artery bypass surgery, there was no demonstrable correlation between the counts of HITS and POCD.
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Affiliation(s)
- Rosendo A. Rodriguez
- From the Department of Surgery (R.A.R., F.D.R.), Division of Cardiac Surgery, and the Department of Anesthesia (D.W., H.J.N.), Cardiovascular Division, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Fraser D. Rubens
- From the Department of Surgery (R.A.R., F.D.R.), Division of Cardiac Surgery, and the Department of Anesthesia (D.W., H.J.N.), Cardiovascular Division, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Denise Wozny
- From the Department of Surgery (R.A.R., F.D.R.), Division of Cardiac Surgery, and the Department of Anesthesia (D.W., H.J.N.), Cardiovascular Division, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Howard J. Nathan
- From the Department of Surgery (R.A.R., F.D.R.), Division of Cardiac Surgery, and the Department of Anesthesia (D.W., H.J.N.), Cardiovascular Division, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Neumann T, Kuniss M, Conradi G, Janin S, Berkowitsch A, Wojcik M, Rixe J, Erkapic D, Zaltsberg S, Rolf A, Bachmann G, Dill T, Hamm CW, Pitschner HF. MEDAFI-Trial (Micro-embolization during ablation of atrial fibrillation): comparison of pulmonary vein isolation using cryoballoon technique vs. radiofrequency energy. Europace 2010; 13:37-44. [PMID: 20829189 DOI: 10.1093/europace/euq303] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thomas Neumann
- Department of Cardiology, Kerckhoff Heart Center, Benekestrasse 2-8, 61231 Bad Nauheim, Germany.
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24
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Grigore AM, Murray CF, Ramakrishna H, Djaiani G. A Core Review of Temperature Regimens and Neuroprotection During Cardiopulmonary Bypass: Does Rewarming Rate Matter? Anesth Analg 2009; 109:1741-51. [DOI: 10.1213/ane.0b013e3181c04fea] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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25
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Lipperts MGA, Sauren LDC, Maessen JG, Hoeks APG, Mess WH. Quantification of embolic showers using radio-frequency based TCD analysis. ULTRASOUND IN MEDICINE & BIOLOGY 2009; 35:395-402. [PMID: 19084324 DOI: 10.1016/j.ultrasmedbio.2008.09.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 07/21/2008] [Accepted: 09/17/2008] [Indexed: 05/27/2023]
Abstract
During cardiac surgery and cardiology interventions, microemboli may be generated and disperse in the systemic circulation. The amount of microemboli that ends up in cerebral blood vessels is associated with postoperative neurologic complications. During cardiac surgery a large amount of cerebral microemboli can occur at once and create so-called "cerebral embolic showers." To correlate postoperative neurologic outcome to cerebral embolic load, a quantitative evaluation of these embolic showers is necessary. The standard monitoring technology to visualize cerebral microemboli is transcranial Doppler (TCD). Although the conventional TCD systems are equipped with software claiming to detect microembolic signals, none of the existing TCD systems is capable of an accurate estimation of the number of cerebral microemboli in embolic showers. In this study, an algorithm with a high temporal resolution, based on the radiofrequency (RF) signal of a TCD system, has been designed to quantify these showers. Evaluation by three independent observers of a training set demonstrates that the proposed method has a sensitivity of at least one order of magnitude better than the automatic detection algorithm on the existing Doppler device used. RF-based emboli detection can possibly become a standard addition to conventional Doppler methods, considering that accurate estimation of the embolic load supports quantification of neurologic risk during various surgical procedures.
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Affiliation(s)
- M G A Lipperts
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht, Academic Hospital Maastricht, Maastricht, The Netherlands
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26
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Whitley WS, Glas KE. An Argument for Routine Ultrasound Screening of the Thoracic Aorta in the Cardiac Surgery Population. Semin Cardiothorac Vasc Anesth 2008; 12:290-7. [DOI: 10.1177/1089253208328583] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Stroke and neurological injury are among the most devastating and disabling complications associated with cardiac surgery. Transesophageal echocardiography and epiaortic ultrasound allow for sensitive, point-of-care diagnosis of thoracic aortic disease, which is especially common in patients with heart disease. Unlike other operative procedures, the manipulation of the ascending aorta is routine in cardiac surgery and often unavoidable. Dislodgement and embolization from the ascending and aortic arch atheromas have been clearly associated with manipulation during cardiac surgery. Epiaortic ultrasound and transesophageal echocardiography screening are more accurate and more accessible to the operative team than any other available modality to diagnose atherosclerosis of the aorta. The goal of this review is to review the rationale and scientific evidence that suggests that the routine use of ultrasound guidance in cardiac surgery may improve postoperative outcomes in this patient population.
