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Harky A, Chow VJ, Voller C, Goyal K, Shaw M, Bhawnani A, Kenawy A, Wilson I, Lip GYH, Field M, Kuduvalli M. Stroke outcomes following cardiac and aortic surgery are improved by the involvement of a stroke team. Eur J Clin Invest 2024:e14275. [PMID: 38943528 DOI: 10.1111/eci.14275] [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: 02/10/2024] [Accepted: 06/10/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVES Post-cardiac and aortic surgery stroke is often underreported. We detail our single-centre experience the following introduction of comprehensive consultant-led daily stroke service, to demonstrate the efficacy of a stroke team in recovery from stroke following cardiac and aortic surgeries. METHODS This retrospective, single-centre observational cohort study analysed consecutive patients undergoing cardiac and aortic surgery at our institution from August 2014 to December 2020. Main outcomes included stroke rate, predictors of stroke, and neurological deficit resolution or persistence at discharge and clinic follow-up. RESULTS A total of 12,135 procedures were carried out in the reference period. Among these, 436 (3.6%) suffered a stroke. Overall survival to discharge and follow-up were 86.0% and 84.0% respectively. Independent risk factors for post-operative stroke included advanced age (OR 1.033, 95% CI [1.023, 1.044], p < .001), female sex (OR 1.491, 95% [1.212, 1.827], p < .001), history of previous cardiac surgeries (OR 1.670, 95% CI [1.239, 2.218], p < .001), simultaneous coronary artery bypass graft + valve procedures (OR 1.825, 95% CI [1.382, 2.382], p < .001) and CPB time longer than 240 min (OR 3.384, 95% CI [2.413, 4.705], p < .001). Stroke patients managed by the multidisciplinary team demonstrated significantly higher rates of survival at discharge (87.3% vs. 61.9%, p = .001). CONCLUSIONS Perioperative stroke can be debilitating immediately long term. The involvement of specialist stroke teams plays a key role in reducing the long-term burden and mortality of this condition.
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Affiliation(s)
- Amer Harky
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Vanessa Jane Chow
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Calum Voller
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Kartik Goyal
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Matthew Shaw
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Anurodh Bhawnani
- Department of Cardiothoracic Anaesthesia and Intensive Care, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Ayman Kenawy
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Ian Wilson
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
| | - Mark Field
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Manoj Kuduvalli
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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Navi BB, Zhang C, Kaiser JH, Liao V, Cushman M, Kasner SE, Elkind MSV, Tagawa ST, Guntupalli SR, Gaudino MFL, Lee AYY, Khorana AA, Kamel H. Cancer and the risk of perioperative arterial ischaemic events. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:345-356. [PMID: 37757472 DOI: 10.1093/ehjqcco/qcad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND AND AIMS Most cancer patients require surgery for diagnosis and treatment. This study evaluated whether cancer is a risk factor for perioperative arterial ischaemic events. METHODS The primary cohort included patients registered in the National Surgical Quality Improvement Program (NSQIP) between 2006 and 2016. The secondary cohort included Healthcare Cost and Utilization Project (HCUP) claims data from 11 US states between 2016 and 2018. Study populations comprised patients who underwent inpatient (NSQIP, HCUP) or outpatient (NSQIP) surgery. Study exposures were disseminated cancer (NSQIP) and all cancers (HCUP). The primary outcome was a perioperative arterial ischaemic event, defined as myocardial infarction or stroke diagnosed within 30 days after surgery. RESULTS Among 5 609 675 NSQIP surgeries, 2.2% involved patients with disseminated cancer. The perioperative arterial ischaemic event rate was 0.96% among patients with disseminated cancer vs. 0.48% among patients without (hazard ratio [HR], 2.01; 95% confidence interval [CI], 1.90-2.13). In Cox analyses adjusting for demographics, functional status, comorbidities, surgical specialty, anesthesia type, and clinical factors, disseminated cancer remained associated with higher risk of perioperative arterial ischaemic events (HR, 1.37; 95% CI, 1.28-1.46). Among 1 341 658 surgical patients in the HCUP cohort, 11.8% had a diagnosis of cancer. A perioperative arterial ischaemic event was diagnosed in 0.74% of patients with cancer vs. 0.54% of patients without cancer (HR, 1.35; 95% CI, 1.27-1.43). In Cox analyses adjusted for demographics, insurance, comorbidities, and surgery type, cancer remained associated with higher risk of perioperative arterial ischaemic events (HR, 1.31; 95% CI, 1.21-1.42). CONCLUSION Cancer is an independent risk factor for perioperative arterial ischaemic events.
