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Khamtuikrua C, Chaikittisilpa N, Suksompong S, Slisatkorn W, Raykateeraroj N. Prevalence of ascending aortic atheromatous plaques and risk factors in Thai cardiac surgery patients: A prospective cohort study. Heliyon 2024; 10:e36607. [PMID: 39262997 PMCID: PMC11388658 DOI: 10.1016/j.heliyon.2024.e36607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 07/30/2024] [Accepted: 08/19/2024] [Indexed: 09/13/2024] Open
Abstract
Cerebral embolism, a serious complication in cardiac surgery, is significantly impacted by atheromatous plaques in the ascending aorta and aortic arch. However, data on the prevalence of these plaques in Asian populations are sparse. This study aimed to evaluate the prevalence of atheromatous plaques in the ascending aorta among Thai cardiac surgery patients, thereby facilitating risk stratification and improving preoperative management. We conducted intraoperative epiaortic ultrasound examinations on 239 cardiac surgery patients. Clinically significant atheromatous plaques were defined as those exceeding 3.0 mm in thickness. The collected demographic and clinical data included sex, age, body weight, height, American Society of Anesthesiologists physical status classification, smoking status, alcohol consumption, and comorbidities. Atheromatous plaques were found in 33.5 % of the ascending aortas and 41.4 % of the aortic arches. The primary risk factors were advanced age (over 80 years; relative risk (RR) 1.444, 95 % confidence interval (CI) 1.113-1.874, P = 0.006) and carotid stenosis (RR 1.247, 95 % CI 1.04-1.495, P = 0.017). The prevalence of atheromatous plaques in Thai cardiac surgery patients was significant, with older age and carotid stenosis being major risk factors. Preoperative aortic imaging, such as computed tomography angiography or epiaortic ultrasound, should be applied to cardiac surgery candidates. In resource-limited settings, prioritizing patients of advanced age or those with carotid stenosis for imaging is advised.
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Affiliation(s)
- Chaowanan Khamtuikrua
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nophanan Chaikittisilpa
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sirilak Suksompong
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Worawong Slisatkorn
- Division of Cardio-Thoracic Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nattaya Raykateeraroj
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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2
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Uyanik M, Yildirim U, Avci B, Soylu K. Assessment of silent brain injury in patients undergoing elective percutaneous coronary intervention due to chronic total occlusion. Scand Cardiovasc J Suppl 2023; 57:25-30. [PMID: 36443919 DOI: 10.1080/14017431.2022.2150786] [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: 11/30/2022]
Abstract
Objective: Silent brain infarcts (SBI) are thromboembolic complications associated with cardiac surgery, diagnostic angiography, and percutaneous interventions. Serum neuron-specific enolase (NSE) is the proven biomarker for measuring neuronal damage. This study aimed to evaluate the incidence of SBI, defined as elevated NSE after coronary chronic total occlusion (CTO) intervention and elective coronary stenting. Design: The study population consisted of two patient groups: the CTO group included consecutive patients with coronary CTO intervention, and the control group consisted of patients who underwent elective coronary intervention. NSE blood levels were measured before and 12-18 h after the procedure. NSE blood levels of >20 ng/mL were considered SBI. Results: A total of 108 patients were included in the study. Of these, 55 (50.9%) had SBI after the procedure. The SBI rate was 59.7% in the CTO group and 39.1% in the control group. Patients with SBI were more likely to have diabetes mellitus, hyperlipidemia, higher HbA1c, higher total stent length, and longer procedural time. Multivariate logistic regression analysis showed that CTO procedure (odds ratio [OR]: 3.129; 95% confidence interval [CI]: 1.246-7.858; p < 0.015) and diabetes mellitus (OR: 2.93; 95% CI: 1.185-7.291; p < 0.020) are independent predictors of SBI. Conclusion: Our data suggest that SBI occurs more frequently after CTO intervention than after non-CTO intervention. Intervention complexity and patient clinical characteristics may explain the increased incidence.
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Affiliation(s)
- Muhammet Uyanik
- Faculty of Medicine, Department of Cardiology, Ondokuz Mayıs University, Samsun, Turkey
| | - Ufuk Yildirim
- Faculty of Medicine, Department of Cardiology, Ondokuz Mayıs University, Samsun, Turkey
| | - Bahattin Avci
- Faculty of Medicine, Department of Biochemistry, Ondokuz Mayıs University, Samsun, Turkey
| | - Korhan Soylu
- Faculty of Medicine, Department of Cardiology, Ondokuz Mayıs University, Samsun, Turkey
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3
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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4
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Nazer RI, Albarrati AM. The brain-before-heart strategy for coronary artery bypass grafting in the severely atherosclerotic aorta: A single-institution experience. Clin Cardiol 2022; 45:1264-1271. [PMID: 36124340 DOI: 10.1002/clc.23913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/26/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Severe atherosclerosis of the ascending aorta (SAA) in patients undergoing surgical revascularization by coronary artery bypass grafting (CABG) is becoming an increasing problem as more elderly patients are diagnosed with coronary artery disease. Strokes and other neurologic insults are common complications in this group, with devastating impacts on outcomes and prognoses. HYPOTHESIS Early detection of the atherosclerotic aorta and the application of a stroke prevention protocol will reduce the risk of stroke in patients with SAA. METHODS In 2012, we adopted a protocol devised to preemptively detect and manage patients suspected of having SAA. From the time of the application of the protocol, we compared the immediate and late outcomes of CABG in SAA in the 8 years preceding the protocol in a "control" group (30 patients) and in the 8 years following the protocol in a "brain" group (69 patients). RESULTS More patients with SAA were detected after the initiation of the protocol. They had significantly more history of stroke, renal dysfunction, and left main coronary disease. The percutaneous coronary intervention was utilized more after the protocol (26% vs. 7%) and there was far less utilization of replacement of the ascending aorta (12% vs. 37%). Postoperative stroke rates were significantly less after the protocol (2% vs. 18%), with an almost twofold reduction in stroke associated with SAA even after risk adjustment. The composite endpoints of cardiac death, nonfatal myocardial infarction, and stroke were significantly reduced after initiating the protocol at a median of 2.3 years from the time of revascularization. CONCLUSION Early detection of SAA and individualized therapeutic strategies for revascularization is effective in reducing athero-embolic brain injury and are associated with better prognosis.
