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Dąbrowski EJ, Kurasz A, Pasierski M, Pannone L, Kołodziejczak MM, Raffa GM, Matteucci M, Mariani S, de Piero ME, La Meir M, Maesen B, Meani P, McCarthy P, Cox JL, Lorusso R, Kuźma Ł, Rankin SJ, Suwalski P, Kowalewski M. Surgical Coronary Revascularization in Patients With Underlying Atrial Fibrillation: State-of-the-Art Review. Mayo Clin Proc 2024; 99:955-970. [PMID: 38661599 DOI: 10.1016/j.mayocp.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/30/2023] [Accepted: 12/14/2023] [Indexed: 04/26/2024]
Abstract
The number of individuals referred for coronary artery bypass grafting (CABG) with preoperative atrial fibrillation (AF) is reported to be 8% to 20%. Atrial fibrillation is a known marker of high-risk patients as it was repeatedly found to negatively influence survival. Therefore, when performing surgical revascularization, consideration should be given to the concomitant treatment of the arrhythmia, the clinical consequences of the arrhythmia itself, and the selection of adequate surgical techniques. This state-of-the-art review aimed to provide a comprehensive analysis of the current understanding of, advancements in, and optimal strategies for CABG in patients with underlying AF. The following topics are considered: stroke prevention, prophylaxis and occurrence of postoperative AF, the role of surgical ablation and left atrial appendage occlusion, and an on-pump vs off-pump strategy. Multiple acute complications can occur in patients with preexisting AF undergoing CABG, each of which can have a significant effect on patient outcomes. Long-term results in these patients and the future perspectives of this scientific area were also addressed. Preoperative arrhythmia should always be considered for surgical ablation because such an approach improves prognosis without increasing perioperative risk. While planning a revascularization strategy, it should be noted that although off-pump coronary artery bypass provides better short-term outcomes, conventional on-pump approach may be beneficial at long-term follow-up. By collecting the current evidence, addressing knowledge gaps, and offering practical recommendations, this state-of-the-art review serves as a valuable resource for clinicians involved in the management of patients with AF undergoing CABG, ultimately contributing to improved outcomes and enhanced patient care.
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Affiliation(s)
- Emil J Dąbrowski
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Anna Kurasz
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Michał Pasierski
- Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Michalina M Kołodziejczak
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Anesthesiology and Intensive Care, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, Antoni Jurasz University Hospital No.1, Bydgoszcz, Poland
| | - Giuseppe M Raffa
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Matteo Matteucci
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Silvia Mariani
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands; Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Maria E de Piero
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Mark La Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Bart Maesen
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Paolo Meani
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico, San Donato Milanese, Milan, Italy
| | - Patrick McCarthy
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL
| | - James L Cox
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Scott J Rankin
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown
| | - Piotr Suwalski
- Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Mariusz Kowalewski
- Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy; Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.
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Jaffar-Karballai M, Kayali F, Botezatu B, Satti DI, Harky A. The Rationalisation of Intra-Operative Imaging During Cardiac Surgery: A Systematic Review. Heart Lung Circ 2023; 32:567-586. [PMID: 36870922 DOI: 10.1016/j.hlc.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 03/05/2023]
Abstract
INTRODUCTION One critical complication of cardiac surgery is cerebrovascular accidents (CVAs). Ascending aorta atherosclerosis poses a significant risk of embolisation to distal vessels and to cerebral arteries. Epi-aortic ultrasonography (EUS) is thought to offer a safe, high-quality accurate visualisation of the diseased aorta to guide the surgeon on the best surgical approach to the planned procedure and potentially improve neurological outcomes post-cardiac surgery. METHOD The authors conducted a comprehensive search of PubMed, Scopus and Embase. Studies that reported on epi-aortic ultrasound use in cardiac surgery were included. Major exclusion criteria were: (1) abstracts, conference presentations, editorials, literature reviews; (2) case series with <5 participants; (3) epi-aortic ultrasound in trauma or other surgeries. RESULTS A total of 59 studies and 48,255 patients were included in this review. Out of the studies that reported patient co-morbidities prior to cardiac surgery, 31.6% had diabetes, 59.5% had hyperlipidaemia and 66.1% had a diagnosis of hypertension. Of those that reported significant ascending aorta atherosclerosis found on EUS, this ranged from 8.3% of patients to 95.2% with a mean percentage of 37.8%. Hospital mortality ranged from 7% to 13%; four studies reported zero deaths. Long-term mortality and stroke rate varied significantly with hospital duration. CONCLUSION Current data have shown EUS to have superiority over manual palpation and transoesophageal echocardiography in the prevention of CVAs following cardiac surgery. Yet, EUS has not been implemented as a routine standard of care. Extensive adoption of EUS in clinical practice is warranted to aid large, randomised trials before making prospective conclusions on the efficacy of this screening method.
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Affiliation(s)
| | - Fatima Kayali
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Bianca Botezatu
- Queen's University Belfast, School of Medicine, Dentistry and Biomedical Sciences, Belfast, Northern Ireland
| | - Danish Iltaf Satti
- Shifa College of Medicine, Shifa Tameer-e-millat University, Islamabad, Pakistan
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.
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Ioannou S, Braun C, Hartrumpf M, Kühnel RU, Vafa A, Schröter F, Albes J. CALA: Cumulative Volume of Calcified Lesions of the Aorta in Cardiac Surgery. Thorac Cardiovasc Surg 2022; 70:630-636. [PMID: 35817061 DOI: 10.1055/s-0042-1748194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
One of the major key questions raised in this retrospective study was to identify any correlation of atherosclerotic plaque volume of the ascending aorta and aortic arch with adverse events such as postoperative stroke, critical illness polyneuropathy and myopathy, as well as delirium and all-cause in-hospital mortality. In a second phase of this study, we investigated the relationship between atherosclerotic plaque volume and adverse events regarding the construction of proximal anastomosis on coronary artery bypass grafting procedures using different clamping techniques such as construction of anastomosis on cross-clamping or cross-clamping plus consecutive partial clamping of the aorta. The key findings of our research were that the size of calcium lesions of the ascending aorta and aortic arch correlates with early mortality, critical illness polyneuropathy/myopathy, and delirium but not with stroke. On the other hand, there were no significant differences between isolated cross-clamping versus cross-clamping plus consecutive partial clamping of the aorta regarding the primary adverse events by means of mean plaque volume.