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Affiliation(s)
- Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY 10021, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Jed H Kaiser
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Vanessa Liao
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Mary Cushman
- Division of Hematology and Oncology, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT 05446, USA
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Scott T Tagawa
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine, New York, NY 10021, USA
| | - Saketh R Guntupalli
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Colorado School of Medicine at Denver, Aurora, CO 80045, USA
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York NY 10021, USA
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, University of British Columbia, BC Cancer, Vancouver, BC, Canada
| | - Alok A Khorana
- Department of Hematology and Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY 10021, USA
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Guo Y, Yang C, Zhu W, Zhao R, Ren K, Duan W, Liu J, Ma J, Chen X, Liu B, Xu C, Jin Z, Shi X. Electrical impedance tomography provides information of brain injury during total aortic arch replacement through its correlation with relative difference of neurological biomarkers. Sci Rep 2024; 14:14236. [PMID: 38902461 PMCID: PMC11190256 DOI: 10.1038/s41598-024-65203-0] [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] [Received: 10/17/2023] [Accepted: 06/18/2024] [Indexed: 06/22/2024] Open
Abstract
Postoperative neurological dysfunction (PND) is one of the most common complications after a total aortic arch replacement (TAAR). Electrical impedance tomography (EIT) monitoring of cerebral hypoxia injury during TAAR is a promising technique for preventing the occurrence of PND. This study aimed to explore the feasibility of electrical impedance tomography (EIT) for warning of potential brain injury during total aortic arch replacement (TAAR) through building the correlation between EIT extracted parameters and variation of neurological biomarkers in serum. Patients with Stanford type A aortic dissection and requiring TAAR who were admitted between December 2021 to March 2022 were included. A 16-electrode EIT system was adopted to monitor each patient's cerebral impedance intraoperatively. Five parameters of EIT signals regarding to the hypothermic circulatory arrest (HCA) period were extracted. Meanwhile, concentration of four neurological biomarkers in serum were measured regarding to time before and right after surgery, 12 h, 24 h and 48 h after surgery. The correlation between EIT parameters and variation of serum biomarkers were analyzed. A total of 57 TAAR patients were recruited. The correlation between EIT parameters and variation of biomarkers were stronger for patients with postoperative neurological dysfunction (PND(+)) than those without postoperative neurological dysfunction (PND(-)) in general. Particularly, variation of S100B after surgery had significantly moderate correlation with two parameters regarding to the difference of impedance between left and right brain which were MRAIabs and TRAIabs (0.500 and 0.485 with p < 0.05, respectively). In addition, significantly strong correlations were seen between variation of S100B at 24 h and the difference of average resistivity value before and after HCA phase (ΔARVHCA), the slope of electrical impedance during HCA (kHCA) and MRAIabs (0.758, 0.758 and 0.743 with p < 0.05, respectively) for patients with abnormal S100B level before surgery. Strong correlations were seen between variation of TAU after surgery and ΔARVHCA, kHCA and the time integral of electrical impedance for half flow of perfusion (TARVHP) (0.770, 0.794 and 0.818 with p < 0.01, respectively) for patients with abnormal TAU level before surgery. Another two significantly moderate correlations were found between TRAIabs and variation of GFAP at 12 h and 24 h (0.521 and 0.521 with p < 0.05, respectively) for patients with a normal GFAP serum level before surgery. The correlations between EIT parameters and serum level of neurological biomarkers were significant in patients with PND, especially for MRAIabs and TRAIabs, indicating that EIT may become a powerful assistant for providing a real-time warning of brain injury during TAAR from physiological perspective and useful guidance for intensive care units.
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Affiliation(s)
- Yitong Guo
- Shaanxi Provincial Key Laboratory of Bioelectromagnetic Detection and Intelligent Perception, Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, 710032, China
- Department of Ultrasound Diagnosis, Tangdu Hospital, Fourth Medical University, Xi'an, 710038, China
| | - Chen Yang
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Wenjing Zhu
- Shaanxi Provincial Key Laboratory of Bioelectromagnetic Detection and Intelligent Perception, Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, 710032, China
- Institute of Medical Research, Northwestern Polytechnical University, Xi'an, 710072, China
| | - Rong Zhao
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Kai Ren
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Weixun Duan
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Jincheng Liu
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Jing Ma
- Shaanxi Provincial Key Laboratory of Bioelectromagnetic Detection and Intelligent Perception, Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, 710032, China
| | - Xiuming Chen
- Shaanxi Provincial Key Laboratory of Bioelectromagnetic Detection and Intelligent Perception, Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, 710032, China
- UTRON Technology Co., Ltd., Hangzhou, 310051, China
| | - Benyuan Liu
- Shaanxi Provincial Key Laboratory of Bioelectromagnetic Detection and Intelligent Perception, Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, 710032, China
| | - Canhua Xu
- Shaanxi Provincial Key Laboratory of Bioelectromagnetic Detection and Intelligent Perception, Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, 710032, China
| | - Zhenxiao Jin
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China.
| | - Xuetao Shi
- Shaanxi Provincial Key Laboratory of Bioelectromagnetic Detection and Intelligent Perception, Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, 710032, China.