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Affiliation(s)
| | - Kathryn E. Glas
- Department of Anesthesia, Emory University Hospital, Atlanta, Georgia
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27
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Pillai JB, Suri RM. Coronary Artery Surgery and Extracorporeal Circulation: The Search for a New Standard. J Cardiothorac Vasc Anesth 2008; 22:594-610. [DOI: 10.1053/j.jvca.2008.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Indexed: 01/19/2023]
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28
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Bhaskar J. Carbon dioxide flooding of the pericardium-An old practice revisited. Indian J Thorac Cardiovasc Surg 2008. [DOI: 10.1007/s12055-008-0012-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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29
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Djaiani G, Ali M, Borger MA, Woo A, Carroll J, Feindel C, Fedorko L, Karski J, Rakowski H. Epiaortic scanning modifies planned intraoperative surgical management but not cerebral embolic load during coronary artery bypass surgery. Anesth Analg 2008; 106:1611-8. [PMID: 18499587 DOI: 10.1213/ane.0b013e318172b044] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patients with aortic atheroma are at increased risk for neurological injury after coronary artery bypass graft (CABG) surgery. We sought to determine the role of epiaortic ultrasound scanning for reducing cerebral embolic load, and whether its use leads to changes of planned intraoperative surgical management in patients undergoing CABG surgery. METHODS Patients >70-yr-of-age scheduled for CABG surgery were prospectively randomized to either an epiaortic scanning (EAS) group (aortic manipulation guided by epiaortic ultrasound) or a control group (manual aortic palpation without EAS). All patients received a comprehensive transesophageal echocardiographic examination. Transcranial Doppler (TCD) was used to monitor the middle cerebral arteries for emboli continuously from 2 min before aortic cannulation to 2 min after aortic decannulation. Neurological assessment was performed with the National Institute of Health stroke scale before surgery and at hospital discharge. The NEECHAM confusion scale was used for assessment and monitoring of patient global cognitive function on each day after surgery until hospital discharge. RESULTS Intraoperative surgical management was changed in 16 of 55 (29%) patients in the EAS group and in 7 of 58 (12%) patients in the control group (P = 0.025). These changes included adjustments of the ascending aorta cannulation site for cardiopulmonary bypass (CPB), the avoidance of aortic cross-clamping by using ventricular fibrillatory arrest during surgery, or by conversion to off-pump surgery. During surgery, 7 of 58 (12%) patients in the control group crossed over to the EAS group based on the results of manual aortic palpation. The median [range] TCD detected cerebral embolic count did not differ between the EAS and control groups during aortic manipulations (EAS, 11.5 [1-516] vs control, 22.0 [1-160], P = 0.91) or during CPB (EAS, 42.0 [4-516] vs control, 63.0 [5-758], P = 0.46). The NEECHAM confusion scores and National Institute of Health stroke scale scores were similar between the two groups. CONCLUSIONS These results show that the use of EAS led to modifications in intraoperative surgical management in almost one-third of patients undergoing CABG surgery. The use of EAS did not lead to a reduced number of TCD-detected cerebral emboli before or during CPB.
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Affiliation(s)
- George Djaiani
- Department of Anesthesiology, Toronto General Hospital, Eaton North 3-410, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
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31
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Abstract
Cardiac surgery continues to be associated with significant adverse cerebral outcomes, ranging from stroke to cognitive decline. The underlying mechanism of the associated cerebral injury is incompletely understood but is believed to be primarily caused by cerebral embolism and hypoperfusion, exacerbated by ischemia/reperfusion injury. Extensive research has been undertaken in an attempt to minimize the incidence of perioperative cerebral injury, and both pharmacological and nonpharmacological strategies have been investigated. Although many agents demonstrated promise in preclinical studies, there is currently insufficient evidence from clinical trials to recommend the routine administration of any pharmacological agents for neuroprotection during cardiac surgery. The nonpharmacological strategies that can be recommended on the basis of evidence include transesophageal echocardiography and epiaortic ultrasound-guided assessment of the atheromatous ascending aorta with appropriate modification of cannulation, clamping or anastomotic technique and optimal temperature management. Large-scale randomized controlled trials are still required to address further the issues of optimal pH management, glycemic control, blood pressure management and hematocrit during cardiopulmonary bypass. Past, present and future directions in the field of neuroprotection in cardiac surgery will be discussed.