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Affiliation(s)
- Stelios Ioannou
- Department of Cardiovascular Surgery, Heart Center Brandenburg, University Hospital Brandenburg Medical School, Faculty of Health Sciences Brandenburg, Bernau, Germany
| | - Christian Braun
- Department of Cardiovascular Surgery, Heart Center Brandenburg, University Hospital Brandenburg Medical School, Faculty of Health Sciences Brandenburg, Bernau, Germany
| | - Martin Hartrumpf
- Department of Cardiovascular Surgery, Heart Center Brandenburg, University Hospital Brandenburg Medical School, Faculty of Health Sciences Brandenburg, Bernau, Germany
| | - Ralf-Uwe Kühnel
- Department of Cardiovascular Surgery, Heart Center Brandenburg, University Hospital Brandenburg Medical School, Faculty of Health Sciences Brandenburg, Bernau, Germany
| | - Ali Vafa
- Department of Cardiovascular Surgery, Heart Center Brandenburg, University Hospital Brandenburg Medical School, Faculty of Health Sciences Brandenburg, Bernau, Germany
| | - Filip Schröter
- Department of Cardiovascular Surgery, Heart Center Brandenburg, University Hospital Brandenburg Medical School, Faculty of Health Sciences Brandenburg, Bernau, Germany
| | - Johannes Albes
- Department of Cardiovascular Surgery, Heart Center Brandenburg, University Hospital Brandenburg Medical School, Faculty of Health Sciences Brandenburg, Bernau, Germany
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Letsou GV, Musfee FI, Zhang Q, Loor G, Lee AD. Stroke and mortality rates after off-pump vs. pump-assisted/no-clamp coronary artery bypass grafting. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:742-748. [PMID: 36168952 DOI: 10.23736/s0021-9509.22.12337-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Ascending aorta manipulation during on-pump coronary artery bypass grafting (CABG) surgery can release embolic matter and may cause stroke. Strategies for lowering the stroke rate associated with coronary artery bypass grafting surgery include off-pump surgery without cardiopulmonary bypass and pump-assisted surgery with minimal aortic manipulation (i.e., without aortic cross-clamping). We examined whether one approach is superior to the other in reducing stroke and perioperative mortality rates. METHODS We reviewed consecutive elective, urgent, and emergency off-pump/no-bypass and pump-assisted/no-clamp coronary artery bypass grafting procedures performed by a single surgeon at our institution from June 2011 through October 2017. RESULTS Of 570 patients analyzed, 395 (69.3%) underwent off-pump/no-bypass surgery, 43 (7.5%) underwent pump-assisted/no-clamp surgery, and 132 (23.2%) transitioned mid-procedure from off-pump/no-bypass to pump-assisted/no-clamp surgery. Patients who were >70 years old, were female, or had diabetes, cardiomegaly, or a history of myocardial infarction or congestive heart failure were more likely to undergo pump-assisted/no-clamp surgery or the combined technique. None of the pump-assisted/no-clamp patients had a stroke, versus 0.3% of the off-pump/no-bypass patients and 0.8% of the combination patients. Stroke and in-hospital mortality rates did not differ by technique. CONCLUSIONS A hybrid strategy incorporating off-pump, pump-assisted, and combined off-pump/pump-assisted techniques achieved very low stroke rates in patients undergoing coronary revascularization. Perioperative mortality was similar for all three techniques. Avoiding aortic clamping may be crucial for decreasing CABG-related stroke rates. Off-pump/no-bypass surgery had no significant advantage over the pump-assisted/no-clamp or combined techniques in reducing the stroke rate after coronary artery bypass grafting surgery.
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Affiliation(s)
- George V Letsou
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Cardiothoracic Transplantation and Circulatory Support, Texas Heart Institute, Houston, TX, USA
| | - Fadi I Musfee
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UT Health School of Public Health, Houston, TX, USA
| | - Qianzi Zhang
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Gabriel Loor
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Division of Cardiothoracic Transplantation and Circulatory Support, Texas Heart Institute, Houston, TX, USA
| | - Andrew D Lee
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
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Avances en cirugía coronaria. Cirugía coronaria sin bomba y sin manipulación de la aorta ascendente. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Roth S, Moss HE, Vajaranant TS, Sweitzer B. Perioperative Care of the Patient with Eye Pathologies Undergoing Nonocular Surgery. Anesthesiology 2022; 137:620-643. [PMID: 36179149 PMCID: PMC9588701 DOI: 10.1097/aln.0000000000004338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The authors reviewed perioperative ocular complications and implications of ocular diseases during nonocular surgeries. Exposure keratopathy, the most common perioperative eye injury, is preventable. Ischemic optic neuropathy, the leading cause of perioperative blindness, has well-defined risk factors. The incidence of ischemic optic neuropathy after spine fusion, but not cardiac surgery, has been decreasing. Central retinal artery occlusion during spine fusion surgery can be prevented by protecting eyes from compression. Perioperative acute angle closure glaucoma is a vision-threatening emergency that can be successfully treated by rapid reduction of elevated intraocular pressure. Differential diagnoses of visual dysfunction in the perioperative period and treatments are detailed. Although glaucoma is increasingly prevalent and often questions arise concerning perioperative anesthetic management, evidence-based recommendations to guide safe anesthesia care in patients with glaucoma are currently lacking. Patients with low vision present challenges to the anesthesia provider that are becoming more common as the population ages.
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Affiliation(s)
- Steven Roth
- Department of Anesthesiology, University of Illinois at Chicago, College of Medicine, Chicago, Illinois
| | - Heather E Moss
- Departments of Ophthalmology and Neurology & Neurologic Sciences, Stanford University, Palo Alto, California
| | - Thasarat Sutabutr Vajaranant
- Department of Ophthalmology and Visual Science, University of Illinois at Chicago, College of Medicine, Chicago, Illinois
| | - BobbieJean Sweitzer
- University of Virginia, Charlottesville, Virginia; Perioperative Medicine, Inova Health System, Falls Church, Virginia
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Spanjersberg AJ, Ottervanger JP, Nierich AP, Hoogendoorn M, Bruinsma GJBB. Mortality Reduction After a Preincision Safety Check Before Cardiac Surgery: Is It the Aorta? J Cardiothorac Vasc Anesth 2022; 36:2954-2960. [PMID: 35288024 DOI: 10.1053/j.jvca.2022.01.047] [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: 11/17/2021] [Revised: 01/13/2022] [Accepted: 01/29/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The introduction and use of a preincision safety check were associated with lower mortality after mixed adult cardiac surgery; however, an explanatory mechanism is lacking. Stroke, one of the most severe complications after cardiac surgery, with high mortality, may be reduced by adapting the surgical handling of the ascending aorta. This study assessed the prevalence and predictors of this adaptation after a preincision safety check and the subsequent effect on outcome. DESIGN A prospective, single-center, observational study comparing adaptation with no-adaptation. The primary outcome measure was 30-day mortality. Multivariate analyses were performed to determine independent predictors of adaptation. To study the effect of adaptation on outcome, a propensity score-matched cohort was constructed in a 1:3 intervention:control ratio. SETTING At Isala Zwolle (NL), a large, nonacademic teaching hospital. PARTICIPANTS All consecutive cardiac surgery procedures from 2012 until 2015, including 4,752 surgeries. INTERVENTIONS The adaptation of surgical handling of the ascending aorta. MEASUREMENTS AND MAIN RESULTS In 283 cardiac surgeries (5.9%), adaptation was indicated. The most important independent predictors for adaptation were extracardiac atherosclerosis, current smoking, and increasing age. In the propensity score-matched cohort consisting of 1,069 procedures, there were no significant differences in outcome. After correction for propensity score, the hazard ratio of adaptation for 30-day mortality was 1.8 (0.85-3.79). CONCLUSIONS The adaptation of aortic surgical handling after a preincision safety check was necessary for 5.9% of cardiac surgeries, with extracardiac atherosclerosis as the strongest predictor. Outcome was not significantly different between patients with and without adaptation. Although promising, it remains unclear whether adaptation may fully explain mortality reduction after the use of a preincision safety check.