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Nawrozi P, Ratschiller T, Schimetta W, Gierlinger G, Pirklbauer M, Müller H, Zierer A. Perioperative and Long-Term Outcomes in Patients Undergoing Synchronous Carotid Endarterectomy and Coronary Artery Bypass Grafting: A Single-Center Experience. Adv Ther 2024; 41:1911-1922. [PMID: 38480660 PMCID: PMC11052859 DOI: 10.1007/s12325-024-02805-0] [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] [Received: 10/29/2023] [Accepted: 01/29/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Patients requiring coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) can be managed with staged (CEA before CABG), reverse staged (CABG before CEA) or synchronous treatment. This single-center retrospective study evaluated the outcomes in patients undergoing planned synchronous CEA and CABG. METHODS Between 2000 and 2020 a total of 185 patients with symptomatic triple-vessel or left main coronary artery disease associated with 70-99% asymptomatic or 50-99% symptomatic uni- or bilateral internal carotid artery (ICA) stenosis underwent synchronous CEA and CABG at our institution. Study endpoints were defined as mortality, stroke and myocardial infarction at 30 days. Additionally, the composite endpoint of these events was investigated. RESULTS At 30 days, mortality, stroke and myocardial infarction rates were 5.9%, 8.1% (permanent [unresolved deficit at discharge] 5.4%) and 3.8%, respectively, and the composite endpoint was reached in 13.0% of patients. Patients suffering from a stroke more frequently had a contralateral 70-99% ICA stenosis (60.0% vs. 17.3%; p < 0.001), peripheral artery disease (73.3% vs. 38.9%; p = 0.013) and prolonged cardiopulmonary bypass time (mean 119 ± 62 min vs. 84 ± 29 min; p = 0.012). Multivariate logistic regression analysis revealed the duration of cardiopulmonary bypass (odds ratio [OR] 1.024; 95% confidence interval [CI] 1.002-1.046; p = 0.034), a history of type 2 diabetes mellitus (OR 5.097; 95% CI 1.161-22.367; p = 0.031) and peripheral artery disease (OR 5.814; 95% CI 1.231-27.457; p = 0.026) as independent risk factors for reaching the composite endpoint. CONCLUSION Patients undergoing synchronous CEA and CABG face an elevated risk of perioperative cardiovascular events, particularly an increased stroke risk in patients with symptomatic and bilateral ICA stenosis. Graphical Abstract available for this article.
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Affiliation(s)
- Paimann Nawrozi
- Department of Cardiac, Vascular and Thoracic Surgery, Kepler University Hospital, Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria.
- Medical Faculty, Johannes Kepler University, Linz, Austria.
| | - Thomas Ratschiller
- Department of Cardiac, Vascular and Thoracic Surgery, Kepler University Hospital, Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Wolfgang Schimetta
- Department of Applied Systems Research and Statistics, Johannes Kepler University, Linz, Austria
| | - Gregor Gierlinger
- Medical Faculty, Johannes Kepler University, Linz, Austria
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
| | - Markus Pirklbauer
- Department of Internal Medicine IV - Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Hannes Müller
- Department of Cardiac, Vascular and Thoracic Surgery, Kepler University Hospital, Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
| | - Andreas Zierer
- Department of Cardiac, Vascular and Thoracic Surgery, Kepler University Hospital, Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
- Medical Faculty, Johannes Kepler University, Linz, Austria
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5
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Ohira S, Kai M, Goldberg JB, Malekan R, Gregory V, Pena CDL, Aoki K, Egawa S, Lansman SL, Spielvogel D. Stroke After Acute Type A Dissection Repair Using Right Axillary Cannulation First Approach. Ann Thorac Surg 2024; 117:753-760. [PMID: 38081500 DOI: 10.1016/j.athoracsur.2023.11.028] [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: 02/17/2023] [Revised: 10/12/2023] [Accepted: 11/20/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND This study sought to analyze the details of strokes after acute type A dissection repair (ATAD) using a right axillary artery (RAX) first approach. METHODS A total of 356 consecutive ATAD repairs from 2005 to 2022 were analyzed on the basis of arterial cannulation site. Strokes were evaluated by head computed tomography. RESULTS The rate of RAX cannulation was 82.6% (n = 294), with a 38.2% rate of antegrade cerebral perfusion use, both of which had increased over the years. The non-RAX group had more cardiogenic shock (RAX, 16.3% vs non-RAX, 37.1%; P < .001), cerebral malperfusion (8.8% vs 25.8%, respectively; P < .001), and innominate artery dissection (45.9% vs 69.2%, respectively; P = .007). Eight patients died before undergoing a full neurologic assessment. The overall stroke rate was 8.4% (n = 30), and it was lower in the RAX group (5.1% vs 24.2%; P < .001). All strokes were ischemic, with concomitant hemorrhagic strokes occurring in 6 patients. Strokes diagnosed immediately after surgery (perioperative stroke) accounted for 70% (n = 21 of 30) of cases. Strokes predominantly affected the right anterior circulation (right anterior, 80% vs left anterior, 46.7% vs left posterior, 26.7%; P = .013), independent of arterial cannulation site. The proposed mechanism of perioperative strokes was not uniform (embolism, 33.3%; hypoperfusion, 42.8%; embolism and hypoperfusion, 14.3%; lacunar infarct, 10%), whereas most postoperative strokes were embolic (77.8%). The mean National Institutes of Health Stroke Scale score was 20.6 ± 9.9, and the modified Rankin score at discharge was 4.1±2.2. CONCLUSIONS Most strokes in ATAD occurred perioperatively from various mechanisms predominantly affecting the right anterior circulation irrespective of the arterial cannulation site. This complication is most likely the result of unstable hemodynamics and dissection of the innominate artery (IA) or its downstream vessels.