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Affiliation(s)
- Niamh Conlon
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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32
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Dittrich R, Ringelstein EB. Occurrence and clinical impact of microembolic signals during or after cardiosurgical procedures. Stroke 2008; 39:503-11. [PMID: 18174490 DOI: 10.1161/strokeaha.107.491241] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Microembolic signals (MESs) are detectable within the transcranial Doppler frequency spectrum downstream from vascular atherothrombotic or cardiothrombotic lesions. A frequent occurrence of MESs has also been shown during bypass surgery or after mechanical valve implantation. We sought to compile the knowledge on MES prevalence, the clinical impact of these cardiogenic MESs, and microemboli composition. SUMMARY OF REVIEW We performed a systematic MEDLINE search and summarized the currently available literature about MESs during or after cardiosurgical procedures for this state-of-the-art report. CONCLUSIONS The nature of cardiogenic MESs is heterogeneous, and their prevalence is highly variable, reflecting their different origin from a broad spectrum of cardiosurgical conditions. The occurrence and number of MESs during cardiac catheterization and percutaneous coronary angioplasty seem to have a clinical impact but need to be explored further. In patients with prosthetic heart valves, in those with left ventricular assist devices, and during cardiac surgery, the occurrence of MESs has an important clinical impact, and MES monitoring has proven its reliability. Although the data encourage intensifying MES detection in cardiac disorders, their heterogeneous nature does not yet allow the use of MESs as a general surrogate parameter for neuronal damage or cardial thromboembolic risk.
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Affiliation(s)
- Ralf Dittrich
- Department of Neurology, Leibniz Institute for Atherosclerosis Research, University of Muenster, Muenster, Germany.
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Abstract
Numerous authors have associated gaseous microembolization with adverse cerebral outcomes during cardiopulmonary bypass (CPB). The introduction to this review provides background on the connection between microemboli and adverse cerebral outcomes. This connection is often difficult to quantify, as outcomes depend on a number of factors, including the size of the bubble, where it passes through the patient, patient co-morbidities and other factors. Nonetheless, numerous studies have shown statistically significant differences in the mean number of cerebral emboli detected in patients that stroked and those that did not, as well as for patients with major cardiac complications and patients with a longer length of hospital stay. Our introduction is followed by case reports and laboratory studies showing how monitoring for gaseous microemboli (GME) can be used to reduce the embolic load delivered to the patient through the bypass circuit. These methods include improved qualification of bypass circuit design prior to surgery, modification of priming procedures to reduce air in the circuit at the start of surgery, new methods for injecting drugs into the circuit during surgery, and better detection of removal of sources of air during surgery. The review concludes with background on the ultrasonic detection of GME, comparing through-transmission gross air detectors and Doppler ultrasound technology with fixed-beam ultrasonic imaging of emboli, a new ultrasonic technique that images moving emboli in the blood using a single ultrasound transducer element in a fixed position. This overview is meant to shed light on why different ultrasonic detection technologies report widely varying counts and emboli loads, and why fixed-beam ultrasonic imaging represents an improvement in the ability to monitor, measure and quantitate embolic load during CPB.
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Affiliation(s)
- JE Lynch
- Luna Innovations Incorporated, Hampton, VA
| | - JB Riley
- AACP Member Sponsor, Mayo Clinic, Saint Mary’s Hospital, Cardiovascular Perfusion, Rochester, MN
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34
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Voshaar RCO, Purandare N, Hardicre J, McCollum C, Burns A. Asymptomatic spontaneous cerebral emboli and cognitive decline in a cohort of older people: a prospective study. Int J Geriatr Psychiatry 2007; 22:794-800. [PMID: 17192026 DOI: 10.1002/gps.1744] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Asymptomatic spontaneous cerebral emboli (SCE) are common in dementia and are associated with cognitive decline in dementia. The significance of their presence in older people is unknown. METHOD We included 96 participants (mean (SD) age 76.8 (6.7) years, 46% female) who were the control group in a case-control study to evaluate SCE in dementia. Cognitive functioning was assessed prospectively over 2.5 years, using the MMSE and CAMCOG. RESULTS The mean (SD) MMSE score was 28.7 (1.4) at baseline with an average (SD) drop of 0.79 (0.91) per year. The presence of SCE was not related to the annual drop in MMSE score, nor to the CAMCOG score at follow-up (p = 0.88 and p = 0.41, respectively). Linear regression analyses identified higher age in years (beta = 0.29, p = 0.003), history of stroke (beta = 0.31, p = 0.001) and carotid stenosis (beta = 0.28, p = 0.003) as independent predictors of cognitive decline. CONCLUSION We found no association between the presence of SCE and subsequent cognitive decline in older people without dementia.