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Affiliation(s)
- Alexander J Spanjersberg
- Division Cardiothoracic Anesthesiology, Department of Anesthesiology and Intensive Care, Isala Heart Centre, Isala Zwolle, The Netherlands.
| | | | - Arno P Nierich
- Division Cardiothoracic Anesthesiology, Department of Anesthesiology and Intensive Care, Isala Heart Centre, Isala Zwolle, The Netherlands
| | - Marga Hoogendoorn
- Division Cardiothoracic Anesthesiology, Department of Anesthesiology and Intensive Care, Isala Heart Centre, Isala Zwolle, The Netherlands
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MacKay EJ, Zhang B, Augoustides JG, Groeneveld PW, Desai ND. Association of Intraoperative Transesophageal Echocardiography and Clinical Outcomes After Open Cardiac Valve or Proximal Aortic Surgery. JAMA Netw Open 2022; 5:e2147820. [PMID: 35138396 PMCID: PMC8829659 DOI: 10.1001/jamanetworkopen.2021.47820] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Intraoperative transesophageal echocardiography (TEE) is used frequently in cardiac valve and proximal aortic surgical procedures, but there is a lack of evidence associating TEE use with improved clinical outcomes. OBJECTIVE To test the association between intraoperative TEE use and clinical outcomes following cardiac valve or proximal aortic surgery. DESIGN, SETTING, AND PARTICIPANTS This matched, retrospective cohort study used national registry data from the Society of Thoracic Surgeon (STS) Adult Cardiac Surgery Database (ACSD) to compare clinical outcomes among patients undergoing cardiac valve or proximal aortic surgery with vs without intraoperative TEE. Statistical analyses used optimal matching within propensity score calipers to conduct multiple matched comparisons including within-hospital and within-surgeon matches, a negative control outcome analysis, and sensitivity analyses. STS ACSD data encompasses more than 90% of all hospitals that perform cardiac surgery in the US. The study cohort consisted of all patients aged at least 18 years undergoing open cardiac valve repair or replacement surgery and/or proximal aortic surgery between 2011 and 2019. Statistical analysis was performed from October 2020 to April 2021. EXPOSURES The exposure was receipt of intraoperative TEE during the cardiac valve or proximal aortic surgery. MAIN OUTCOMES AND MEASURES The primary outcome was death within 30 days of surgery. The secondary outcomes were (1) a composite outcome of stroke or 30-day mortality and (2) a composite outcome of reoperation or 30-day mortality. RESULTS Of the 872 936 patients undergoing valve or aortic surgery, 540 229 (61.89%) were male; 63 565 (7.28%) were Black and 742 384 (85.04%) were White; 711 326 (81.5%) received TEE and 161 610 (18.5%) did not receive TEE; the mean (SD) age was 65.61 years (13.17) years. After matching, intraoperative TEE was significantly associated with a lower 30-day mortality rate compared with no TEE: 3.81% vs 5.27% (odds ratio [OR], 0.69 [95% CI, 0.67-0.72]; P < .001), a lower incidence of stroke or 30-day mortality: 5.56% vs 7.01% (OR, 0.77 [95% CI, 0.74-0.79]; P < .001), and a lower incidence of reoperation or 30-day mortality: 7.18% vs 8.87% (OR, 0.78 [95% CI, 0.76-0.80]; P < .001). Results were similar across all matched comparisons (including within-hospital, within-surgeon matched analyses) and were robust to a negative control and sensitivity analyses. CONCLUSIONS AND RELEVANCE Among adults undergoing cardiac valve or proximal aortic surgery, intraoperative TEE use was associated with improved clinical outcomes in this cohort study. These findings support routine use of TEE in these procedures.
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Affiliation(s)
- Emily J. MacKay
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Penn Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia
- Penn’s Cardiovascular Outcomes, Quality and Evaluative Research Center (CAVOQER), University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia
| | - Bo Zhang
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia
| | - John G. Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Peter W. Groeneveld
- Penn’s Cardiovascular Outcomes, Quality and Evaluative Research Center (CAVOQER), University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia
- Department of Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia
| | - Nimesh D. Desai
- Penn’s Cardiovascular Outcomes, Quality and Evaluative Research Center (CAVOQER), University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Ruka E, Lesur O, Gingras M, Buruian M, Voisine É, Marzouk M, Dagenais F, Voisine P. Relationship Between the Degree of Carotid Stenosis and the Risk of Stroke in Patients Undergoing Cardiac Surgery. Can J Cardiol 2021; 38:347-354. [PMID: 34808321 DOI: 10.1016/j.cjca.2021.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND The impact of carotid stenosis (CS) in patients undergoing cardiac surgery remains controversial. The aim of this study was to evaluate the association between carotid stenosis and stroke and/or transient ischemic attack (TIA) in patients undergoing cardiac surgery on cardiopulmonary bypass. METHODS This is a retrospective cohort study including patients undergoing cardiac surgery on cardiopulmonary bypass between January 2006 and March 2018 at the Quebec Heart and Lung Institute. Data of patients' preoperative demographic characteristics, operative and postoperative variables were taken from a computerized database and patients' charts. Univariate and multivariate analyses were performed. RESULTS A total of 20,241 patients were included in the study. Among those who had received preoperative carotid ultrasound, 516 (2.6% of the total population) had unilateral or bilateral CS ≥50%. Categorized levels of carotid stenosis severity were identified as independent risk factors for post-operative stroke and/or transient ischemic attack occurrence. There was an almost three-fold increased risk of post-operative neurologic events in 80-99% CS vs. less severe 50-79% CS [OR 2.91; IC95% (1.30-6.54)] suggesting that the degree of severity of CS is potentially a strong independent predictor of post-operative neurologic events. CONCLUSIONS CS is an independent risk factor of post-operative stroke and/or TIA. This study suggests for the first time that the risk of stroke increases with the degree of severity of CS, with the greatest risk being for CS between 80-99%. The strength of this relationship and potential causality effect should be further explored in a prospective study focusing on this most at risk population.
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Affiliation(s)
- Emmeline Ruka
- Quebec Heart and Lung Institute, Québec, Canada; Faculty of Medicine, University of Sherbrooke, Québec, Canada
| | - Olivier Lesur
- Faculty of Medicine, University of Sherbrooke, Québec, Canada
| | | | | | | | | | - François Dagenais
- Quebec Heart and Lung Institute, Québec, Canada; Faculty of Medicine, Laval University, Québec, Canada
| | - Pierre Voisine
- Quebec Heart and Lung Institute, Québec, Canada; Faculty of Medicine, Laval University, Québec, Canada.