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Affiliation(s)
- Suguru Ohira
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.
| | - Masashi Kai
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Joshua B Goldberg
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Ramin Malekan
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Vasiliki Gregory
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Corazon de la Pena
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Kosuke Aoki
- Department of Neurosurgery and Biochemistry, University of Miami, Miami, Florida
| | - Satoshi Egawa
- Department of Neurology, Colombia University Irving Medical Center, New York, New York
| | - Steven L Lansman
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - David Spielvogel
- Division of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
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Fong KY, Yeo S, Luo H, Kofidis T, Teoh KLK, Kang GS. Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. ANZ J Surg 2024; 94:522-535. [PMID: 38529814 DOI: 10.1111/ans.18947] [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: 08/01/2022] [Revised: 01/15/2023] [Accepted: 03/04/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted. METHODS An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE). RESULTS Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE. CONCLUSION This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Selvie Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Haidong Luo
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Theodoros Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Kristine L K Teoh
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Giap Swee Kang
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
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Qiu K, Xie T, Wei K, Shi HB, Liu S. Validation of the prehospital stroke scales as a tool for in-hospital large vessel occlusion stroke: whether we satisfied? Acta Neurol Belg 2024; 124:467-474. [PMID: 37889423 DOI: 10.1007/s13760-023-02402-y] [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] [Received: 02/28/2023] [Accepted: 08/18/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Prehospital stroke severity scales have been widely used to identify whether community stroke patients presented with large vessel occlusion (LVO) or not. However, whether these scales are also applicable to in-hospital stroke patients remains unknown. PURPOSE We aim to validate and compare the predictive capability of these scales for these patients. MATERIAL AND METHODS From January 2016 to October 2020, a total of 243 patients who activated in-hospital stroke alerts, were included in this study. The area under the curve (AUC) was used to assess the predictive ability of five scales (Field Assessment Stroke Triage for Emergency Destination [FAST-ED], Rapid Arterial Occlusion Evaluation [RACE], Los Angeles Motor Scale [LAMS], Cincinnati Prehospital Stroke Severity Scale [CPSSS], and Prehospital Acute Stroke Severity scale [PASS]) for LVO. In addition, multivariable logistic analysis was adopted to determine the predictors of LVO in our patients cohort. RESULTS Finally, 94 (38.7%) patients were confirmed presence of persistent LVO. The AUC for the FAST-ED, RACE, LAMS, CPSSS, and PASS scales to predict the presence of LVO in patients activating in-hospital stroke alerts were 0.82, 0.89, 0.86, 0.81, and 0.79, respectively. After multivariable analysis, baseline NIHSS (adjusted odds ratio [OR] = 1.160, 95% confidence interval [CI] = 1.110-1.212; P < 0.001) atrial fibrillation (adjusted OR = 2.940, 95% CI = 1.387-6.230; P = 0.005) and cardiac/pulmonary procedure (adjusted OR = 6.861, 95% CI = 2.437-19.315; P < 0.001) remained independent predictors of LVO. CONCLUSION The prehospital stroke scales also showed good predictive capabilities in discriminating LVO among inpatients who activated stroke alerts. However, given that inpatients' history is more readily available, a specifically designed in-hospital stroke scale that combines stroke severity and history is warranted.
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Affiliation(s)
- Kai Qiu
- Department of Interventional Radiology, The First Affiliated Hospital With Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, China
| | - Ting Xie
- Department of Radiology, Women's Hospital of Nanjing Medical University, Nanjing, 210000, China
| | - Ke Wei
- Department of Stroke Center, The First Affiliated Hospital With Nanjing Medical University, Nanjing, 210029, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, The First Affiliated Hospital With Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, China.
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital With Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, China.
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8
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Krahn KM, Koshman SL, Wang T, Chen J, Bungard TJ, Zhou JS, Omar MA, Cowley EC. Anticoagulant Prescribing Patterns in New-Onset Atrial Fibrillation After Cardiac Surgery. Ann Thorac Surg 2024; 117:859-865. [PMID: 38081497 DOI: 10.1016/j.athoracsur.2023.11.031] [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: 06/10/2023] [Revised: 11/08/2023] [Accepted: 11/20/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and is associated with an increased risk of thromboembolic stroke. Recommendations regarding the optimal anticoagulant, timing of initiation, and duration of therapy remain uncertain. METHODS Administrative databases were used to include adult patients who presented with POAF after cardiac surgery between January 1, 2015, and December 31, 2020. Key exclusion criteria included preexisting atrial fibrillation, mechanical valve replacement, or anticoagulant prescription fill within 6 months before the index admission. RESULTS A total of 3214 of patients were included, and 878 (27.3%) were prescribed an oral anticoagulant (OAC) on discharge, with 536 (61%) prescribed warfarin and 342 (39%) prescribed a direct OAC. More than half of the patients (56.1%) stopped their OAC by 6 months. There was no difference in stroke or systemic embolism at 30 days, 3 months, or 6 months between those with and without anticoagulation prescribed. However, those on any OAC had higher rates of any bleeding at all time points. CONCLUSIONS A minority of patients who presented with POAF after cardiac surgery were prescribed OAC, with warfarin being the most common agent. OAC initiation was associated with increased bleeding risk, warranting special consideration when assessing a patient's risk of stroke with the increased risk of bleeding, particularly in the postoperative period.