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Affiliation(s)
- Rakan I Nazer
- Department of Cardiac Science, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Ali M Albarrati
- Department of Rehabilitation Science, College of Applied Medical Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
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5
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Alghamdi FA, AlShehri SA, Maghraby NH, Shaib M, Alfaraj D. A Cerebrovascular Incident Secondary to Extensive Aortic Arch Atheroma. Cureus 2022; 14:e28954. [PMID: 36237761 PMCID: PMC9547671 DOI: 10.7759/cureus.28954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2022] [Indexed: 11/23/2022] Open
Abstract
Plaques can form across different parts of the aorta, from the aortic arch to the thoracic and abdominal aorta. Aortic arch atheroma, however, is highly associated with cerebrovascular insults due to their dislodgement. Although no concise management protocol has been defined for dealing with such presentations, antiplatelet agents and anticoagulants are most frequently used. In this case, we present a 78-year-old male with a known case of diabetes mellitus type 2, hypertension, and dyslipidemia who presented to the emergency department with acute onset of slurred speech. A CT angiography was performed that revealed extensive plaque formations across the aortic arch with a 90% occlusion of the distal left common carotid artery and carotid bifurcation along with 99% stenosis of the internal carotid artery. The patient underwent aspiration thrombectomy and was started on dual antiplatelets but passed away after developing decompensated heart failure.
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6
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 612] [Impact Index Per Article: 306.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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7
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 160] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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8
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Atherosclerotic Disease of the Proximal Aorta. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00033-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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9
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Sylaja PN, Arun K, Nambiar P, Kannath S, Sreedharan S, Sukumaran S, Sarma S. Prevalence of Aortic Plaques in Cryptogenic Ischemic Stroke: Correlation to Vascular Risk Factors and Future Events. Neurol India 2022; 70:182-187. [DOI: 10.4103/0028-3886.336332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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10
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Kundel V, Reid M, Fayad Z, Ayappa I, Mani V, Rueschman M, Redline S, Shea S, Shah N. Sleep duration and vascular inflammation using hybrid positron emission tomography/magnetic resonance imaging: results from the Multi-Ethnic Study of Atherosclerosis (MESA). J Clin Sleep Med 2021; 17:2009-2018. [PMID: 33969819 DOI: 10.5664/jcsm.9382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Short sleep duration (SD) is associated with cardiovascular disease (CVD). We investigated the relationship between objective SD and subclinical atherosclerosis employing hybrid PET/MRI with 18F-FDG tracer in the MESA cohort. METHODS We utilized data from MESA-SLEEP and MESA-PET ancillary studies. SD and sleep fragmentation index (SFI) were assessed using 7-day actigraphy. The primary and secondary outcomes were carotid inflammation, defined using target-to-background ratios (TBR), and measures of carotid wall remodeling (carotid wall thickness [CWT]), summarized by SD category. Multivariate linear regression was performed to assess the association between SD and SFI with the primary/secondary outcomes, adjusting for several covariates including apnea-hypopnea index (AHI), and CVD risk. RESULTS Our analytical sample (n=58) was 62% female (mean age 68±8.4 years). Average SD was 5.1±0.9 hours in the short SD group (≤6 hours/night, 31%), and 7.1±0.8 hours in the normal SD group (69%). Prevalence of pathologic vascular inflammation (TBRmax>1.6) was higher in the short SD group (89% vs. 53%, p=0.009). Those with short SD had a higher TBRmax (1.77 vs 1.71), though this was not statistically significant (p=0.39). CWT was positively correlated with SFI even after adjusting for covariates (Beta [SE]=0.073±[0.032], p=0.025). CONCLUSIONS Prevalence of pathologic vascular inflammation was higher among those who slept ≤6 hours, and vascular inflammation was higher among those with a SD of ≤6 hours. Interestingly, SFI was positively correlated with CWT even after adjustment for covariates. Our results are hypothesis-generating but suggest that both habitual SD and SFI should be investigated in future studies as potential risk factors for subclinical atherosclerosis.
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Affiliation(s)
- Vaishnavi Kundel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Zahi Fayad
- Biomedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Indu Ayappa
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Venkatesh Mani
- Biomedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Steven Shea
- Department of Medicine, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Neomi Shah
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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11
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Viedma-Guiard E, Guidoux C, Amarenco P, Meseguer E. Aortic Sources of Embolism. Front Neurol 2021; 11:606663. [PMID: 33519684 PMCID: PMC7843443 DOI: 10.3389/fneur.2020.606663] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/25/2020] [Indexed: 12/15/2022] Open
Abstract
Aortic arch atheroma is a frequent finding in ischemic stroke patients. Its role as a source of cerebral emboli or a marker of atherosclerosis is unclear. Transesophageal echography is considered the gold standard for its detection, whereas computed tomography angiography is a good alternative; magnetic resonance and positron emission tomography could be proposed to better analyze plaque vulnerability. Despite the interest in this condition, the optimal antithrombotic treatment remains uncertain, while intensive lipid-lowering therapy should be recommended. This review aims to offer guidance on patients with aortic arch atheroma, about its causal role in stroke, diagnosis, and treatment based on current available evidence.
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Affiliation(s)
- Elena Viedma-Guiard
- Department of Neurology and Stroke Center, APHP Bichat Hospital, Paris, France Université de Paris, LVTS, Inserm U1148, Paris, France
| | - Celine Guidoux
- Department of Neurology and Stroke Center, APHP Bichat Hospital, Paris, France Université de Paris, LVTS, Inserm U1148, Paris, France
| | - Pierre Amarenco
- Department of Neurology and Stroke Center, APHP Bichat Hospital, Paris, France Université de Paris, LVTS, Inserm U1148, Paris, France
| | - Elena Meseguer
- Department of Neurology and Stroke Center, APHP Bichat Hospital, Paris, France Université de Paris, LVTS, Inserm U1148, Paris, France
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12
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Coronary artery bypass grafting and perioperative stroke: imaging of atherosclerotic plaques in the ascending aorta with ungated high-pitch CT-angiography. Sci Rep 2020; 10:13909. [PMID: 32807858 PMCID: PMC7431556 DOI: 10.1038/s41598-020-70830-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/03/2020] [Indexed: 11/09/2022] Open
Abstract
Perioperative stroke is a devastating complication after coronary artery bypass graft (CABG) surgery, with atherosclerosis of the ascending aorta as important risk factor. During surgical manipulation, detachment of plaques can lead to consecutive embolization into brain-supplying arteries. High-pitch computed tomography angiography (HP-CTA) represents a non-invasive imaging modality, which provides the opportunity for comprehensive imaging of the ascending aorta, including plaque detection and advanced characterization. In our present retrospective study on 719 individuals, who had undergone HP-CTA within 6 months prior to CABG, atherosclerotic disease of the ascending aorta was evaluated with respect to perioperative stroke rates. For image analysis, the ascending aorta was divided into a proximal and distal part, consisting of four segments, and evaluated for presence and distribution of calcified and mixed plaques. All patients with perioperative stroke presented with atherosclerotic disease of the ascending aorta. The stroke rate was significantly associated with the presence and extent of atherosclerotic disease. Patients burdened with mixed plaques presented with significantly higher perioperative stroke rates. This study demonstrates that HP-CTA allows accurate evaluation of plaque extent and composition in the ascending aorta, and therefore may improve risk stratification of stroke prior to CABG.