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Affiliation(s)
- Richard C Oude Voshaar
- University of Manchester, Division of Psychiatry, Education and Research Centre, South Manchester University Hospital, Wythenshawe, Manchester, UK
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35
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Rodriguez RA, Rodriguez CD, Mesana T, Nathan HJ. Distinguishing air from solid emboli using ultrasound: in-vitro study of the effect of Doppler carrier frequency. J Neuroimaging 2007; 17:211-8. [PMID: 17608906 DOI: 10.1111/j.1552-6569.2007.00107.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To compare the ability of the signal relative-intensity and sample-volume-length (SVL) to discriminate air bubbles from solid spheres in an in-vitro model using two different carrier frequencies of the Doppler transducer. METHODS A gel ultrasound phantom was connected to a circuit in which blood-mimicking fluid circulated. Air bubbles (100-140 microm) and latex spheres (125 +/- 10 microm) were injected into the circuit and interrogated using 1- and 2-MHz transducers. High-intensity-transient-signals (HITS) were recorded with a dual-gated transcranial Doppler (TCD) system. Receiver-Operating-Characteristic curves determined the best cut-off points that would distinguish between embolic materials. RESULTS HITS from air bubbles had higher intensities and longer SVL than solid spheres with either transducer (P < .0001). Air bubbles (P < .0001) and microspheres (P= .049) showed higher intensities with the 1-MHz relative to the 2-MHz transducer. The intensity increase with the 1-MHz transducer was greater for air bubbles than microspheres (P < .0001). The discriminating efficacy of both the relative-intensity and SVL was similar between transducers (intensity, P= .201; SVL, P= .98). CONCLUSIONS The relative-intensity and SVL are equally effective to distinguish solid from air emboli using 1- and 2-MHz transducers. Our study indicates that using a lower carrier frequency does not improve the discrimination of air from solid emboli.
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Affiliation(s)
- Rosendo A Rodriguez
- Department of Surgery, Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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36
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Bokeriia LA, Golukhova EZ, Breskina NY, Polunina AG, Davydov DM, Begachev AV, Kazanovskaya SN. Asymmetric Cerebral Embolic Load and Postoperative Cognitive Dysfunction in Cardiac Surgery. Cerebrovasc Dis 2006; 23:50-6. [PMID: 16968987 DOI: 10.1159/000095759] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2006] [Accepted: 06/27/2006] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The aim of the study was to determine the effects of asymmetric cerebral embolic load on cognitive functions. METHODS Thirty-six open heart surgery (OH) and 26 coronary artery bypass grafting (CABG) patients were evaluated by neuropsychological and transcranial Doppler tests. RESULTS OH was associated with a significantly larger microembolic load in comparison to CABG. In OH patients, the microembolic load at the left middle cerebral artery correlated with a verbal memory decline, whereas the microembolic load at the right middle cerebral artery correlated with a nonverbal memory deficit. CABG patients also showed a postoperative verbal memory decline which correlated with cardiopulmonary bypass length but not with microembolic load. CONCLUSION Massive microembolic load during OH induces specific cognitive impairment in accordance to the brain region to which they are delivered. In atherosclerotic patients, the left temporal region is especially prone to perioperative ischemia.
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Affiliation(s)
- Leo A Bokeriia
- A N Bakulev Scientific Center of Cardiovascular Surgery, Russian Academy of Medical Sciences, Moscow, Russia
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Newman MF, Mathew JP, Grocott HP, Mackensen GB, Monk T, Welsh-Bohmer KA, Blumenthal JA, Laskowitz DT, Mark DB. Central nervous system injury associated with cardiac surgery. Lancet 2006; 368:694-703. [PMID: 16920475 DOI: 10.1016/s0140-6736(06)69254-4] [Citation(s) in RCA: 195] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Millions of individuals with coronary artery or valvular heart disease have been given a new chance at life by heart surgery, but the potential for neurological injury is an Achilles heel. Technological advancements and innovations in surgical and anaesthetic technique have allowed us to offer surgical treatment to patients at the extremes of age and infirmity-the group at greatest risk for neurological injury. Neurocognitive dysfunction is a complication of cardiac surgery that can restrict the improved quality of life that patients usually experience after heart surgery. With a broader understanding of the frequency and effects of neurological injury from cardiac surgery and its implications for patients in both the short term and the long term, we should be able to give personalised treatments and thus preserve both their quantity and quality of life. We describe these issues and the controversies that merit continued investigation.