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Sirin G. Surgical strategies for severely atherosclerotic (porcelain) aorta during coronary artery bypass grafting. World J Cardiol 2021; 13:309-324. [PMID: 34589167 PMCID: PMC8436682 DOI: 10.4330/wjc.v13.i8.309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/27/2021] [Accepted: 07/26/2021] [Indexed: 02/06/2023] Open
Abstract
Porcelain aorta (PA) is an asymptomatic atherosclerotic disease, characterized by circumferential calcification throughout the whole perimeter of the aorta. It is seen in 2% to 9.3% of patients undergoing elective coronary artery bypass grafting (CABG) and makes manipulation of the ascending aorta impossible. It has been clearly shown that most emboli seen and detected during the CABG procedure occur during aortic cross-clamping and aortic side-clamping. Manipulation of porcelain or a severely atherosclerotic aorta increases the risk of perioperative stroke. The incidence of stroke after CABG is between 0.48% and 2.9%, and the risk is correlated with the extent and severity of the atherosclerotic disease. A conventional CABG procedure involves successive steps that include cannulation of the ascending aorta, application of a cross-clamp to the aorta, and partial clamping of the aorta to create the proximal anastomosis. Therefore in procedures that involve cannulation, clamping, or proximal anastomosis, and where aortic manipulation is inevitable, preassessment of the atherosclerotic aortic plaques is crucial. Although many surgeons still rely on intraoperative manual aortic palpation, this approach has very low sensitivity and underestimates the severity of the atherosclerotic illness. Imaging methods including preoperative computed tomography or intraoperative epiaortic ultrasonography enable modification of the surgical technique according to the severity of atherosclerosis. Various surgical techniques have been described to reduce the risk of atheroembolism that may lead to cerebrovascular events in patients with severely atherosclerotic ascending aorta. Anaortic or "no-touch" techniques that do not utilize aortic manipulation may significantly decrease the development of neurological complications by avoiding aortic maneuvers known to cause emboli. In cases where severe atherosclerotic disease or other factors preclude safe use of the ascending aorta, modifications in the surgical techniques, such as switching to different cannulation sites including the axillary/subclavian, femoral and innominate arteries, or using hypothermic ventricular fibrillation and in-situ pedicled arterial grafts, or performing proximal anastomoses at alternative anatomical locations will enable CABG operations to be performed safely with low morbidity and mortality rates in patients with porcelain aortas.
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Affiliation(s)
- Gokce Sirin
- Department of Cardiovascular Surgery, Biruni University, Istanbul 34010, Turkey
- Department of Cardiovascular Surgery, Camlica Medicana Hospital, Istanbul 34692, Turkey.
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Surgical strategies for severely atherosclerotic (porcelain) aorta during coronary artery bypass grafting. World J Cardiol 2021. [DOI: 10.4330/wjc.v13.i8.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Sandner SE, Nolz R, Loewe C, Gregorich M, Heinze G, Andreas M, Kolh P, Zimpfer D, Laufer G. Routine preoperative aortic computed tomography angiography is associated with reduced risk of stroke in coronary artery bypass grafting: a propensity-matched analysis. Eur J Cardiothorac Surg 2021; 57:684-690. [PMID: 31504374 DOI: 10.1093/ejcts/ezz237] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/22/2019] [Accepted: 07/31/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The aim of this study was to determine stroke rates in patients who did or did not undergo routine computed tomography angiography (CTA) aortic imaging before isolated coronary artery bypass grafting (CABG). METHODS We conducted a retrospective analysis of a prospectively maintained single-centre registry. Between 2009 and 2016, a total of 2320 consecutive patients who underwent isolated CABG at our institution were identified. Propensity score matching was used to create a paired cohort of patients with similar baseline characteristics who did (CTA cohort) or did not (non-CTA cohort) undergo preoperative aortic CTA. The primary end point of the analysis was in-hospital stroke. RESULTS In 435 propensity score-matched pairs, stroke occurred in 4 patients (0.92%) in the CTA cohort and in 14 patients (3.22%) in the non-CTA cohort (P = 0.017). Routine preoperative aortic CTA was associated with a significantly reduced risk of in-hospital stroke [relative risk 0.29, 95% confidence interval (CI) 0.09-0.86; P = 0.026; absolute risk reduction 2.3%, 95% CI 0.4-4.2; P = 0.017; number needed to treat = 44, 95% CI 24-242]. CONCLUSIONS A preoperative screening for atheromatous aortic disease using CTA is associated with reduced risk of stroke after CABG. The routine use of preoperative aortic CTA could be applied so that surgical manipulation of the ascending aorta can be selectively reduced or avoided in patients with atheromatous aortic disease.
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Affiliation(s)
- Sigrid E Sandner
- Division of Cardiac Surgery, Department of Surgery, Medical University Vienna, Vienna, Austria
| | - Richard Nolz
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Christian Loewe
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria
| | - Mariella Gregorich
- Center for Medical Statistics, Informatics and Intelligent Systems, Clinical Biometrics Section, Medical University Vienna, Vienna, Austria
| | - Georg Heinze
- Center for Medical Statistics, Informatics and Intelligent Systems, Clinical Biometrics Section, Medical University Vienna, Vienna, Austria
| | - Martin Andreas
- Division of Cardiac Surgery, Department of Surgery, Medical University Vienna, Vienna, Austria
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University of Liege, Liege, Belgium
| | - Daniel Zimpfer
- Division of Cardiac Surgery, Department of Surgery, Medical University Vienna, Vienna, Austria
| | - Guenther Laufer
- Division of Cardiac Surgery, Department of Surgery, Medical University Vienna, Vienna, Austria
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MacKay EJ, Zhang B, Heng S, Ye T, Neuman MD, Augoustides JG, Feinman JW, Desai ND, Groeneveld PW. Association between Transesophageal Echocardiography and Clinical Outcomes after Coronary Artery Bypass Graft Surgery. J Am Soc Echocardiogr 2021; 34:571-581. [DOI: 10.1016/j.echo.2021.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 12/18/2022]
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Vecherskiĭ II, Zatolokin VV, Kozlov BN, Panfilov DS. [Role of intraoperative flowmetric assessment of coronary artery bypass grafts established on-pump]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:45-52. [PMID: 33063751 DOI: 10.33529/angiq2020323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM This study was undertaken to evaluate the efficacy of three-stage measurement of the transit-time flow through coronary bypass grafts with the help of flowmetry for early verification of technical errors during on-pump coronary artery bypass graft surgery. PATIENTS AND METHODS We performed an intraoperative analysis of 214 bypass grafts with the help of three-stage flowmetry. The first stage of measuring was performed on-pump with and without the proximal loop test, the second stage of measurement was performed after weaning the patient off the heart-lung machine, and the third stage of measurement was carried out after heparin inactivation prior to chest wound closure. RESULTS Amongst the 214 transplants regarded as functioning, intraoperative flowmetry revealed insufficient blood flow in 9 (4.2%) cases. Technical surgical errors were confirmed in these shunts during revision thereof. In 6 (2.8%) of the 9 such grafts we detected non-optimal parameters of flowmetry during the first measurement (while the heart was stopped); of these, in 5 (2.3%) cases non-optimal blood flow was verified with the use of the proximal loop test on the target coronary artery and in 1 (0.47%) case without it. In another one (0.47%) of the nine such transplants, inadequate blood flow was revealed during the second measurement, which confirmed technical errors in proximal anastomoses. In a further 2 (0.93%) of the 9 such transplants we observed low parameters of blood flow during the third measurement, which was related to kinking of the shunts due to their excessive length. All surgical errors were corrected immediately at the stage of verification thereof. CONCLUSION The strategy of three-stage assessment of flowmetry makes it possible to ensure and confirm adequate functionality of coronary artery bypass grafts at all stages of the operation, thus allowing timely verification and immediate correction of any technical problems with coronary artery bypass grafts.