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13
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Conway AM, Nguyen Tran NT, Qato K, Ehidom C, Stoffels GJ, Giangola G, Carroccio A. Complexity of Aortic Arch Anatomy Affects the Outcomes of Transcarotid Artery Revascularization Versus Transfemoral Carotid Artery Stenting. Ann Vasc Surg 2020; 67:78-89. [PMID: 32339690 DOI: 10.1016/j.avsg.2020.04.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/09/2020] [Accepted: 04/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transcarotid artery revascularization (TCAR) has been shown to have half the rates of transient ischemic attack (TIA), stroke, and death compared with transfemoral carotid artery stenting (TFCAS). Successful outcomes of TFCAS require careful patient selection. The aim of this study was to determine the outcomes of TFCAS versus TCAR in both simple (type I) and complex (type II and III) aortic arches. METHODS A retrospective cohort study was performed comparing the outcomes of patients undergoing TFCAS versus TCAR with simple and complex aortic arches using the Vascular Quality Initiative registry from August 2011 to May 2019. The primary outcome was a composite of in-hospital TIA/stroke/death. RESULTS About 6,108 carotid artery interventions were analyzed, including 3,536 (57.9%) patients with type I, 2,013 (33.0%) with type II, and 559 (9.2%) with type III aortic arch. In 3,535 patients with a simple arch, 1,917 underwent TFCAS and 1,619 had TCAR. Mean age was 70.6 (±9.5) years, and 2,382 (67.4%) patients were males. The primary outcome of postoperative TIA/stroke/death was seen significantly less frequently in those undergoing TCAR compared with TFCAS in simple arches (odds ratio [OR], 0.63; 95% confidence interval [95% CI], 0.43-0.94; P = 0.0236). Although the individual outcome of death occurred less often in TCAR (P = 0.0025), there was no difference in the occurrence of in-hospital stroke (P = 0.8836) or TIA (P = 0.4608). On multivariable analysis, TCAR was associated with improved outcomes (P = 0.0062). A worse outcome was associated with increasing age (P < 0.001), a prior stroke (P < 0.0001), and increasing number of stents (P = 0.0483). In 2,572 patients with a complex arch, 1,416 underwent TFCAS and 1,156 had TCAR. Mean age was 73.0 (±9.1) years, and 1,655 (64.4%) were males. In complex arch anatomy, the primary outcome of in-hospital TIA/stroke/death was seen significantly less frequently in TCAR compared with TFCAS (OR, 0.49; 95% CI, 0.31-0.77; P = 0.0022). Again noted was a significant difference in death, with better outcomes in TCAR (P = 0.0133). Although the occurrence of in-hospital TIA was no different between the 2 approaches (P = 0.6158), there were significantly fewer strokes in those treated with TCAR (P = 0.0132). TCAR (P = 0.0146) was associated with improved outcomes. A worse outcome was seen with advancing age (P = 0.0003), prior strokes (P = 0.01), and a left-sided lesion (P = 0.0176). CONCLUSIONS TCAR has improved outcomes of TIA/stroke/death compared with TFCAS in both simple and complex aortic arch anatomy. In simple aortic arches, there is no difference in neurologic outcomes between both approaches. In complex arch anatomy, TCAR has fewer strokes.
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Affiliation(s)
- Allan M Conway
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY.
| | - Nhan T Nguyen Tran
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Khalil Qato
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Clinton Ehidom
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | | | - Gary Giangola
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Alfio Carroccio
- Department of Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
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14
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Shapeton AD, Leissner KB, Zorca SM, Amirfarzan H, Stock EM, Biswas K, Haime M, Srinivasa V, Quin JA, Zenati MA. Epiaortic Ultrasound for Assessment of Intraluminal Atheroma; Insights from the REGROUP Trial. J Cardiothorac Vasc Anesth 2019; 34:726-732. [PMID: 31787434 DOI: 10.1053/j.jvca.2019.10.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/27/2019] [Accepted: 10/31/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To assess the use of epiaortic ultrasound in contemporary cardiac surgery, as well as its impact on surgical cannulation strategy and cerebrovascular events. DESIGN Epiaortic ultrasound data was prospectively collected in the Randomized Endovein Graft Prospective (REGROUP) trial (VA Cooperative Studies Program #588, ClinicalTrials.gov, NCT01850082), which randomized 1,150 coronary artery bypass graft patients between 2014 and 2017 to endoscopic or open-vein graft harvest. SETTING Sixteen cardiac surgery programs within the Veterans Affairs Healthcare System with expertise at performing endoscopic vein-graft harvesting. PARTICIPANTS Veterans Affairs patients, greater than 18 years of age, undergoing elective or urgent coronary artery bypass grafting with cardiopulmonary bypass and cardioplegic arrest with at least one planned saphenous vein graft were eligible for enrollment. INTERVENTIONS Epiaortic ultrasound was performed by the surgeon using a high frequency (>7 MHz) ultrasound transducer. Two-dimensional images of the ascending aorta in multiple planes were acquired before aortic cannulation and cross-clamping. MEASUREMENTS AND MAIN RESULTS Epiaortic ultrasound was performed in 34.1% (269 of 790) of patients in REGROUP. Among these patients, simple intraluminal atheroma was observed in 21.9% (59 269), and complex intraluminal atheroma comprised 2.2% (6 of 269). The aortic cannulation or cross-clamp strategy was modified based on these findings in 7.1% of cases (19 of 269). There was no difference in stroke between patients who underwent epiaortic ultrasound and those who did not (1.9% v 1.2% p = 0.523). CONCLUSIONS Despite current guidelines recommending routine use of epiaortic ultrasound (IIa/B) to reduce the risk of stroke in cardiac surgery, in this contemporary trial, use remains infrequent, with significant site-to-site variability.