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Affiliation(s)
- Kaitlyn M Krahn
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sheri L Koshman
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Ting Wang
- Data and Research Services, Alberta Strategy for Patient Oriented Research Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - June Chen
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Tammy J Bungard
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Jian Song Zhou
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Mohamed A Omar
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Emily C Cowley
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada.
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9
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Jain B, Rahim FO, Thirumala PD, McGarvey ML, Balzer J, Nogueira RG, van der Goes DN, de Havenon A, Sultan I, Ney J. Cost-benefit analysis of intraoperative neuromonitoring for cardiac surgery. J Stroke Cerebrovasc Dis 2024; 33:107576. [PMID: 38232584 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107576] [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: 06/10/2023] [Revised: 12/25/2023] [Accepted: 01/11/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Intraoperative neuromonitoring (IONM) can detect large vessel occlusion (LVO) in real-time during surgery. The aim of this study was to conduct a cost-benefit analysis of utilizing IONM among patients undergoing cardiac surgery. METHODS A decision-analysis tree with terminal Markov nodes was constructed to model functional outcome, as measured via the modified Rankin Scale (mRS), among 65-year-old patients undergoing cardiac surgery. Our cost-benefit analysis compares the use of IONM (electroencephalography and somatosensory evoked potential) against no IONM in preventing neurological complications from perioperative LVO during cardiac surgery. The study was performed over a lifetime horizon from a societal perspective in the United States. Base case and one-way probabilistic sensitivity analyses were performed. RESULTS At a baseline LVO rate of 0.31%, the mean attributable lifetime expenditure for IONM-monitored cardiac surgeries relative to unmonitored cardiac surgeries was $1047.41 (95% CI, $742.12 - $1445.10). At a critical LVO rate of approximately 3.67%, the costs of both monitored and unmonitored cardiac surgeries were the same. Above this critical rate, implementing IONM became cost-saving. On one-way sensitivity analysis, variation in LVO rate from 0% - 10% caused lifetime costs attributable to receiving IONM to range from $1150.47 - $29404.61; variations in IONM cost, percentage of intervenable LVOs, IONM sensitivity, and mechanical thrombectomy cost exerted comparably minimal influence over lifetime costs. DISCUSSION We find considerable cost savings favoring the use of IONM under certain parameters corresponding to high-risk patients. This study will provide financial perspective to policymakers, clinicians, and patients alike on the appropriate use of IONM during cardiac surgery.
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Affiliation(s)
- Bhav Jain
- Stanford University School of Medicine, Stanford, CA, United States; Massachusetts Institute of Technology, Cambridge, MA, United States
| | | | - Parthasarathy D Thirumala
- Department of Neurological Surgery and Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Michael L McGarvey
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Jeffrey Balzer
- Department of Neurological Surgery and Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Raul G Nogueira
- Department of Neurological Surgery and Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; UPMC Stroke Institute, Pittsburgh, PA, United States
| | - David N van der Goes
- Department of Economics, University of New Mexico, Albuquerque, NM, United States
| | - Adam de Havenon
- Department of Neurology, Yale University, New Haven, CT, United States
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - John Ney
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States; West Haven VA Medical Center, West Haven, CT, United States.
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10
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Jarry S, Couture EJ, Beaubien-Souligny W, Fernandes A, Fortier A, Ben-Ali W, Desjardins G, Huard K, Mailhot T, Denault AY. Clinical relevance of transcranial Doppler in a cardiac surgery setting: embolic load predicts difficult separation from cardiopulmonary bypass. J Cardiothorac Surg 2024; 19:90. [PMID: 38347542 PMCID: PMC10863099 DOI: 10.1186/s13019-024-02591-4] [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] [Received: 06/14/2023] [Accepted: 01/30/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND During cardiac surgery, transcranial Doppler (TCD) represents a non-invasive modality that allows measurement of red blood cell flow velocities in the cerebral arteries. TCD can also be used to detect and monitor embolic material in the cerebral circulation. Detection of microemboli is reported as a high intensity transient signal (HITS). The importance of cerebral microemboli during cardiac surgery has been linked to the increased incidence of postoperative renal failure, right ventricular dysfunction, and hemodynamic instability. The objective of this study is to determine whether the embolic load is associated with hemodynamic instability during cardiopulmonary bypass (CPB) separation and postoperative complications. METHODS A retrospective single-centre cohort study of 354 patients undergoing cardiac surgery between December 2015 and March 2020 was conducted. Patients were divided in tertiles, where 117 patients had a low quantity of embolic material (LEM), 119 patients have a medium quantity of microemboli (MEM) and 118 patients who have a high quantity of embolic material (HEM). The primary endpoint was a difficult CPB separation. Multivariate logistic regression was used to determine the potential association between a difficult CPB separation and the number of embolic materials. RESULTS Patients who had a difficult CPB separation had more HITS compared to patients who had a successful CPB separation (p < 0.001). In the multivariate analysis, patients with MEM decreased their odds of having a difficult CPB weaning compared to patients in the HEM group (OR = 0.253, CI 0.111-0.593; p = 0.001). In the postoperative period patients in the HEM group have a higher Time of Persistent Organ Dysfunction (TPOD), a longer stay in the ICU, a longer duration under vasopressor drugs and a higher mortality rate compared to those in the MEM and LEM groups. CONCLUSION The result of this study suggests that a high quantity of cerebral embolic material increases the odds of having a difficult CPB separation. Also, it seems to be associated to more complex surgery, a longer CPB time, a higher TPOD and a longer stay in the ICU. Six out of eight patients who died in this cohort were in the HEM group.
