Neurocognitive and neuroanatomic changes after off-pump versus on-pump coronary artery bypass grafting: Long-term follow-up of a randomized trial

Effects of short-term preoperative intranasal dexmedetomidine plus conventional treatment on delirium following cardiac surgery in patients with sleep disorders

STUDY OBJECTIVES

To assess whether preoperative dexmedetomidine (DEX) nasal drips combined with conventional treatment could mitigate the occurrence of postoperative delirium (POD).

DESIGN

A prospective randomised controlled study.

SETTING

The cardiac surgery intensive care unit (CSICU) and patient hospitalisation ward at a university hospital.

PARTICIPANTS

A total of 100 patients (aged ≥60 years) undergoing cardiac surgery at a university hospital between 7 January 2022, and 30 November 2022 met the eligibility criteria and were included in the study.

INTERVENTIONS

Patients with sleep disorders (Pittsburgh Sleep Quality Index ≥8) were divided into two groups: Group A (the placebo group, n=50), receiving a short-term preoperative placebo combined with conventional treatment and Group B (the DEX group, n=50), receiving short-term preoperative DEX combined with conventional treatment.

MEASUREMENTS AND RESULTS

The Confusion Assessment Method for the ICU (CAM-ICU) was used for POD assessment in the CSICU, while the CAM was employed to assess delirium in the patient ward. Group B demonstrated a reduced incidence of POD compared to Group A (12% vs. 30%, odds ratio: 0.318, 95% confidence interval: 0.112-0.905, p=0.027).

CONCLUSION

The combined treatment involving DEX demonstrated a decreased incidence of POD in elderly individuals with sleep disorders undergoing cardiac surgery compared to the placebo combination treatment.

TRIAL REGISTRATION

URL: www.chictr.org.cn with registration number ChiCTR 2100043968, registered on 06/03/2021.

Effect of different coronary artery revascularization procedures on cognition: A systematic review

Coronary revascularization interventions have been associated with post-intervention cognitive decline. Hence, this systematic review aims to compare the long-term effects of different coronary revascularization interventions on cognition. The Cochrane Library and MEDLINE databases were searched for articles published between January 2009 and January 2023. Articles on clinical trials and cohort studies that compared at least two different interventions with a minimum three months follow up were included to evaluate the consequences of different intervention techniques on cognition. Each selected study was evaluated using a revised tool to assess the risk of bias in randomized trials (RoB 2), and Risk of Bias In Non-Randomized Studies - of Interventions(ROBINS-1) was used for evaluating non-randomized studies. Five eligible studies, with four different comparisons, were included. Out of these studies, three RCTs and two cohort studies were included A participants gone through different procedures; on-pump and off-pump coronary artery bypass grafting (CABG), Percutaneous coronary intervention (PCI conventional cardiopulmonary bypass (CCPB), the miniaturized cardiopulmonary bypass (MCPB) and endoscopic coronary artery bypass grafting (Endo-CABG). These comparisons showed that different interventions have different effects on cognition; however, there is no solid evidence of correlations between them. Thus, the results of this review suggest that there should be greater focus on comparing interventions and that a reasonable follow-up duration should be set to avoid the influence of confounders. There is also a need to determine the effect of long-term cognitive decline while reducing interference by other variables.

Impact of access route to the left ventricle on asymptomatic periprocedural brain injury: the results of a randomized trial in patients undergoing catheter ablation of ventricular tachycardia

AIMS

Catheter ablation of ventricular tachycardia (VT) is an effective treatment in patients with structural heart disease (SHD) and recurrent arrhythmias. However, the procedure is associated with the risk of complications, including both manifest and asymptomatic cerebral thromboembolic events. We hypothesized that periprocedural asymptomatic brain injury (ABI) can be reduced by using transseptal instead of the retrograde access route to the left ventricle (LV).

METHODS AND RESULTS

Consecutive patients undergoing VT ablation for SHD were randomized 1:1 to either retrograde or transseptal LV access. All patients underwent radiofrequency ablation in conscious sedation with the use of an irrigated tip catheter. The degree of brain damage was evaluated by serum level of biomarker S100B. Significant ABI was defined as a post-ablation relative increase of S100B level >30%. A total of 144 patients (66 ± 9 years; 14 females; 90% coronary artery disease; LV ejection fraction: 30 ± 8%) were enrolled and 72 were allocated to each study groups. Symptomatic neurological complication of the procedure was not observed in any subject. A significant ABI was detected in 19.4% of patients. It was more commonly observed in subjects randomized to retrograde vs. transseptal LV access (26.4% vs. 12.5%, P = 0.04). In a multivariate analysis, only retrograde LV access and advanced age were independent determinants of significant ABI.

CONCLUSION

Significant ABI after ablation of VT in patients with SHD can be detected in one-fifth of subjects. Retrograde access to LV is associated with a two-fold higher probability of significant ABI.

Anesthesia and Cognitive Outcome in Elderly Patients: A Narrative Viewpoint

Better ways to manage preoperative, intraoperative and postoperative care of surgical patients is the bailiwick of anesthesiologists. Although we care for patients of all ages, protecting the cognitive capacity of elderly patients more frequently requires procedures and practices that go beyond routine care for nonelderly adults. This narrative review will consider current understanding of the reasons that elderly patients need enhanced care, and recommendations for that care based on established and recent empirical research. In that latter regard, unless and until we are able to classify anesthetic neurotoxicity as a rare complication, the first-do-no-harm approach should: (1) add anesthesia to surgical intervention on the physiological cost side of the cost/benefit ratio when making decisions about whether and when to proceed with surgery; (2) minimize anesthetic depth and periods of electroencephalographic suppression; (3) limit the duration of continuous anesthesia whenever possible; (4) consider the possibility that regional anesthesia with deep sedation may be as neurotoxic as general anesthesia; and (5) when feasible, use regional anesthesia with light or no sedation.