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Affiliation(s)
- Iu Iu Vecherskiĭ
- Department of Cardiovascular Surgery, Research Institute of Cardiology, Tomsk National Research Centre of the Russian Academy of Sciences, Tomsk, Russia
| | - V V Zatolokin
- Department of Cardiovascular Surgery, Research Institute of Cardiology, Tomsk National Research Centre of the Russian Academy of Sciences, Tomsk, Russia
| | - B N Kozlov
- Department of Cardiovascular Surgery, Research Institute of Cardiology, Tomsk National Research Centre of the Russian Academy of Sciences, Tomsk, Russia
| | - D S Panfilov
- Department of Cardiovascular Surgery, Research Institute of Cardiology, Tomsk National Research Centre of the Russian Academy of Sciences, Tomsk, Russia
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15
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Gaudino M, Benesch C, Bakaeen F, DeAnda A, Fremes SE, Glance L, Messé SR, Pandey A, Rong LQ. Considerations for Reduction of Risk of Perioperative Stroke in Adult Patients Undergoing Cardiac and Thoracic Aortic Operations: A Scientific Statement From the American Heart Association. Circulation 2020; 142:e193-e209. [DOI: 10.1161/cir.0000000000000885] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Perioperative stroke is one of the most severe and feared complications of cardiac surgery. Based on the timing of onset and detection, perioperative stroke can be classified as intraoperative or postoperative. The pathogenesis of perioperative stroke is multifactorial, which makes prediction and prevention challenging. However, information on its incidence, mechanisms, diagnosis, and treatment can be helpful in minimizing the perioperative neurological risk for individual patients. We herein provide suggestions on preoperative, intraoperative, and postoperative strategies aimed at reducing the risk of perioperative stroke and at improving the outcomes of patients who experience a perioperative stroke.
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16
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Biancari F, Santini F, Tauriainen T, Bancone C, Ruggieri VG, Perrotti A, Gherli R, Demal T, Dalén M, Santarpino G, Rubino AS, Nardella S, Nicolini F, Zanobini M, De Feo M, Onorati F, Mariscalco G, Gatti G. Epiaortic Ultrasound to Prevent Stroke in Coronary Artery Bypass Grafting. Ann Thorac Surg 2020; 109:294-301. [DOI: 10.1016/j.athoracsur.2019.06.078] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/26/2019] [Accepted: 06/20/2019] [Indexed: 12/31/2022]
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17
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Lorusso R, Moscarelli M, Di Franco A, Grazioli V, Nicolini F, Gherli T, De Bonis M, Taramasso M, Villa E, Troise G, Scrofani R, Antona C, Mariscalco G, Beghi C, Miceli A, Glauber M, Ranucci M, De Vincentiis C, Gaudino M. Association Between Coronary Artery Bypass Surgical Techniques and Postoperative Stroke. J Am Heart Assoc 2019; 8:e013650. [PMID: 31830873 PMCID: PMC6951073 DOI: 10.1161/jaha.119.013650] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The impact of the coronary artery bypass grafting (CABG) technique (on- versus off-pump, single versus multiple aortic clamping) on postoperative neurological outcome remains a matter of controversy. The aim of this study was to assess the association between the incidence of postoperative stroke and the degree of aortic manipulation in one of the largest contemporary CABG series. Methods and Results A retrospective, multicenter, international study was conducted in 25 388 patients undergoing isolated CABG procedures with on-pump CABG (ONCAB) or off-pump CABG (OPCAB) technique including single or multiple aortic clamping. Postoperative stroke was defined as a postoperative neurological deficit lasting more than 24 hours and associated with evidence of a brain lesion on computed tomography. The degree of aortic manipulation was assumed to be higher for on-pump versus off-pump surgery and for multiple versus single or no aortic clamping. Logistic regression and propensity matching were used. ONCAB procedures were performed in 17 231 cases and OPCAB in 8157. The incidence of postoperative stroke was significantly lower in the OPCAB group even after propensity matching (0.4% OPCAB versus 1.2% ONCAB, P=0.02). In the ONCAB group (but not in the OPCAB arm) the use of single aortic clamping was associated with significantly reduced postoperative stroke rate (odds ratio, 0.05; 95% CI, 0.008 to 0.07 [P<0.001]). Conclusions OPCAB and the use of single aortic clamping in the ONCAB arm were associated with a reduced incidence of postoperative stroke. Our data confirm a strong association between aortic manipulation and neurological outcome after CABG surgery.
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Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Unit, Heart and Vascular Centre Maastricht University Medical Centre (MUMC) Cardiovascular Research Institute Maastricht (CARIM) Maastricht The Netherlands.,Cardiac Surgery Unit Community Hospital Brescia Italy
| | - Marco Moscarelli
- Cardiothoracic and Vascular Department Maria Cecilia Hospital GVM Care & Research Cotignola (RA) Italy
| | - Antonino Di Franco
- Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York NY
| | | | | | - Tiziano Gherli
- Cardiac Surgery Unit Ospedale Maggiore University of Parma Italy
| | - Michele De Bonis
- Cardiac Surgery Unit San Raffaele Hospital University of Milan Italy
| | | | - Emmanuel Villa
- Cardiac Surgery Unit Poliambulanza Hospital Fondazione Poliambulanza Brescia Italy
| | - Giovanni Troise
- Cardiac Surgery Unit Poliambulanza Hospital Fondazione Poliambulanza Brescia Italy
| | | | - Carlo Antona
- Cardiac Surgery Unit Ospedale Sacco University of Milan Italy
| | | | - Cesare Beghi
- Cardiac Surgery Unit Ospedale di Circolo University of Varese Italy
| | | | | | - Marco Ranucci
- Cardiac Surgery and Intensive Care Units S. Donato Hospital IRCCS University of Milan Italy
| | - Carlo De Vincentiis
- Cardiac Surgery and Intensive Care Units S. Donato Hospital IRCCS University of Milan Italy
| | - Mario Gaudino
- Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York NY
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18
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Vechersky YY, Zatolokin VV, Kozlov BN, Nenakhova AA, Shipulin VM. Enhancement of flow measurement for graft verification. Asian Cardiovasc Thorac Ann 2019; 27:646-651. [PMID: 31564112 DOI: 10.1177/0218492319881034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background We aimed to evaluate multiple transit-time flow measurements during coronary artery bypass grafting. Methods Transit-time flow measurements were performed first on the arrested heart both with and without a proximal snare on the target coronary artery, second, after weaning from cardiopulmonary bypass, and third, before chest closure. Results Among the 214 grafts considered, 9 (4.2%) were patent and 6 (2.8%) were failing. In the failed grafts, an abnormal transit-time flow was found during the first measurement, in 5 (2.3%) cases with a proximal snare and in one (0.47%) without a snare. In these cases, technical errors with the distal anastomoses were found and immediately corrected. A problem with the proximal anastomosis was found in one graft during the second measurement and corrected right away. Bending due to excessive length was found in 2 (0.93%) grafts during the third measurement, and graft repositioning was performed. The first transit-time flow measurement showed that mean graft flow was significantly decreased with a proximal snare compared to without a proximal snare, throughout the entire coronary territory. Pulsatility index during the first transit-time flow measurement was higher with a proximal snare than without one. Conclusions The 3-time transit-time flow measurement strategy makes it possible to verify and immediately correct technical problems with coronary bypass grafts.