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Affiliation(s)
- Mark F Newman
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 277110, USA.
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Hogue CW, Palin CA, Arrowsmith JE. Cardiopulmonary bypass management and neurologic outcomes: an evidence-based appraisal of current practices. Anesth Analg 2006; 103:21-37. [PMID: 16790619 DOI: 10.1213/01.ane.0000220035.82989.79] [Citation(s) in RCA: 167] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Neurologic complications after cardiac surgery are of growing importance for an aging surgical population. In this review, we provide a critical appraisal of the impact of current cardiopulmonary bypass (CPB) management strategies on neurologic complications. Other than the use of 20-40 microm arterial line filters and membrane oxygenators, newer modifications of the basic CPB apparatus or the use of specialized equipment or procedures (including hypothermia and "tight" glucose control) have unproven benefit on neurologic outcomes. Epiaortic ultrasound can be considered for ascending aorta manipulations to avoid atheroma, although available clinical trials assessing this maneuver are limited. Current approaches for managing flow, arterial blood pressure, and pH during CPB are supported by data from clinical investigations, but these studies included few elderly or high-risk patients and predated many other contemporary practices. Although there are promising data on the benefits of some drugs blocking excitatory amino acid signaling pathways and inflammation, there are currently no drugs that can be recommended for neuroprotection during CPB. Together, the reviewed data highlight the deficiencies of the current knowledge base that physicians are dependent on to guide patient care during CPB. Multicenter clinical trials assessing measures to reduce the frequency of neurologic complications are needed to develop evidence-based strategies to avoid increasing patient morbidity and mortality.
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Affiliation(s)
- Charles W Hogue
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University Medical School, 600 North Wolfe Street, Tower 711, Baltimore, MD 21205, USA.
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Whitaker D, Stygall J, Harrison M, Newman S. Relationship between white cell count, neuropsychologic outcome, and microemboli in 161 patients undergoing coronary artery bypass surgery. J Thorac Cardiovasc Surg 2006; 131:1358-63. [PMID: 16733170 DOI: 10.1016/j.jtcvs.2006.01.042] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2005] [Revised: 10/31/2005] [Accepted: 01/03/2006] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Neuropsychologic impairment remains a problem after coronary artery bypass grafting. Relatively few studies have examined the potential role of the perioperative inflammatory response. This study aimed to determine whether there was any association between perioperative white cell count, microemboli, and cognitive performance after surgical intervention. METHODS White cell count and differential were prospectively measured perioperatively in 161 patients undergoing coronary artery bypass grafting. A neuropsychologic test battery (9 tests) was administered preoperatively and 6 to 8 weeks postoperatively in all 161 patients. Cerebral microemboli during cardiopulmonary bypass were also recorded by means of a transcranial Doppler scan of the right middle cerebral artery. RESULTS There was no correlation between microemboli and white cell counts at any time point. There were weak but significant inverse correlations between both preoperative (r = -0.19, P = .02) and postoperative (r = -0.21, P < .01) white cell count and a measure of overall neuropsychologic test performance (total z change score). There was a weak but significant positive correlation between the neutrophil count 10 minutes after bypass and the intraoperative microemboli count (r = 0.23, P = .01). CONCLUSIONS The correlation between white cell count and neuropsychologic outcome suggests that an inflammatory response might have a role in determining cognitive outcome after coronary artery surgery with cardiopulmonary bypass. The positive correlation between the microemboli during cardiopulmonary bypass and the neutrophil count 10 minutes after bypass is compatible with microemboli contributing to the inflammatory response. The patients' preoperative inflammatory status might also be predictive of the response to surgical intervention.