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Affiliation(s)
- Alexander D Shapeton
- Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD.
| | - Kay B Leissner
- Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD
| | - Suzana M Zorca
- Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD
| | - Houman Amirfarzan
- Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD
| | - Eileen M Stock
- Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD
| | - Kousick Biswas
- Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD
| | - Miguel Haime
- Division of Cardiac Surgery, Veterans Affairs Boston Healthcare System and Harvard Medical School, Boston, MA
| | - Venkatesh Srinivasa
- Department of Anesthesia, Critical Care and Pain Medicine, Veterans Affairs Boston Healthcare System and Harvard Medical School, Boston, MA
| | - Jacquelyn A Quin
- Division of Cardiac Surgery, Veterans Affairs Boston Healthcare System and Harvard Medical School, Boston, MA
| | - Marco A Zenati
- Division of Cardiac Surgery, Veterans Affairs Boston Healthcare System and Harvard Medical School, Boston, MA
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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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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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17
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Kim J, Budoff MJ, Nasir K, Wong ND, Yeboah J, Al-Mallah MH, Shea S, Dardari ZA, Blumenthal RS, Blaha MJ, Cainzos-Achirica M. Thoracic aortic calcium, cardiovascular disease events, and all-cause mortality in asymptomatic individuals with zero coronary calcium: The Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis 2017; 257:1-8. [PMID: 28033543 PMCID: PMC5325775 DOI: 10.1016/j.atherosclerosis.2016.12.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 11/28/2016] [Accepted: 12/09/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS TAC is associated with incident CVD and all-cause mortality. Nevertheless, the independent 10-year prognostic value of TAC in individuals with CAC = 0 beyond traditional risk factors is not well established. METHODS 3415 MESA participants with baseline CAC = 0 were followed for CHD, CVD events and all-cause mortality. TAC was measured in the ascending and descending aorta in all participants and quantified using Agatston's score. Multivariable Cox proportional hazards regression models were used to study the associations between TAC and incident CHD, CVD events and all-cause mortality. Likelihood ratio tests were used to compare prediction models including traditional risk factors plus TAC versus risk factors alone. RESULTS 406 participants (11.9%) had TAC>0 at baseline. Over a median follow-up of 11.3 years, unadjusted event rates per 1000 person-years were higher in TAC>0 than in TAC = 0 participants: CHD 2.18 vs. 2.03; CVD 6.85 vs. 3.42; all-cause mortality 12.84 vs. 4.96. However, in multivariable Cox regression analyses adjusting for CVD risk factors, neither TAC>0, TAC>100 nor log(TAC+1) were independently associated with any of the study outcomes, nor improved their prediction compared to traditional risk factors alone (p value of likelihood ratio tests >0.05). CONCLUSIONS In a multi-ethnic, modern US population of asymptomatic individuals with CAC = 0 at baseline, the prevalence of TAC>0 was low, and TAC did not improve 10-year estimation of prognosis beyond traditional risk factors. In the presence of CAC = 0, measurement of TAC is unlikely to provide sufficient additional prognostic information to further improve risk assessment.
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Affiliation(s)
- Joonseok Kim
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45257, USA; Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Department of Cardiology, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
| | - Matthew J Budoff
- Division of Cardiology, Los Angeles Biomedical Research Center at Harbor-UCLA, Division of Cardiology, Torrance, CA 90502, USA
| | - Khurram Nasir
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Department of Cardiology, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA; Center for Prevention and Wellness Research, Baptist Health South Florida, Miami, FL 33139, USA
| | - Nathan D Wong
- Division of Cardiology, University of California, Irvine, CA 92697, USA
| | - Joseph Yeboah
- Division of Cardiology, Department of Medicine, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Mouaz H Al-Mallah
- Division of Cardiology, Henry Ford Hospital, Detroit, MI 48202, USA; King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Cardiac Center, Ministry of National Guard, Health Affairs, Saudi Arabia
| | - Steve Shea
- Departments of Medicine and Epidemiology, Columbia University, New York, NY 10032, USA
| | - Zeina A Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Department of Cardiology, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Department of Cardiology, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Department of Cardiology, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD 21205, USA.
| | - Miguel Cainzos-Achirica
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Department of Cardiology, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD 21205, USA
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Canale JM, Cardoza-Encinas R, Canale-Segovia A. Peculiaridades de la ecocardiografía transesofágica en pacientes octogenarios. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2017; 87:35-42. [DOI: 10.1016/j.acmx.2016.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 11/14/2016] [Accepted: 11/14/2016] [Indexed: 10/20/2022] Open
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Djaiani GN. Aortic Arch Atheroma: Stroke Reduction in Cardiac Surgical Patients. Semin Cardiothorac Vasc Anesth 2016; 10:143-57. [PMID: 16959741 DOI: 10.1177/1089253206289006] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cardiac surgery is increasingly performed on elderly patients with extensive coronary artery abnormalities who have impaired left ventricular function, decreased physiologic reserve, and multiple comorbid conditions. Considerable numbers of these patients develop perioperative neurologic complications ranging from subtle cognitive dysfunction to more evident postoperative confusion, delirium, and, less commonly, clinically apparent stroke. Magnetic resonance imaging studies have elucidated that a considerable number of patients have new ischemic brain infarcts, particularly after conventional coronary artery bypass graft surgery. Mechanisms of cerebral injury during and after cardiac surgery are discussed. Intraoperative transesophageal echocardiography and epiaortic scanning for detection of atheromatous disease of the proximal thoracic aorta is paramount in identifying patients at high risk from neurologic injury. It is important to recognize that our efforts to minimize neurologic injury should not be limited to the intraoperative period. Particular efforts should be directed to temperature management, glycemia control, and pharmacologic neuroprotection extending into the postoperative period. Preoperative magnetic resonance angiography may be of value for screening patients with significant atheroma of the proximal thoracic aorta. It is likely that for patients with no significant atheromatous disease, conventional coronary artery revascularization is the most effective long-term strategy, whereas patients with atheromatous thoracic aorta may be better managed with beating heart surgery, hybrid techniques, or medical therapy alone. Patient stratification based on the aortic atheromatic burden should be addressed in future trials designed to tailor treatment strategies to improve long-term outcomes of coronary heart disease and reduce the risks of perioperative neurologic injury.
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Affiliation(s)
- George N Djaiani
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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20
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Abstract
It is well known that subtle neurologic and neuropsychologic adverse effects are associated with cardiac surgery. Microgaseous emboli may arise from the cardiac pulmonary bypass apparatus; however, most particulate emboli arise from the ascending aorta. Atherosclerosis of the ascending aorta may effect up to 38% of cardiac surgical patients greater than 50 years of age. In addition to avoiding cardiopulmonary bypass with off-pump procedures, avoiding manipulation of the ascending aorta in any way is also associated with a reduction in embolic complications. Epiaortic scanning is the most accurate way to assess the location and severity of atheromata in the ascending aorta. Management of the atheromatous ascending aorta may include changes to cannulation options for cardiopulmonary bypass, such as femoral or axillary cannulation. Complete avoidance of the cross-clamp may be entertained. Aorta cannulae incorporate a number of filtration and deflection devices that may offer some protection to the brachiocephalic vessels. In some cases, replacement of the ascending aorta under deep hypothermic circulatory arrest is appropriate. Avoidance of the ascending aorta by using arterial revascularization as sequential or Y grafts, or placing proximal anastomoses on the subclavian arteries, may allow for complete revascularization without touching the ascending aorta. A full appreciation of the information obtained with epiaortic scanning or transesophageal echocardiography allows for decisions to be made to tailor each procedure to the patient's unique needs and circumstances for optimal outcomes.