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Affiliation(s)
- Stéphanie Jarry
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada
| | - Etienne J Couture
- Department of Anesthesiology and Department of Medicine, Division of Intensive Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada
| | | | - Armindo Fernandes
- Perfusion Service, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Annik Fortier
- Montreal Health Innovations Coordinating Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Walid Ben-Ali
- Department of Surgery and Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada
| | - Georges Desjardins
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada
| | - Karel Huard
- Université de Montréal, Montreal, QC, Canada
| | - Tanya Mailhot
- Research Center, Montreal Heart Institute, and Faculty of Nursing, Université de Montréal, Montreal, QC, Canada
| | - André Y Denault
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada.
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11
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Fanning JP, Campbell BCV, Bulbulia R, Gottesman RF, Ko SB, Floyd TF, Messé SR. Perioperative stroke. Nat Rev Dis Primers 2024; 10:3. [PMID: 38238382 DOI: 10.1038/s41572-023-00487-6] [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] [Accepted: 12/01/2023] [Indexed: 01/23/2024]
Abstract
Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.
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Affiliation(s)
- Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Anaesthesia & Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
- The George Institute for Global Health, Sydney, New South Wales, Australia.
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Bruce C V Campbell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | - Sang-Bae Ko
- Department of Neurology and Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Thomas F Floyd
- Department of Anaesthesiology & Pain Management, Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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12
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Baron Shahaf D, Abergel E, Sivan Hoffmann R, Meirovitch E, Konstadt S, Feierman DE, Derman R, Shahaf G. Evaluating a Novel EEG-Based Index for Stroke Detection Under Anesthesia During Mechanical Thrombectomy. J Neurosurg Anesthesiol 2024; 36:60-68. [PMID: 36730962 DOI: 10.1097/ana.0000000000000889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 08/21/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The rapid identification of acute stroke (AS) during and after anesthesia might lead to early interventions and improved outcomes. We investigated a novel 2-channel electroencephalogram (EEG)-based marker for stroke detection-the lateral interconnection ratio (LIR)-in AS patients having endovascular thrombectomy (EVT) with general anesthesia (GA) or sedation. The LIR in 2 reference groups of patients without postoperative neurological complications was used for comparison. METHODS The National Institutes of Health stroke scale score was assessed before and after thrombectomy in 100 patients having EVT with GA or sedation. The EEG was monitored during and for 4 hours following EVT in the AS group and during surgery in the 2 reference groups. We compared: (1) LIR between AS and reference groups; (2) LIR and stroke dynamics (clinical improvement or deterioration after EVT assessed by the National Institutes of Health stroke scale score); (3) the impact of stroke site (anterior vs. posterior circulation) and anesthesia type (GA vs. sedation) on the LIR. RESULTS Median (interquartile range) LIR was lower in patients with AS compared with reference patients (0.09, 0.05 to 0.16 vs. 0.39, 0.24 to 0.52, respectively; P <0.000002), and LIR increased in AS patients whose clinical status recovered after EVT compared with nonrecovered patients (0.20, 0.12 to 0.29 vs. 0.09, 0.05 to 0.11, respectively; P <0.007). The LIR might be more sensitive to anterior circulation stroke but is not impacted by anesthesia type. CONCLUSIONS We demonstrated the utility of using AS patients undergoing EVT as a platform for assessing a novel EEG marker for the identification of stroke during anesthesia. Further, large-scale studies in AS patients during EVT and in patients undergoing different surgeries and anesthesia are required to validate the LIR.
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Affiliation(s)
| | | | | | | | | | - Dennis E Feierman
- Department of Anesthesiology
- IRB, Maimonides Medical Center, Brooklyn NY
| | | | - Goded Shahaf
- Applied Neurophysiology Lab, Rambam Health Care Campus, Haifa
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13
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Umar MF, Bellamy SE, Ahmad M, Mirza M, Sitara A, Benz M, Ameen AA. Staged Versus Concomitant Carotid Endarterectomy and Aortic Valve Replacement: A Case Report and Literature Review. Cureus 2023; 15:e49773. [PMID: 38161544 PMCID: PMC10757739 DOI: 10.7759/cureus.49773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 01/03/2024] Open
Abstract
Stroke is a common complication of cardiac surgery, and carotid artery stenosis is an established risk factor for stroke. Therefore, patients with carotid artery stenosis who are undergoing cardiac surgery require proper management of the former either simultaneously or before cardiac surgery. We present a challenging case of a 67-year-old male patient who presented with generalized weakness, severe aortic stenosis, and significant bilateral carotid artery stenosis. The coexistence of these findings sparked a debate about whether to perform a carotid endarterectomy first or an aortic valve replacement. Moreover, a past history of percutaneous coronary intervention and coronary artery bypass grafts made the decision more challenging. Multiple approaches have been employed for the management of coexisting carotid artery stenosis with cardiac surgery; however, no definitive guidelines exist, especially for surgeries other than coronary artery bypass grafts or where the carotid stenosis is bilateral and severe.