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Affiliation(s)
- Donald Whitaker
- University College London and University College London Hospitals, London, United Kingdom
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Selnes OA, McKhann GM, Borowicz LM, Grega MA. Cognitive and neurobehavioral dysfunction after cardiac bypass procedures. Neurol Clin 2006; 24:133-45. [PMID: 16443135 DOI: 10.1016/j.ncl.2005.10.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
From a cognitive standpoint, CABG as currently practiced appears to be safe for the great majority of patients, but transient changes involving memory, executive functions, and motor speed may still occur in a subset of patients during the first few days to weeks after CABG. The etiology most likely is multifactorial and includes a synergistic effect of microemboli, hypo-perfusion, and other variables associated with major surgery. Older age and degree of pre-existing cerebrovascular disease have been identified as important risk factors. The short-term cognitive changes appear to be reversible by 3 months after surgery for most patients. Late cognitive decline after CABG,occurring between 1 and 5 years after the surgery, has been well documented,but controlled studies demonstrating that this decline is specifically attributable to the use of cardiopulmonary bypass itself rather than to progression of underlying cerebrovascular disease or other age-related changes are pending.
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Affiliation(s)
- Ola A Selnes
- Department of Neurology, Division of Cognitive Neuroscience, Johns Hopkins University School of Medicine, Reed Hall East-2, 1620 McElderry Street, Baltimore, MD 21287, USA.
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Padanilam BJ. Cerebral Microembolism During AF Ablation: An Innocent Bystander or an Accessory to Brain Injury? J Cardiovasc Electrophysiol 2006; 17:502-3. [PMID: 16684022 DOI: 10.1111/j.1540-8167.2006.00475.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Background and Purpose—
As a result of advances in surgical, anesthetic, and medical management, cardiac surgery can now be performed on older, sicker patients, some of whom have had prior cardiac interventions. As surgical mortality has declined in recent years, attention has focused on the complications of stroke and encephalopathy after cardiac surgery.
Summary of Review—
Patients with preexisting cerebrovascular disease are at increased risk for these untoward neurological outcomes, which are associated with longer lengths of hospital stay, higher costs, and greater mortality. The mechanisms underlying these neurological events may include microemboli and hypoperfusion during surgery, and postoperative atrial fibrillation. Predictive models, based on information available before surgery, allow identification of these “high risk” patients.
Conclusion—
Establishing the degree of functionally significant vascular disease of the brain before surgery should be an essential part of the preoperative evaluation, particularly when modifications in surgical technique or novel neuroprotective agents are being evaluated.
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Affiliation(s)
- Guy M McKhann
- Department of Neurology, The Johns Hopkins University, School of Medicine, Baltimore, MD, USA.
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Butterworth J, Wagenknecht LE, Legault C, Zaccaro DJ, Kon ND, Hammon JW, Rogers AT, Troost BT, Stump DA, Furberg CD, Coker LH. Attempted control of hyperglycemia during cardiopulmonary bypass fails to improve neurologic or neurobehavioral outcomes in patients without diabetes mellitus undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 2005; 130:1319. [PMID: 16256784 DOI: 10.1016/j.jtcvs.2005.02.049] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2004] [Revised: 12/08/2004] [Accepted: 02/28/2005] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Hyperglycemia worsens outcomes in critical illness. This randomized, double-blind, placebo-controlled clinical trial tested whether insulin treatment of hyperglycemia during cardiopulmonary bypass would reduce neurologic, neuro-ophthalmologic, and neurobehavioral outcomes after coronary artery bypass grafting. METHODS Three hundred eighty-one nondiabetic patients undergoing isolated coronary artery bypass grafting were given infusions of insulin or placebo when their blood glucose concentration exceeded 100 mg/dL during cardiopulmonary bypass. The primary outcome measure was the combined incidence of new neurologic, neuro-ophthalmologic, or neurobehavioral deficits or neurologic death observed at 4 to 8 days postoperatively. This same measure was assessed secondarily at 6 weeks and 6 months. Length of hospital stay was also compared as a secondary assessment. RESULTS The 2 groups were well matched at baseline. The insulin-treated group had significantly lower blood glucose concentrations during bypass. Sixty-six percent of subjects in the insulin-treated group and 67% of subjects in the control group demonstrated a new or worsening neurologic, neuro-ophthalmologic, or neurobehavioral deficit or neurologic death at the 4- to 8-day assessment. Outcomes were also similar in the 2 groups at 6 weeks (37% and 39% incidence, respectively) and 6 months (30% and 25%, respectively). Median lengths of stay were 7 and 6 days, respectively, in the treatment and control groups. None of these outcome differences was statistically significant. CONCLUSION Attempted control of hyperglycemia during cardiopulmonary bypass had no significant effect on the combined incidence of neurologic, neuro-ophthalmologic, or neurobehavioral deficits or neurologic death and failed to shorten the length of hospital stay. These results do not contradict those of other studies showing that aggressive control of hyperglycemia in the postoperative period will improve outcome.