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Abstract
Despite an overall decrease in perioperative morbidity and mortality, evidence of some degree of central nervous system dysfunction associated with coronary artery bypass graft (CABG) surgery—with or without cardiopulmonary bypass— has steadily mounted. From preoperative studies of CABG patients, it is apparent that over 50% of patients who present for cardiac surgery have evidence of either extracranial or intracranial atherosclerotic disease. Patient-specific factors thus have a fundamental impact on the risks of a brain injury developing after CABG surgery. Cerebral embolization and/or ischemic hypoperfusion are the most likely etiologic mechanisms for perioperative brain injury associated with cardiac surgery, and these factors are closely interrelated. Various monitoring techniques can decrease risk of intraoperative cerebral embolization and hypoperfusion and are associated with improved outcomes. Ultrasound guided aortic instrumentation (epiaortic scanning) can markedly decrease atheroembolic load and risk of stroke. Unrecognized sources of microgaseous emboli, including air entrainment from surgical purse string sutures and perfusionist interventions, can be identified and reduced by transcranial Doppler monitoring. Cerebral hypoperfusion from unrecognized cerebral venous obstruction, inadequate mean arterial pressure, or from hypocapnic cerebral alkalosis can be identified by multimodality neuromonitoring using regional cerebral oxygen saturation and transcranial Doppler. Overall patient outcomes can be improved, and hospital length of stay shortened, by applied neuromonitoring techniques.
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Affiliation(s)
- John M Murkin
- University of Western Ontario, London, Ontario, Canada.
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22
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Abstract
Patients undergoing coronary artery bypass grafting are at higher risk of neurologic events than demographi cally similar patients undergoing noncardiac surgery. Postoperative stroke has been shown to occur two to three times more frequently than in age-, gender-, and education-matched patients undergoing noncardiac vas cular or thoracic surgery. The incidence of more subtle brain syndromes, giving rise to symptoms of memory loss and cognitive deterioration as documented in up to 79% of coronary bypass patients, varies depending on whether prospective or retrospective data are analyzed, and whether or not serial cognitive testing is used, and is also significantly higher in coronary bypass patients. Various factors have been identified as causative in the genesis of perioperative neurologic injury in these pa tients. Although there is evidence that microgaseous and microparticulate emboli are instrumental in the production of postoperative cognitive impairment, the role of ascending aortic atherosclerosis is increasingly recognized as being the greatest single risk factor for postoperative stroke.
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Murkin JM. Pathophysiological Basis of CNS Injury in Cardiac Surgical Patients: Detection and Prevention. Perfusion 2016; 21:203-8. [PMID: 16939113 DOI: 10.1191/0267659106pf869oa] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The current understanding of adverse central nervous system (CNS) events following cardiac surgery involves several identifiable, evidence-based mechanisms: athero-sclerotic emboli, microgaseous and microparticulate emboli, and hypoperfusion.1 Secondary factors, including patient co-morbidities and inherent genetic susceptibilities, as well as systemic inflammatory processes and a suboptimal metabolic milieu may interact to potentiate the extent of injury.2 In this review a number of these factors and their potential interactions will be explored with a view towards developing a comprehensive management strategy to minimize CNS injury.
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Khosravi A, Skrabal CA, Westphal B, Kundt G, Greim B, Kunesch E, Liebold A, Steinhoff G. Evaluation of coated oxygenators in cardiopulmonary bypass systems and their impact on neurocognitive function. Perfusion 2016; 20:249-54. [PMID: 16231620 DOI: 10.1191/0267659105pf818oa] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Introduction: Coronary artery bypass graft surgery (CABG) using cardiopulmonary bypass (CPB) is assumed to be associated with a decline of neurocognitive functions. This study was designed to analyse the neurocognitive function of patients with coronary heart disease before and after CABG and to determine possible protective effects of oxygenator surface coating on neurological outcome.Methods: Forty patients scheduled for selective CABG were prospectively randomized into two groups of 20 patients each according to the type of hollow-fibre membrane oxygenator used. Non-coated oxygenators (Group A) were compared to phosphorylcholine (PC)- coated oxygenators (Group B). A battery of six neurological tests was administered preoperatively, 7 - 10 days and 4 - 6 months after surgery.Results: One patient of Group A suffered from a perioperative stroke and died on postoperative day 3, presumably because of sudden heart failure. Two patients of Group A (10%) developed a symptomatic transitory delirious psychotic syndrome (STPT) on postoperative days 3 and 5. None of the patients of Group B had perioperative complications. The test analysis revealed a trend of declined neurocognitive function early after CABG, but did not show any difference in neurocognitive outcome between the two groups.Discussion: PC coating of the oxygenators did not show any significant benefit on neurocognitive function after CABG using CPB.
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Affiliation(s)
- Amir Khosravi
- Department of Cardiac Surgery, University of Rostock, Rostock, Germany
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Kodumuri N, Giamberardino L, Hinderliter A, Sen S. Association of Dietary Factors with Progression of AA in Stroke/TIA Patients. ACTA ACUST UNITED AC 2016; 4. [PMID: 28989944 DOI: 10.4172/2329-6895.1000270] [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: 11/09/2022]
Abstract
OBJECTIVE To investigate the effect of dietary factors such as calorie intake and dietary fats on the progression of aortic arch atheroma (AA). BACKGROUND In stroke/TIA patients, progression of AA is associated with recurrent vascular events. DESIGN/METHODS Consecutive patients with measurable (>1 mm) AA atheroma on baseline transesophageal echocardiogram (TEE) evaluation consented to a protocol mandated follow-up TEE at 12 months. Patients that had adequate paired AA images were assessed for progression, defined as Δ ≥ 1 grade worsening (based on plaque thickness over 12 months). Stroke risk factors and fasting lipid profile were assessed at baseline. The patient's nutritional intake was measured at baseline using the Gladys Block Food Frequency Questionnaire. RESULTS One-hundred-nine patients (70 strokes, 33 TIAs) had sequential TEEs, of whom 27% (N=30) progressed and 73% (N=79) did not. Patients with progression had higher daily calorie (1778 ± 623 vs. 1378 ± 406 Calories, p=0.008), fat (76 ± 33 vs. 52 ± 23 grams, p=0.0002), carbohydrate (208 ± 78 vs. 169 ± 57 grams, p=0.01) and protein (73 ± 26 vs. 57 ± 21 grams, p=0.005) intake. On Further analysis among different fats showed a higher consumption of saturated fats (25 ± 12 vs. 17 ±8 grams, p=0.00051) as well as unsaturated fats (44 ± 20 vs. 30 ± 13 grams, p=0.002). These differences remained significant after we adjusted for the medication use. However the significance of these differences was attenuated after adjusting for the calorie intake. Cholesterol consumption did not differ between the progression and no-progression group (262 ± 125 vs. 213 ± 149 mg, p=0.2). CONCLUSIONS/RELEVANCE Calorie intake plays a significant role in the progression of AA. Further studies are needed to confirm these findings and determine the specific dietary modifications that may prevent AA progression and associated recurrent vascular events.