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Affiliation(s)
- Muhammad Faiq Umar
- Internal Medicine, Mayo Hospital, Lahore, PAK
- Cardiology, Jersey City Medical Center, Jersey City, USA
| | | | - Muhammad Ahmad
- Internal Medicine, Jersey City Medical Center, Jersey City, USA
| | - Muhammad Mirza
- Internal Medicine, Jersey City Medical Center, Jersey City, USA
| | - Ayesham Sitara
- Internal Medicine, Jersey City Medical Center, Jersey City, USA
| | - Michael Benz
- Interventional Cardiology, Jersey City Medical Center, Jersey City, USA
- Cardiology, Rutgers New Jersey Medical School, Newark, USA
- Cardiology, Christ Hospital, Jersey City, USA
| | - Abdul A Ameen
- Cardiology, Jersey City Medical Center, Jersey City, USA
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14
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Shou BL, Wilcox C, Florissi IS, Krishnan A, Kim BS, Keller SP, Whitman GJR, Uchino K, Bush EL, Cho SM. National Trends, Risk Factors, and Outcomes of Acute In-Hospital Stroke Following Lung Transplantation in the United States: Analysis of the United Network for Organ Sharing Registry. Chest 2023; 164:939-951. [PMID: 37054775 PMCID: PMC10567928 DOI: 10.1016/j.chest.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/01/2023] [Accepted: 04/03/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Lung transplantation (LTx) is the definitive treatment for end-stage lung failure. However, there have been no large, long-term studies on the impact of acute in-hospital stroke in this population. RESEARCH QUESTION What are the trends, risk factors, and outcomes of acute stroke in patients undergoing LTx in the United States? STUDY DESIGN AND METHODS We identified adult first-time isolated LTx recipients from the United Network for Organ Sharing database, which comprehensively captures every transplant in the United States, between May 2005 and December 2020. Stroke was defined as occurring at any time after LTx but prior to discharge. Multivariable logistic regression with stepwise feature elimination was used to identify risk factors for stroke. Freedom from death in patients with a stroke vs those without a stroke was evaluated with Kaplan-Meier analysis. Cox proportional hazards analysis was used to identify predictors of death at 24 months. RESULTS Of 28,564 patients (median age, 60 years; 60% male), 653 (2.3%) experienced an acute in-hospital stroke after LTx. Median follow-up was 1.2 (stroke) and 3.0 (non-stroke) years. Annual incidence of stroke increased (1.5% in 2005 to 2.4% in 2020; P for trend = .007), as did lung allocation score and utilization of post-LTx extracorporeal membrane oxygenation (P = .01 and P < .001, respectively). Compared with those without stroke, patients with stroke had lower survival at 1 month (84% vs 98%), 12 months (61% vs 88%), and 24 months (52% vs 80%) (log-rank test, P < .001 for all). In Cox analysis, acute stroke conferred a high hazard of mortality (hazard ratio, 3.01; 95% CI, 2.67-3.41). Post-LTx extracorporeal membrane oxygenation was the strongest risk factor for stroke (adjusted OR, 2.98; 95% CI, 2.19-4.06). INTERPRETATION Acute in-hospital stroke post-LTx has been increasing over time and is associated with markedly worse short- and long-term survival. As increasingly sicker patients undergo LTx as well as experience stroke, further research on stroke characteristics, prevention, and management strategies is warranted.
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Affiliation(s)
- Benjamin L Shou
- Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Christopher Wilcox
- Division of Neurosciences Critical Care, Johns Hopkins School of Medicine, Baltimore, MD
| | - Isabella S Florissi
- Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Aravind Krishnan
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Steven P Keller
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Errol L Bush
- Division of General Thoracic Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, MD; Division of Neurosciences Critical Care, Johns Hopkins School of Medicine, Baltimore, MD.