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Affiliation(s)
- Yury Y Vechersky
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Vasily V Zatolokin
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Boris N Kozlov
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Aleksandra A Nenakhova
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - Vladimir M Shipulin
- Cardiovascular Surgery Department, Cardiology Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
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Gaudino M, Rahouma M, Di Mauro M, Yanagawa B, Abouarab A, Demetres M, Di Franco A, Arisha MJ, Ibrahim DA, Baudo M, Girardi LN, Fremes S. Early Versus Delayed Stroke After Cardiac Surgery: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2019; 8:e012447. [PMID: 31215306 PMCID: PMC6662344 DOI: 10.1161/jaha.119.012447] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 05/22/2019] [Indexed: 12/11/2022]
Abstract
Background Although it is traditionally regarded as a single entity, perioperative stroke comprises 2 separate phenomena (early/intraoperative and delayed/postoperative stroke). We aimed to systematically evaluate incidence, risk factors, and clinical outcome of early and delayed stroke after cardiac surgery. Methods and Results A systematic review ( MEDLINE , EMBASE , Cochrane Library) was performed to identify all articles reporting early (on awakening from anesthesia) and delayed (after normal awakening from anesthesia) stroke after cardiac surgery. End points were pooled event rates of stroke and operative mortality and incident rate of late mortality. Thirty-six articles were included (174 969 patients). The pooled event rate for early stroke was 0.98% (95% CI 0.79% to 1.23%) and was 0.93% for delayed stoke (95% CI 0.77% to 1.11%; P=0.68). The pooled event rate of operative mortality was 28.8% (95% CI 17.6% to 43.4%) for early and 17.9% (95% CI 14.0% to 22.7%) for delayed stroke, compared with 2.4% (95% CI 1.9% to 3.1%) for patients without stroke ( P<0.001 for early versus delayed, and for perioperative stroke, early stroke, and delayed stroke versus no stroke). At a mean follow-up of 8.25 years, the incident rate of late mortality was 11.7% (95% CI 7.5% to 18.3%) for early and 9.4% (95% CI 5.9% to 14.9%) for delayed stroke, compared with 3.4% (95% CI 2.4% to 4.8%) in patients with no stroke. Meta-regression demonstrated that off-pump was inversely associated with early stroke (β=-0.009, P=0.01), whereas previous stroke (β=0.02, P<0.001) was associated with delayed stroke. Conclusions Early and delayed stroke after cardiac surgery have different risk factors and impacts on operative mortality as well as on long-term survival.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNY
| | - Mohammed Rahouma
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNY
| | - Michele Di Mauro
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNY
| | - Bobby Yanagawa
- Division of Cardiac SurgerySt. Michael's HospitalUniversity of TorontoCanada
| | - Ahmed Abouarab
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNY
| | - Michelle Demetres
- Samuel J. Wood Library & C.V. Starr Biomedical Information CenterWeill Cornell MedicineNew YorkNY
| | | | - Mohammed J. Arisha
- Internal Medicine DepartmentWest Virginia University Charleston DivisionCharleston Area Medical CenterCharlestonWV
| | - Dina A. Ibrahim
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNY
| | - Massimo Baudo
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNY
| | | | - Stephen Fremes
- Schulich Heart CentreSunnybrook Health Sciences CentreUniversity of TorontoCanada
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20
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Raphael J, Moss HE, Roth S. Perioperative Visual Loss in Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 33:1420-1429. [PMID: 30616896 DOI: 10.1053/j.jvca.2018.11.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Jacob Raphael
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Heather E Moss
- Department of Ophthalmology and Neurology, Stanford University, Palo Alto, CA; Department of Neurological Sciences, Stanford University, Palo Alto, CA
| | - Steven Roth
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, IL; Department of Ophthalmology and Visual Sciences, University of Illinois College of Medicine, Chicago, IL.
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21
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Aortic clamping strategy and postoperative stroke. J Thorac Cardiovasc Surg 2018; 156:1451-1457.e4. [DOI: 10.1016/j.jtcvs.2018.03.160] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 03/01/2018] [Accepted: 03/07/2018] [Indexed: 11/19/2022]
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22
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Devgun JK, Gul S, Mohananey D, Jones BM, Hussain MS, Jobanputra Y, Kumar A, Svensson LG, Tuzcu EM, Kapadia SR. Cerebrovascular Events After Cardiovascular Procedures. J Am Coll Cardiol 2018; 71:1910-1920. [DOI: 10.1016/j.jacc.2018.02.065] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/18/2018] [Accepted: 02/19/2018] [Indexed: 12/14/2022]
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Paone G. Aortic clamping and stroke: Because two isn't worse doesn't mean one isn't better. J Thorac Cardiovasc Surg 2018; 156:1458-1459. [PMID: 29691048 DOI: 10.1016/j.jtcvs.2018.03.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 03/27/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Gaetano Paone
- Division of Cardiac Surgery, Henry Ford Hospital, Detroit, Mich.
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24
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Chen L, Hua X, Song J, Wang L. Which aortic clamp strategy is better to reduce postoperative stroke and death: Single center report and a meta-analysis. Medicine (Baltimore) 2018; 97:e0221. [PMID: 29561451 PMCID: PMC5895326 DOI: 10.1097/md.0000000000010221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Stroke is severe complication of coronary artery bypass grafting (CABG) which may be associated with clamp strategy, there are 2 strategies to clamp aorta including single aortic clamp (SAC) and partial aortic clamp (PAC). It is controversial that which clamping strategy is better to reduce the postoperative stroke and death, so this study aims to investigate which is better for reducing postoperative stroke and death within 30 days. METHODS We collected 469 patients who had on-pump CABG in Fuwai Hospital during January 2014 to July 2015. The SAC group consisted of 265 patients while the PAC group included 204 patients. We compared the 2 group patient difference. At the same time, 12 studies were identified by systematic search. The odds ratio (OR) was used as effect index to compare SAC and PAC strategy by fix-effect modeling. We also tested heterogeneity and publication bias. The primary end point of study was occurrence of postoperative stroke within 30 days of operation, the second end point of study was the incidence of 30-day mortality. RESULTS The single center retrospective study showed that the patients in the SAC group were older than those in the PAC group (62.5 ± 8.1 vs 60.3 ± 8.0 years, P = .01). The proportions of peripheral vascular disease and hypertension of SAC were higher than PAC (71 (26.8%) versus 36 (17.6%), P = .02; 183 (69.1%) versus 115 (56.4%), P = .01, respectively). Besides, the number of vascular anastomosis was more in the SAC group (3.29 ± 0.74 versus 2.97 ± 0.974, P < .001). The linear-regression analysis suggested that the time of cardiopulmonary bypass of SAC was shorter than the PAC group (93.2 ± 22.4 vs.103.4 ± 26.8 minutes, P-regression < .001) and postoperative death within 30-days was similar (1 (0.4%) vs. 2 (1.0%), P-regression = .47). There was no stroke occurring in both the groups. And the meta-analysis suggested the postoperative stroke and death within 30-days were similar between SAC group and PAC group (OR: 0.78, 95% CI: 0.58-1.06; OR: 0.82, 95% CI: 0.61-1.10; respectively). Moreover, subgroup meta-analysis also had the same results. CONCLUSION There was no significant difference between SAC and PAC clamping strategy on postoperative stroke and death within 30-days; however, SAC can reduce the usage time of cardiopulmonary bypass.