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Affiliation(s)
| | | | - Alan Hinderliter
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Souvik Sen
- University of South Carolina, Columbia, South Carolina, USA
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Goksuluk H, Gulec S, Ozcan OU, Gerede M, Vurgun VK, Ozyuncu N, Erol C. Usefulness of Neuron-Specific Enolase to Detect Silent Neuronal Ischemia After Percutaneous Coronary Intervention. Am J Cardiol 2016; 117:1917-20. [PMID: 27134059 DOI: 10.1016/j.amjcard.2016.03.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 03/16/2016] [Accepted: 03/16/2016] [Indexed: 10/22/2022]
Abstract
Increased plasma levels of neuron-specific enolase (NSE) are related to damage of neurons and neuroendocrine cells. We aimed to investigate elevation of NSE after elective percutaneous coronary intervention (PCI) on the prediction of silent cerebral infarct (SCI). Study population consisted of 2 groups of patients. Group 1 included 92 consecutive patients with normal coronary angiograms, whereas group 2 consisted of 89 patients who underwent elective coronary stenting. NSE levels were studied before and 12 hours after the procedure. Elevation of >0.12 μg/L was considered as SCI. Forty-seven of 181 study patients (26%) had SCI after the procedure. NSE elevation was significantly more prevalent in patients with PCI than that of controls. Elevation of NSE was observed in 42% of patients who underwent elective PCI (n = 37) and 11% of the normal coronary artery group (n = 10) (p <0.001). The incidence of SCI was higher in active smokers and patients who had history of myocardial infarction (MI) (55% vs 10%, p <0.001 for active smokers and 40% vs 8%, p <0.001 for history of MI, respectively). Multivariate analysis demonstrated history of smoking (odds ratio [OR] 9.9; 95% confidence interval [CI] 3.7 to 26.9; p <0.001) and previous MI (OR 4.4; 95% CI 1.7 to 11.4; p = 0.01) as independent predictors of SCI. For patients who underwent elective PCI, NSE levels after procedure increases. Invasive coronary procedures have risk of SCIs, even in patients with normal coronary arteries. In conclusion, increased diagnosis of SCIs might improve understanding of their relation with invasive cardiac procedures, facilitate to prevent occurrence of silent microemboli and decrease the risk of adverse neurologic events.
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Taggart DP. ¿Hay todavía un lugar para la cirugía coronaria sin circulación extracorpórea en 2015? Ciertamente sí. CIRUGIA CARDIOVASCULAR 2016. [DOI: 10.1016/j.circv.2015.06.010] [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] Open
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Atherosclerotic Disease of the Proximal Aorta. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00033-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Taggart DP. Is there still a role for off-pump CABG in 2015? Certainly yes. CIRUGIA CARDIOVASCULAR 2016. [DOI: 10.1016/j.circv.2015.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Multimodality Imaging of Diseases of the Thoracic Aorta in Adults: From the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28:119-82. [DOI: 10.1016/j.echo.2014.11.015] [Citation(s) in RCA: 409] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RSV, Vrints CJM. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014; 35:2873-926. [PMID: 25173340 DOI: 10.1093/eurheartj/ehu281] [Citation(s) in RCA: 2903] [Impact Index Per Article: 290.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Yadav BK, Hong Y, Shin BS. Correlation of VEGF genetic polymorphisms and lipid profile to aortic calcification. Gene 2014; 550:33-9. [PMID: 25108133 DOI: 10.1016/j.gene.2014.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 06/26/2014] [Accepted: 08/05/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Aortic calcification is developed due to accumulation of a large amount of calcium in the aorta of the heart and it is the leading cause of aortic valve replacement and third leading cause of cardiovascular disease. The purpose of this study was to investigate the relation between aortic calcification and VEGF SNPs (-2578C>A, -1154G>A and +936C>T) and to evaluate the association of these SNPs with biochemical parameter in relation to aortic calcification. METHODS Aortic calcification was diagnosed by examining the posteroanterior chest X-rays by a radiologist and graded into four groups. The real-time polymerase chain reaction with melting curve analysis in LightCycler was used to genotype the VEGF SNPs. RESULTS Among the VEGF SNPs, a significant genetic difference was found only between the aortic calcification and control group with VEGF SNP -2578C>A but haplotypes T-A-A of (+936/-1154/-2578) were significantly different in control and aortic calcification and could enhance the aortic calcification development. By regression analysis, it was found that age, hypertension, diabetes, dyslipidemia, and hyperhomocysteinemia were found significantly different with the different genotypes of VEGF SNPs which may induce aortic calcification development. CONCLUSION Age, hypertension, diabetes, dyslipidemia, and hyperhomocysteinemia were established as aggravating factors for the aortic calcification in association with different VEGF genotypes.
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Affiliation(s)
- Binod Kumar Yadav
- Department of Medical Sciences, Chonbuk National University Graduate School, Jeonju, Chonbuk, Republic of Korea; Department of Biochemistry, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Yoochan Hong
- Department of Biological Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Byoung-Soo Shin
- Department of Neurology, Chonbuk National University Medical School, Jeonju, Chonbuk, Republic of Korea; Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Chonbuk, Republic of Korea.