Cognitive function in patients with coronary artery disease: A literature review

Objective Cognitive function impairment is a well-documented complication of cerebrovascular disease (CBVD). Less is known about what factors affect the deterioration of cognitive function in patients with coronary artery disease (CAD). The aim of this review is to explore recent studies investigating factors associated with cognitive function in patients with CAD. Methods Studies published from 2010 to 2016 were identified through a systematic search of MEDLINE/PubMed and were included if they addressed factors affecting cognitive function in the CAD population. Results Of the 227 publications identified, 32 were selected for the review. Five factors tentatively affecting cognitive function in patients with CAD were identified: coronary artery bypass grafting (CABG) surgery, apolipoprotein E4 (APOE4) genotype, left ventricular ejection fraction (LVEF), medication use, and various hormones and biomarkers. Conclusion New techniques in CABG surgery have proven to alleviate postoperative cognitive decline. Researchers are still debating the effects of APOE4 genotype, LVEF, and the use of cardiovascular medications on cognitive function. Thyroid hormones and biomarkers are associated with cognitive function, but the exact nature of the association is debatable. Longitudinal studies should clarify those associations. In addition, cross-sectional studies addressing other causes of cognitive decline in patients with CAD are warranted.

Operative strategies to reduce cerebral embolic events during on- and off-pump coronary artery bypass surgery: A stratified, prospective randomized trial

OBJECTIVE

To determine the impact of different aortic clamping strategies on the incidence of cerebral embolic events during coronary artery bypass grafting (CABG).

METHODS

Between 2012 and 2015, 142 patients with low-grade aortic disease (epiaortic ultrasound grade I/II) undergoing primary isolated CABG were studied. Those undergoing off-pump CABG were randomized to a partial clamp (n = 36) or clampless facilitating device (CFD; n = 36) strategy. Those undergoing on-pump CABG were randomized to a single-clamp (n = 34) or double-clamp (n = 36) strategy. Transcranial Doppler ultrasonography (TCD) was performed to identify high-intensity transient signals (HITS) in the middle cerebral arteries during periods of aortic manipulation. Neurocognitive testing was performed at baseline and 30-days postoperatively. The primary endpoint was total number of HITS detected by TCD. Groups were compared using the Mann-Whitney U test.

RESULTS

In the off-pump group, the median number of total HITS were higher in the CFD subgroup (30.0; interquartile range [IQR], 22-43) compared with the partial clamp subgroup (7.0; IQR, 0-16; P < .0001). In the CFD subgroup, the median number of total HITS was significantly lower for patients with 1 CFD compared with patients with >1 CFD (12.5 [IQR, 4-19] vs 36.0 [IQR, 25-47]; P = .001). In the on-pump group, the median number of total HITS was 10.0 (IQR, 3-17) in the single-clamp group, compared with 16.0 (IQR, 4-49) in the double-clamp group (P = .10). There were no differences in neurocognitive outcomes across the groups.

CONCLUSIONS

For patients with low-grade aortic disease, the use of CFDs was associated with an increased rate of cerebral embolic events compared with partial clamping during off-pump CABG. A single-clamp strategy during on-pump CABG did not significantly reduce embolic events compared with a double-clamp strategy.

The impact of off-pump surgery in end-organ function: practical end-points

Most surgeons perform coronary bypass surgery with the aid of cardiopulmonary bypass, which inflicts a massive systemic inflammatory response to the body leading to adverse clinical outcome. In an attempt to make CABG less invasive, interest have been diverted to the off pump technique.

The current review attempts to bring an insight onto the last ten years knowledge on the off-pump impact in end organ function, with an aim to draw some clear conclusions in order to allow practitioners to reflect on the subject.

Is type 2 diabetes related to leukoaraiosis? an updated review

A significantly increased interest has been dedicated to the study of the effects of diabetes mellitus (DM) on the brain. DM is associated with an increased risk of stroke and cognitive decline. In patients with DM, neuroimaging discloses with high-frequency structural changes, such as cerebral atrophy, infarcts and white matter lesions, also called leukoaraiosis (LA), an expression of small vessel disease. A previous review showed a relation between DM and both cerebral atrophy and lacunar infarcts, while the question about the relation between DM and LA remained unanswered. In this review, we provide an update on data on this last association. In the reviewed studies, we examined the presence of DM, other disease characteristics, such as duration and complications, and laboratory markers of the disease such as blood glycated hemoglobin (HbA1c), insulin resistance, insulin concentrations and their association with LA. About 40% of the reviewed studies reported a statistically significant association between DM and LA. Long-standing DM and a poor glycemic control were associated with severe LA. Studies using innovative MRI techniques, such as diffusion tensor imaging (DTI), reported a significant association between microstructural white matter alterations and DM. This review highlights more firmly than previously reported the existence of a relation between DM and both presence and severity of LA. These results are possibly due to more sensitive and advanced imaging techniques recently used to study the extent of LA. However, because of the heterogeneous methodology used in the reviewed studies, a definitive conclusion cannot be drawn.