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Affiliation(s)
- Liyu Chen
- Department of Cardiovascular Surgery
| | - Xiumeng Hua
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiangping Song
- Department of Cardiovascular Surgery
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Does epiaortic ultrasound screening reduce perioperative stroke in patients undergoing coronary surgery? A topical review. J Clin Neurosci 2018; 50:30-34. [PMID: 29398195 DOI: 10.1016/j.jocn.2018.01.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 01/08/2018] [Accepted: 01/11/2018] [Indexed: 02/07/2023]
Abstract
Although the occurrence of stroke in patients undergoing coronary artery bypass grafting (CABG) is decreasing, it remains an important concern. Therefore, it is important to identify and adopt strategies that can decrease the incidence of stroke in these patients. One of the strategies that have demonstrated the potential to decrease the rate of post-CABG stroke is an assessment of aorta for atherosclerosis before surgery and changing the surgical plan accordingly to minimize the stroke risk. This assessment can be done through palpation of the aorta, transesophageal echocardiography (TEE), and epiaortic ultrasound scanning (EAS). EAS has shown superiority over both palpation and TEE for intraoperative evaluation of aorta. However, despite the evidence demonstrating reduced stroke rates with the EAS-guided approach, EAS is not yet the standard of care procedure in patients undergoing CABG. Therefore, we have reviewed the literature for evidence that supports the routine use of EAS in patients undergoing coronary surgery and have presented solutions to overcome the barriers to its routine use.
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26
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Hanif H, Dubois L, Ouzounian M, Peterson MD, El-Hamamsy I, Dagenais F, Hassan A, Chu MWA. Aortic Arch Reconstructive Surgery With Conventional Techniques vs Frozen Elephant Trunk: A Systematic Review and Meta-Analysis. Can J Cardiol 2017; 34:262-273. [PMID: 29395709 DOI: 10.1016/j.cjca.2017.12.020] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 12/16/2017] [Accepted: 12/17/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Frozen elephant trunk (FET) surgery offers a new alternative in the management of complex thoracic aortic aneurysms and dissections. We performed a systematic review and meta-analysis of comparator observational studies evaluating the efficacy of FET compared with conventional aortic arch surgery, primarily focusing on mortality and stroke as well as the secondary outcomes of spinal cord ischemia, major bleeding, and operative time. METHODS We searched MEDLINE, EMBASE, PubMed, and the Cochrane Library for trials and studies comparing the FET technique with conventional surgery in patients with aortic aneurysms or dissections, or both. The overall quality of evidence was low, as assessed by Grading of Recommendations, Assessment, Development, and Evaluation, based primarily on the risk of bias secondary to study design, plausible confounding, and imprecision. RESULTS Meta-analysis revealed a significant reduction in mortality (12 studies, 1803 patients: odds ratio [OR], 0.55; 95% CI, 0.39-0.78) and a nonsignificant reduction in stroke (12 studies, 1803 patients: OR, 0.78; 95% CI, 0.52-1.15) favouring FET; however, FET was associated with a significant increase in spinal cord ischemia (9 studies, 1476 patients: OR, 2.20; 95% CI, 1.10-4.37). No significant differences between groups were observed regarding major bleeding, cardiopulmonary bypass time, or cross-clamp time. CONCLUSIONS Current evidence suggests that FET surgery is associated with lower mortality in patients with thoracic aneurysmal disease and dissections, without a significant increase in stroke, bleeding, or operative times. However, the risk of spinal cord ischemia is increased in patients who undergo FET. A well-powered randomized trial is needed to evaluate this evolving field.
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Affiliation(s)
- Hasib Hanif
- Division of Cardiac Surgery, Department of Surgery, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Luc Dubois
- Division of Vascular Surgery, Department of Surgery, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Mark D Peterson
- Division of Cardiac Surgery, St. Michael's Hospital, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Division of Cardiac Surgery, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Francois Dagenais
- Division of Cardiac Surgery, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Ansar Hassan
- Department of Cardiac Surgery, New Brunswick Heart Centre, Saint John, New Brunswick, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, Lawson Health Research Institute, London, Ontario, Canada.
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27
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Putzu A, Gallo M, Martino EA, Ferrari E, Pedrazzini G, Moccetti T, Cassina T. Coronary artery bypass graft surgery versus percutaneous coronary intervention with drug-eluting stents for left main coronary artery disease: A meta-analysis of randomized trials. Int J Cardiol 2017; 241:142-148. [DOI: 10.1016/j.ijcard.2017.04.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 03/14/2017] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
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Locker C, Schaff HV, Daly RC, Bell MR, Frye RL, Stulak JM, Said SM, Dearani JA, Joyce LD, Greason KL, Pochettino A, Li Z, Lennon RJ, Lerman A. Multiarterial grafts improve the rate of early major adverse cardiac and cerebrovascular events in patients undergoing coronary revascularization: analysis of 12 615 patients with multivessel disease†. Eur J Cardiothorac Surg 2017; 52:746-752. [DOI: 10.1093/ejcts/ezx171] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 04/07/2017] [Indexed: 11/14/2022] Open
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Hornero F. El talón de Aquiles de la cirugía coronaria: el ictus postoperatorio. CIRUGIA CARDIOVASCULAR 2017. [DOI: 10.1016/j.circv.2017.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Pocar M, Airoldi F. Strike at the heart of the stroke. Asian Cardiovasc Thorac Ann 2016; 24:707-8. [DOI: 10.1177/0218492316639411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marco Pocar
- Cardiovascular Department, IRCCS MultiMedica Scientific Institute, Milan, Italy
- Università degli Studi di Milano, Milan, Italy
| | - Flavio Airoldi
- Cardiovascular Department, IRCCS MultiMedica Scientific Institute, Milan, Italy
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Coronary Artery Bypass Grafting in Elderly Patients: Insights from a Comparative Analysis of Total Arterial and Conventional Revascularization. J Cardiovasc Transl Res 2016; 9:223-229. [DOI: 10.1007/s12265-016-9688-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 02/29/2016] [Indexed: 11/26/2022]
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Bassano C, Bovio E, Uva F, Iacobelli S, Iasevoli N, Farinaccio A, Ruvolo G. Partially anaortic clampless off-pump coronary artery bypass prevents neurologic injury compared to on-pump coronary surgery: a propensity score-matched study on 286 patients. Heart Vessels 2015; 31:1412-7. [PMID: 26498755 PMCID: PMC5010601 DOI: 10.1007/s00380-015-0748-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 09/09/2015] [Indexed: 11/26/2022]
Abstract
Anaortic coronary artery bypass proved to prevent early neurologic injury compared to on-pump CABG. The Cardica PAS-Port(®) is a fully automated device that might be able to perform proximal aorto-venous anastomoses without an increased embolic risk. We evaluated early post-operative neurologic outcome in a matched population following clampless OPCAB (CCAB: either "all-arterial" or with automatically anastomosed venous grafts) or on-pump CABG. 366 consecutive patients were submitted to isolated coronary bypass by a single surgeon experienced in both off and on-pump procedures between January 2009 and December 2013. Of these patients, 223 underwent a clampless off-pump revascularization. After propensity score matching, 143 pairs were selected, who received either off-pump or on-pump surgery. In the off-pump group, CCAB was performed with an all-arterial approach (n = 33) or with automated proximal anastomosis of the venous graft(s) by means of the Cardica PAS-Port(®) connector (n = 110). Neurologic injury was defined as non-reversible (NRNI: lethal coma or stroke) or reversible (RNI: TIA or delirium). Operative mortality was 2.4 % (CCAB 1.4 %; CABG 3.5 %; p = 0.14). The global rate of early neurologic injury was 5.6 % (CCAB 2.1 vs. CABG 9.1 %; p = 0.006). Incidence was 1.4 % for NRNI (CCAB 0 vs. CABG 2.8 %; p = 0.04) and 4.2 % for RNI (CCAB 2.1 vs. CABG 6.3 %; p = 0.06). No differences were found among other major perioperative outcomes. CCAB prevents both early post-operative RNI and NRNI. This result can be achieved with a totally anaortic strategy and also with the aid of a fully automated device for proximal aorto-venous anastomoses.