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Cui X, Li Y, Liu J, He S, Liu M. Aortic arch atheroma and the risk of stroke: a meta-analysis. J Evid Based Med 2014; 7:185-91. [PMID: 25154372 DOI: 10.1111/jebm.12113] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 04/24/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUNDS AND OBJECTIVES Epidemiological studies have suggested that aortic atheroma may play a role in cerebral embolization; however, no meta-analysis was conducted to evaluate the relationship between aortic atheroma and risk of stroke. The aim of this study was to investigate the association between the presence of aortic atheroma and risk of stroke. METHODS We performed a comprehensive search of observational studies reporting the relationship between the presence of aortic atheroma and stroke using the PubMed, EMbase, the China National Knowledge Infrastructure database (CNKI), Chinese Technical Periodicals (VIP), and WanFang Data databases. Two reviewers independently assessed the eligibility and extracted data from the included studies. We performed the meta-analysis to estimate the strength of the association according to Meta-analysis of Observational Studies in Epidemiology (MOOSE) guideline and assessed the study quality by the Newcastle-Ottawa Scale (NOS). RESULTS We identified 12 eligible studies with 3918 participants. The scores of the NOS of the included studies ranged from 5 to 9. The pooled estimate of strength of the association between the presence of aortic atheroma and stroke was statistical significant (OR = 3.93, 95%CI 2.86 to 5.40). In subgroup analysis according to plaques' morphology, complex aortic atheroma had significantly higher (OR = 5.90, 95%CI 4.14 to 8.41) risk of stroke than protruding atheroma (OR = 3.75, 95%CI 3.05 to 4.61). CONCLUSIONS This study indicated that aortic atheroma significantly increased the risk of stroke by about four times. Patients with complex aortic atheroma have a higher risk of stroke than protruding atheroma.
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Affiliation(s)
- Xiaoyang Cui
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
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Hart RG, Diener HC, Coutts SB, Easton JD, Granger CB, O'Donnell MJ, Sacco RL, Connolly SJ. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014; 13:429-38. [PMID: 24646875 DOI: 10.1016/s1474-4422(13)70310-7] [Citation(s) in RCA: 1080] [Impact Index Per Article: 108.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Cryptogenic (of unknown cause) ischaemic strokes are now thought to comprise about 25% of all ischaemic strokes. Advances in imaging techniques and improved understanding of stroke pathophysiology have prompted a reassessment of cryptogenic stroke. There is persuasive evidence that most cryptogenic strokes are thromboembolic. The thrombus is thought to originate from any of several well established potential embolic sources, including minor-risk or covert cardiac sources, veins via paradoxical embolism, and non-occlusive atherosclerotic plaques in the aortic arch, cervical, or cerebral arteries. Accordingly, we propose that embolic strokes of undetermined source are a therapeutically relevant entity, which are defined as a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic sources, with a clear indication for anticoagulation. Because emboli consist mainly of thrombus, anticoagulants are likely to reduce recurrent brain ischaemia more effectively than are antiplatelet drugs. Randomised trials testing direct-acting oral anticoagulants for secondary prevention of embolic strokes of undetermined source are warranted.
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Affiliation(s)
- Robert G Hart
- McMaster University and Population Health Research Institute, Hamilton, ON, Canada.
| | | | | | - J Donald Easton
- Department of Neurology, University of California San Francisco, San Francisco, USA
| | | | | | - Ralph L Sacco
- Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Stuart J Connolly
- McMaster University and Population Health Research Institute, Hamilton, ON, Canada
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Head SJ, Börgermann J, Osnabrugge RLJ, Kieser TM, Falk V, Taggart DP, Puskas JD, Gummert JF, Kappetein AP. Coronary artery bypass grafting: Part 2--optimizing outcomes and future prospects. Eur Heart J 2014; 34:2873-86. [PMID: 24086086 DOI: 10.1093/eurheartj/eht284] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Since first introduced in the mid-1960s, coronary artery bypass grafting (CABG) has become the standard of care for patients with coronary artery disease. Surprisingly, the fundamental surgical technique itself did not change much over time. Nevertheless, outcomes after CABG have dramatically improved over the first 50 years. Randomized trials comparing percutaneous coronary intervention (PCI) to CABG have shown converging outcomes for select patient populations, providing more evidence for wider use of PCI. It is increasingly important to focus on the optimization of the short- and long-term outcomes of CABG and to reduce the level of invasiveness of this procedure. This review provides an overview on how new techniques and widespread consideration of evolving strategies have the potential to optimize outcomes after CABG. Such developments include off-pump CABG, clampless/anaortic CABG, minimally invasive CABG with or without extending to hybrid procedures, arterial revascularization, endoscopic vein harvesting, intraprocedural epiaortic scanning, graft flow assessment, and improved secondary prevention measures. In addition, this review represents a framework for future studies by summarizing the areas that need more rigorous clinical (randomized) evaluation.
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Affiliation(s)
- Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, PO Box 2040, 3000 CA Rotterdam, The Netherlands
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Heyer KS, Eskandari MK. Carotid stenting: risk factors for periprocedural stroke. Expert Rev Neurother 2014; 8:469-77. [DOI: 10.1586/14737175.8.3.469] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Hartert M, Abugameh A, Vahl CF. Herausforderung Porzellanaorta. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00398-013-1039-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Aortic arch atheroma in transient ischemic attack patients. Atherosclerosis 2013; 231:124-8. [DOI: 10.1016/j.atherosclerosis.2013.08.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 08/23/2013] [Accepted: 08/23/2013] [Indexed: 11/19/2022]
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Cerebral dysfunction after coronary artery bypass surgery. J Anesth 2013; 28:242-8. [DOI: 10.1007/s00540-013-1699-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Accepted: 08/08/2013] [Indexed: 01/01/2023]
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Fukuda I, Daitoku K, Minakawa M, Fukuda W. Shaggy and calcified aorta: surgical implications. Gen Thorac Cardiovasc Surg 2013; 61:301-13. [DOI: 10.1007/s11748-013-0203-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Indexed: 12/01/2022]
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From accuracy to patient outcome and cost-effectiveness evaluations of diagnostic tests and biomarkers: an exemplary modelling study. BMC Med Res Methodol 2013; 13:12. [PMID: 23368927 PMCID: PMC3724486 DOI: 10.1186/1471-2288-13-12] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 01/24/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Proper evaluation of new diagnostic tests is required to reduce overutilization and to limit potential negative health effects and costs related to testing. A decision analytic modelling approach may be worthwhile when a diagnostic randomized controlled trial is not feasible. We demonstrate this by assessing the cost-effectiveness of modified transesophageal echocardiography (TEE) compared with manual palpation for the detection of atherosclerosis in the ascending aorta. METHODS Based on a previous diagnostic accuracy study, actual Dutch reimbursement data, and evidence from literature we developed a Markov decision analytic model. Cost-effectiveness of modified TEE was assessed for a life time horizon and a health care perspective. Prevalence rates of atherosclerosis were age-dependent and low as well as high rates were applied. Probabilistic sensitivity analysis was applied. RESULTS The model synthesized all available evidence on the risk of stroke in cardiac surgery patients. The modified TEE strategy consistently resulted in more adapted surgical procedures and, hence, a lower risk of stroke and a slightly higher number of life-years. With 10% prevalence of atherosclerosis the incremental cost-effectiveness ratio was € 4,651 and € 481 per quality-adjusted life year in 55-year-old men and women, respectively. In all patients aged 65 years or older the modified TEE strategy was cost saving and resulted in additional health benefits. CONCLUSIONS Decision analytic modelling to assess the cost-effectiveness of a new diagnostic test based on characteristics, costs and effects of the test itself and of the subsequent treatment options is both feasible and valuable. Our case study on modified TEE suggests that it may reduce the risk of stroke in cardiac surgery patients older than 55 years at acceptable cost-effectiveness levels.