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Affiliation(s)
- John Butterworth
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1009, USA.
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Bokeriia LA, Golukhova EZ, Polunina AG, Davydov DM, Begachev AV. Neural correlates of cognitive dysfunction after cardiac surgery. ACTA ACUST UNITED AC 2005; 50:266-74. [PMID: 16198423 DOI: 10.1016/j.brainresrev.2005.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2005] [Revised: 07/29/2005] [Accepted: 08/01/2005] [Indexed: 10/25/2022]
Abstract
Patients who underwent cardiac surgery and their relatives often complain on postoperative memory impairment. Most prospective neuropsychological studies also found postoperative cognitive decline early after surgery. Nevertheless, recently several reports questioned the existence of long-term brain alterations in these patient cohorts. The present review was aimed to clear up the true cardiac surgery effects on brain and cognitive functions. The reviewed data evidence that cardiac surgery interventions induce persistent localized brain ischemic lesions along with rapidly reversing global brain swelling and decreased metabolism. A range of studies showed that left temporal region was especially prone to perioperative ischemic injury, and these findings might explain persistent verbal short-term memory decline in a considerable proportion of cardiac surgery patient cohorts. Speed/time of cognitive performance is commonly decreased early after on-pump surgery either. Nevertheless, no association between psychomotor speed slowing and intraoperative embolic load was found. The rapid recovery of the latter cognitive domain might be better explained by surgery related acute global brain metabolism changes rather than ischemic injury effects. Hence, analyses of performance on separate cognitive tests rather than summarized cognitive indexes are strongly recommended for future neuropsychological studies of cardiac surgery outcomes.
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Affiliation(s)
- Leo A Bokeriia
- A. N. Bakulev Scientific Center of Cardiovascular Surgery, Russian Academy of Medical Sciences, Moscow, Russia
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Abstract
Both short- and long-term cognitive changes continue to occur after coronary artery bypass grafting (CABG), but the pathophysiology of these neurobehavioral changes remains incompletely understood. The persistence of mild postoperative neurocognitive changes despite multiple improvements in the cardiopulmonary bypass procedure may be partially because of surgical populations being older and having more prevalent comorbid disease. The cause of the early postoperative changes is most likely multifactorial and may include ischemic injury from microemboli, hypoperfusion, and other factors resulting from major surgery. Several lines of evidence suggest that the late cognitive decline between 1 and 5 years after surgery may be secondary to high rates of cerebrovascular disease among candidates for CABG. A history of hypertension and other risk factors for vascular disease is known to be associated with increased risk for long-term cognitive decline in community-dwelling elderly individuals. Cerebrovascular risk factors are also associated with silent magnetic resonance imaging abnormalities in patients undergoing CABG. Thus, whereas both short- and long-term postoperative cognitive changes have been associated with CABG, only the short-term, transient changes appear to be directly related to the use of cardiopulmonary bypass.