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Affiliation(s)
- Carlo Bassano
- Operative Units of Cardiac Surgery, Tor Vergata University, Rome, Italy.
| | - Emanuele Bovio
- Operative Units of Cardiac Surgery, Tor Vergata University, Rome, Italy
| | - Floriano Uva
- Operative Units of Cardiac Surgery, Tor Vergata University, Rome, Italy
| | - Simona Iacobelli
- Interdepartmental Center of Biostatistics and Bioinformatics, Tor Vergata University, Rome, Italy
| | - Nicola Iasevoli
- Operative Units of Anesthesiology, Tor Vergata University, Rome, Italy
| | - Andrea Farinaccio
- Operative Units of Anesthesiology, Tor Vergata University, Rome, Italy
| | - Giovanni Ruvolo
- Operative Units of Cardiac Surgery, Tor Vergata University, Rome, Italy
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Seco M, Edelman JJB, Van Boxtel B, Forrest P, Byrom MJ, Wilson MK, Fraser J, Bannon PG, Vallely MP. Neurologic injury and protection in adult cardiac and aortic surgery. J Cardiothorac Vasc Anesth 2015; 29:185-95. [PMID: 25620144 DOI: 10.1053/j.jvca.2014.07.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Michael Seco
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - J James B Edelman
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Benjamin Van Boxtel
- Columbia University Medical Center-New York Presbyterian Hospital, New York, New York
| | - Paul Forrest
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael J Byrom
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael K Wilson
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Paul G Bannon
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael P Vallely
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia.
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Yanagawa B, Orozco-Sevilla V, Pawale A, Puskas JD. Piggyback technique facilitates off-pump coronary artery bypass graft by using a proximal anastamostic device with arterial conduits. J Thorac Cardiovasc Surg 2015; 150:725-7. [PMID: 26162309 DOI: 10.1016/j.jtcvs.2015.05.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 05/16/2015] [Accepted: 05/23/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Bobby Yanagawa
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai and Mount Sinai Beth Israel, New York, NY
| | - Vicente Orozco-Sevilla
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai and Mount Sinai Beth Israel, New York, NY
| | - Amit Pawale
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai and Mount Sinai Beth Israel, New York, NY
| | - John D Puskas
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai and Mount Sinai Beth Israel, New York, NY.
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Affiliation(s)
- Jennifer S Lawton
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
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Engelman RM, Engelman DT. Strategies and Devices to Minimize Stroke in Adult Cardiac Surgery. Semin Thorac Cardiovasc Surg 2015; 27:24-9. [DOI: 10.1053/j.semtcvs.2015.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2015] [Indexed: 01/04/2023]
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Tsuneyoshi H, Komiya T, Shimamoto T, Sakai J, Hiraoka T, Kawashima T, Muraoka G, Fujimoto M, Yamanaka K, Tabayashi A, Wada K, Kaneko H, Fujimoto Y, Furuichi Y. Efficacy of partial clamp during off-pump coronary artery bypass grafting. ACTA ACUST UNITED AC 2015. [DOI: 10.7793/jcoron.20.14-00018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | | | - Jiro Sakai
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | | | | | - Genya Muraoka
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Masato Fujimoto
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Ken Yamanaka
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Azuma Tabayashi
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Kenji Wada
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Hiroyuki Kaneko
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Yuka Fujimoto
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
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Moss E, Puskas JD, Thourani VH, Kilgo P, Chen EP, Leshnower BG, Lattouf OM, Guyton RA, Glas KE, Halkos ME. Avoiding aortic clamping during coronary artery bypass grafting reduces postoperative stroke. J Thorac Cardiovasc Surg 2014; 149:175-80. [PMID: 25293356 DOI: 10.1016/j.jtcvs.2014.09.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 08/31/2014] [Accepted: 09/08/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of this study was to determine whether the incidence of postoperative stroke could be reduced by eliminating aortic clamping during coronary artery bypass grafting. METHODS From 2002 to 2013, 12,079 patients underwent primary, isolated coronary artery bypass grafting at a single US academic institution. Aortic manipulation was completely avoided by using in situ internal thoracic arteries for inflow in 1552 patients (12.9%) (no-touch), a clampless facilitating device for proximal anastomoses in 1548 patients (12.8%), and aortic clamping in 8979 patients (74.3%). These strategies were assessed in a logistic regression model controlling for relevant variables. RESULTS The overall incidence of postoperative stroke was 1.4% (n = 165), with an unadjusted incidence of 0.6% (n = 10) in the no-touch group, 1.2% (n = 18) in the clampless facilitating device group, and 1.5% (n = 137) in the clamp group (P < .01 for no-touch vs clamp). The ratio of observed to expected stroke rate increased as the degree of aortic manipulation increased, from 0.48 in the no-touch group, to 0.61 in the clampless facilitating device group, and to 0.95 in the clamp group. Aortic clamping was independently associated with an increase in postoperative stroke compared with a no-touch technique (adjusted odds ratio, 2.50; P < .01). When separated by cardiopulmonary bypass use, both the off-pump partial clamp and the on-pump crossclamp techniques increased the risk of postoperative stroke compared with no-touch (adjusted odds ratio, 2.52, P < .01; and adjusted odds ratio, 4.25, P < .001, respectively). CONCLUSIONS A no-aortic touch technique has the lowest risk for postoperative stroke for patients undergoing coronary artery bypass grafting. Clamping the aorta during coronary artery bypass grafting increases the risk of postoperative stroke, regardless of the severity of aortic disease.
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Affiliation(s)
- Emmanuel Moss
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - John D Puskas
- Division of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY
| | - Vinod H Thourani
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Patrick Kilgo
- Rollins School of Public Health, Emory University, Atlanta, Ga
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Omar M Lattouf
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Robert A Guyton
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Kathryn E Glas
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Ga
| | - Michael E Halkos
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga.
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