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Ito A, Goto T, Maekawa K, Baba T, Mishima Y, Ushijima K. Postoperative neurological complications and risk factors for pre-existing silent brain infarction in elderly patients undergoing coronary artery bypass grafting. J Anesth 2012; 26:405-11. [DOI: 10.1007/s00540-012-1327-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 01/05/2012] [Indexed: 11/28/2022]
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Telman G, Kouperberg E, Sprecher E, Agmon Y. Aortic Atheromas in Acute Ischemic Stroke Patients in Northern Israel. J Atheroscler Thromb 2012; 19:169-75. [DOI: 10.5551/jat.8334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Barazangi N, Wintermark M, Lease K, Rao R, Smith W, Josephson SA. Comparison of Computed Tomography Angiography and Transesophageal Echocardiography for Evaluating Aortic Arch Disease. J Stroke Cerebrovasc Dis 2011; 20:436-42. [DOI: 10.1016/j.jstrokecerebrovasdis.2010.02.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 01/04/2010] [Accepted: 02/05/2010] [Indexed: 01/25/2023] Open
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Sharma U, Tak T. Aortic Atheromas: Current Knowledge and Controversies: A Brief Review of the Literature. Echocardiography 2011; 28:1157-63. [DOI: 10.1111/j.1540-8175.2011.01478.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Di Tullio MR, Homma S. Atherosclerotic Disease of the Proximal Aorta. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10038-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Budoff MJ, Nasir K, Katz R, Takasu J, Carr JJ, Wong ND, Allison M, Lima JAC, Detrano R, Blumenthal RS, Kronmal R. Thoracic aortic calcification and coronary heart disease events: the multi-ethnic study of atherosclerosis (MESA). Atherosclerosis 2010; 215:196-202. [PMID: 21227418 DOI: 10.1016/j.atherosclerosis.2010.11.017] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Revised: 10/20/2010] [Accepted: 11/13/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND The presence and extent of coronary artery calcium (CAC) is an independent predictor of coronary heart disease (CHD) morbidity and mortality. Few studies have evaluated interactions or independent incremental risk for coronary and thoracic aortic calcification (TAC). The independent predictive value of TAC for CHD events is not well-established. METHODS This study used risk factor and computed tomography scan data from 6807 participants in the multi-ethnic study of atherosclerosis (MESA). Using the same images for each participant, TAC and CAC were each computed using the Agatston method. The study subjects were free of incident CHD at entry into the study. RESULTS The mean age of the study population (n=6807) was 62±10 years (47% males). At baseline, the prevalence of TAC and CAC was 28% (1904/6809) and 50% (3393/6809), respectively. Over 4.5±0.9 years, a total of 232 participants (3.41%) had CHD events, of which 132 (1.94%) had a hard event (myocardial infarction, resuscitated cardiac arrest, or CHD death). There was a significant interaction between gender and TAC for CHD events (p<0.05). Specifically, in women, the risk of all CHD event was nearly 3-fold greater among those with any TAC (hazard ratio: 3.04, 95% CI: 1.60-5.76). After further adjustment for increasing CAC score, this risk was attenuated but remained robust (HR: 2.15, 95% CI: 1.10-4.17). Conversely, there was no significant association between TAC and incident CHD in men. In women, the likelihood ratio chi square statistics indicate that the addition of TAC contributed significantly to predicting incident CHD event above that provided by traditional risk factors alone (chi square=12.44, p=0.0004) as well as risk factors+CAC scores (chi square=5.33, p=0.02). On the other hand, addition of TAC only contributed in the prediction of hard CHD events to traditional risk factors (chi-square=4.33, p=0.04) in women, without contributing to the model containing both risk factors and CAC scores (chi square=1.55, p=0.21). CONCLUSION Our study indicates that TAC is a significant predictor of future coronary events only in women, independent of CAC. On studies obtained for either cardiac or lung applications, determination of TAC may provide modest supplementary prognostic information in women with no extra cost or radiation.
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Affiliation(s)
- Matthew J Budoff
- Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA, United States
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Capmany RP, Ibañez MO, Pesquer XJ. Complex atheromatosis of the aortic arch in cerebral infarction. Curr Cardiol Rev 2010; 6:184-93. [PMID: 21804777 PMCID: PMC2994110 DOI: 10.2174/157340310791658712] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Revised: 04/10/2010] [Accepted: 05/25/2010] [Indexed: 12/13/2022] Open
Abstract
In many stroke patients it is not possible to establish the etiology of stroke. However, in the last two decades, the use of transesophageal echocardiography in patients with stroke of uncertain etiology reveals atherosclerotic plaques in the aortic arch, which often protrude into the lumen and have mobile components in a high percentage of cases. Several autopsy series and retrospective studies of cases and controls have shown an association between aortic arch atheroma and arterial embolism, which was later confirmed by prospectively designed studies. The association with ischemic stroke was particularly strong when atheromas were located proximal to the ostium of the left subclavian artery, when the plaque was ≥ 4 mm thick and particularly when mobile components are present. In these cases, aspirin might not prevent adequately new arterial ischemic events especially stroke. Here we review the evidence of aortic arch atheroma as an independent risk factor for stroke and arterial embolism, including clinical and pathological data on atherosclerosis of the thoracic aorta as an embolic source. In addition, the impact of complex plaques (≥ 4 mm thick, or with mobile components) on increasing the risk of stroke is also reviewed. In non-randomized retrospective studies anticoagulation was superior to antiplatelet therapy in patients with stroke and aortic arch plaques with mobile components. In a retrospective case-control study, statins significantly reduced the relative risk of new vascular events. However, given the limited data available and its retrospective nature, randomized prospective studies are needed to establish the optimal secondary prevention therapeutic regimens in these high risk patients.
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Affiliation(s)
- Ramón Pujadas Capmany
- Department of Cardiology, Hospital Universitari del Sagrat Cor, Address: Viladomat 288, E-08027 Barcelona, Spain
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Gao C, Yang M, Wang G, Wang J, Xiao C, Wu Y, Li J. Totally Endoscopic Robotic Atrial Septal Defect Repair on the Beating Heart. Heart Surg Forum 2010; 13:E155-8. [DOI: 10.1532/hsf98.20091175] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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