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Affiliation(s)
- Ola A Selnes
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Durchführung einer nahtlosen Anastomose für aortale Venengraftanschlüsse führt nicht zu einer Verbesserung des neuropsychologischen Outcomes. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2004. [DOI: 10.1007/s00398-004-0470-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Whitaker DC. Carbon dioxide insufflation on the number and behavior of air microemboli in open-heart surgery. Circulation 2004; 110:e55-6; author reply e55-6. [PMID: 15289397 DOI: 10.1161/01.cir.0000141262.91992.f1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Hogue CW, Lillie R, Hershey T, Birge S, Nassief AM, Thomas B, Freedland KE. Gender influence on cognitive function after cardiac operation. Ann Thorac Surg 2003; 76:1119-25. [PMID: 14529997 DOI: 10.1016/s0003-4975(03)00817-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Women are at higher risk than men for stroke after cardiac operation. The purpose of this study was to evaluate for gender influences on the more common postoperative neurologic complication, cognitive dysfunction. METHODS A standard battery of neuropsychological tests was administered to 117 patients (79 men and 38 women) the day before and again 4 to 6 weeks after cardiac operation. The battery assessed a broad array of cognitive domains, including attention, memory, executive function, and psychomotor processing speed. Analysis was performed only on patients with data from both testing sessions. Data were analyzed to assess for a dichotomous definition of postoperative cognitive impairment and to evaluate for factors influencing test results for specific cognitive domains. RESULTS The frequency of one standard deviation decline on two or more cognitive tests compared with preoperative results (women, 10.7 % versus men, 9.9 %; p = 0.527), no decline, or one standard deviation improvement on each test postoperatively was no different between genders. After adjusting for age, gender, preexisting medical conditions, level of attained education, preoperative cognitive tests results, type of operation, and duration of cardiopulmonary bypass, female gender was independently associated with poorer performance postoperatively on visuospatial tasks. Other variables significantly related to postoperative cognitive function varied among the specific cognitive domains. CONCLUSIONS These data suggest that, although the frequency of cognitive dysfunction after cardiac operation is similar for women and men, women appear more likely to suffer injury to brain areas subserving visuospatial processing. Risk factors for postoperative cognitive impairment vary depending on cognitive domain, suggesting multiple etiologies for this form of perioperative neurologic injury.
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Affiliation(s)
- Charles W Hogue
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Scott DA, Silbert BS, Doyle TJ, Blyth C, Borton MC, O'brien JL, de L Horne DJ. Centrifugal versus roller head pumps for cardiopulmonary bypass: effect on early neuropsychologic outcomes after coronary artery surgery. J Cardiothorac Vasc Anesth 2002; 16:715-22. [PMID: 12486652 DOI: 10.1053/jcan.2002.128413] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To test the hypothesis that routine use of a centrifugal pump in the cardiopulmonary bypass circuit would result in a lower incidence of early neuropsychologic deficit when compared with conventional roller pumps. DESIGN Prospective, randomized, double-blind. SETTING University teaching hospital. PARTICIPANTS Patients (n = 103) scheduled for elective coronary artery surgery. INTERVENTIONS Patients were randomized into group C (centrifugal pump for cardiopulmonary bypass; n = 54) and group R (roller pump for cardiopulmonary bypass; n = 49). MEASUREMENTS AND MAIN RESULTS A neuropsychologic test battery of 6 standard tests was administered before surgery and 5 days after surgery. An abnormal test result was defined as deterioration by >1 group SD from an individual's preoperative test performance. There were no significant differences between groups in preoperative or surgical parameters, intensive care unit stay, or hospital stay. There were no significant differences in the incidence of neuropsychologic deficit for patients with a deficit in at least 1 test (group C, 33%; group R, 51%; odds ratio, 0.48; 95% confidence interval, 0.22 to 1.06) or patients with a deficit in >/=2 tests (group C, 6%; group R, 18%; odds ratio, 0.26; 95% confidence interval, 0.07 to 1.03). In group R, there were more individual test deficits per patient than in group C (p = 0.04). CONCLUSION There was no significant difference in the incidence of neuropsychologic deficit postoperatively with routine use of centrifugal pumps. The larger number of individual test deficits in the roller pump group suggest that further studies to assess the potential neuropsychologic benefits of the use of centrifugal pumps are warranted.
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Affiliation(s)
- David A Scott
- Center for Anaesthesia and Cognitive Function, Department of Anaesthesia and Intensive Care, St. Vincent's Hospital, Melbourne, Australia.
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Willcox TW, van Uden R. Best Practice for Cardiopulmonary Bypass in the High-Risk Elderly Patient. Semin Cardiothorac Vasc Anesth 2002. [DOI: 10.1177/108925320200600403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The management of cardiopulmonary bypass has evolved over the last 50 years resulting in a largely consistent approach to both adult and pediatric perfusion. Very little has been written or prospectively researched on the best practice for cardiopulmonary bypass in the high-risk elderly patient, despite the challenge this patient cohort presents compared to the general adult population and the rapidly increasing number of such patients undergoing cardiac surgery. We propose a framework for perfusion strategies for the high-risk elderly patient from our current understanding of cardiopulmonary bypass. It should stimulate discussion for a consensus on perfusion strategies for the elderly and encourage further research into perfusion variables as they relate to the outcome of patients of advanced age.
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Affiliation(s)
- Timothy W. Willcox
- Department of Clinical Perfusion, Level 2 Building 4, Green Lane Hospital, Green Lane West, Auckland 1006, New Zealand
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