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15
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Gu HQ, Wang CJ, Yang X, Zhao XQ, Wang YL, Liu LP, Jiang Y, Li H, Wang YJ, Li ZX. Clinical characteristics, in-hospital management, and outcomes of patients with in-hospital vs. community-onset ischaemic stroke: a hospital-based cohort study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 38:100890. [PMID: 37790077 PMCID: PMC10544278 DOI: 10.1016/j.lanwpc.2023.100890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/25/2023] [Accepted: 08/15/2023] [Indexed: 10/05/2023]
Abstract
Background Lack of high-quality national-level data on in-hospital ischaemic stroke hinders the development of tailored strategies for this subgroup's identification, treatment, and management. Methods We analyzed and compared clinical characteristics, in-hospital management measures, and outcomes, including death or discharge against medical advice (DAMA), major adverse cardiovascular events (MACEs), disability at discharge, and in-hospital complications between in-hospital and community-onset ischaemic stroke enrolled in the Chinese Stroke Center Association registry from August 2015 to December 2022. Findings The cohort comprised 14,948 in-hospital and 1,366,898 community-onset ischaemic stroke patients. In-hospital ischaemic stroke exhibited greater stroke severity, higher prevalence of comorbidities, more pre-admission medications, and had suboptimal management measures, for example, the onset-to-needle time within 4.5 h (83.3% vs. 93.1%; difference, -9.8% [-11.4% to -8.3%]), and antithrombotics at discharge (78.6% vs. 90.0%; difference, -11.4% [95% CI, -12.1% to -10.7%]). After adjusting for covariates, in-hospital ischaemic stroke remains associated with higher risks of unfavorable outcomes, including in-hospital death/DAMA (13.9% vs. 8.6%; adjusted risk difference [aRD], 2.2% [95% CI, 1.8%-2.7%]; adjusted odds ratio [aOR], 1.35 [95% CI, 1.25-1.45]), MACE (12.6% vs. 6.5%; aRD, 4.1% [95% CI, 3.5%-4.7%]; aOR, 1.68 [95% CI, 1.52-1.85]), and complications (23.7% vs. 12.1%; aRD, 6.5% [95% CI, 5.1%-7.9%]; aOR, 1.72 [95% CI, 1.64-1.80]), except for disability at discharge (41.1% vs. 33.1%; aRD, 0.4% [95% CI, -1.7% to 2.5%]; aOR, 0.99 [95% CI, 0.88-1.11]). Interpretation In-hospital ischaemic stroke demonstrated more severe strokes, worse vascular risk profiles, suboptimal management measures, and worse outcomes compared to community-onset ischaemic stroke. This emphasizes the urgent need for improved hospital systems of care and targeted quality improvement initiatives for better outcomes in in-hospital ischaemic stroke. Funding National Key R&D Programme of China and Beijing Hospitals Authority.
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Affiliation(s)
- Hong-Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chun-Juan Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Yang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xing-Quan Zhao
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi-Long Wang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li-Ping Liu
- Neuro-intensive Care Unit, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong-Jun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zi-Xiao Li
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
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16
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Pereira MDP, Lima EG, Pitta FG, Gowdak LHW, Mioto BM, Carvalho LNS, Darrieux FCDC, Mejia OAV, Jatene FB, Serrano CV. Rivaroxaban versus warfarin in postoperative atrial fibrillation: Cost-effectiveness analysis in a single-center, randomized, and prospective trial. JTCVS OPEN 2023; 15:199-210. [PMID: 37808050 PMCID: PMC10556832 DOI: 10.1016/j.xjon.2023.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/27/2023] [Accepted: 05/22/2023] [Indexed: 10/10/2023]
Abstract
Objectives Postoperative atrial fibrillation is the most common clinical complication after coronary artery bypass graft surgery. It is associated with a high risk of both stroke and death and increases the length of hospital stay and costs. This study aimed to evaluate anticoagulants in postoperative atrial fibrillation. Methods A single-center, randomized, prospective, and open-label study. The trial was conducted in Heart Institute at University of São Paulo, Brazil. Patients who developed postoperative atrial fibrillation were randomized to anticoagulation with rivaroxaban or warfarin plus enoxaparin bridging. The primary objective was the cost-effectiveness evaluated by quality-adjusted life years, using the SF-6D questionnaire. The secondary end point was the combination of death, stroke, myocardial infarction, thromboembolic events, infections, bleeding, readmissions, and surgical reinterventions. The safety end point was any bleeding using the International Society on Thrombosis and Haemostasis score. Follow-up period was 30 days after hospital discharge. Results We analyzed 324 patients and 53 patients were randomized. The median cost-effectiveness was $1423.20 in the warfarin group versus $586.80 in the rivaroxaban group (P = .002). The median cost was lower in the rivaroxaban group, $450.20 versus $947.30 (P < .001). The secondary outcome was similar in both groups, 44.4% in warfarin group versus 38.5% in the rivaroxaban group (P = .65). Bleeding occured in 25.9% in the warfarin group versus 11.5% in the rivaroxaban group (P = .18). Conclusions Rivaroxaban was more cost-effective when compared with warfarin associated with enoxaparin bridging in postoperative atrial fibrillation after isolated coronary artery bypass grafting.
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Affiliation(s)
- Marcel de Paula Pereira
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Eduardo Gomes Lima
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Fabio Grunspun Pitta
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Luís Henrique Wolff Gowdak
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Bruno Mahler Mioto
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Leticia Neves Solon Carvalho
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | | | - Omar Asdrubal Vilca Mejia
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Fabio Biscegli Jatene
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Carlos Vicente Serrano
- Instituto do coração, Hospital das clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
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17
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Ramponi F, Seco M, Vallely MP. Defining the Role of Anaortic Coronary Artery Bypass Grafting. J Clin Med 2023; 12:4697. [PMID: 37510812 PMCID: PMC10380961 DOI: 10.3390/jcm12144697] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
As the population ages and co-morbidities become more prevalent, the complexity of patients presenting for coronary artery bypass surgery is increasing. Cardiopulmonary bypass and aortic cross-clamping in these patients carry increased risk and, indeed, in some patients, with ascending aortic disease, the risks are prohibitive. Total-arterial anaortic coronary artery surgery is a technique that provides complete surgical coronary artery revascularization without cardiopulmonary bypass and without manipulating the ascending aorta. The technique essentially eliminates the risk of cerebral embolization of aortic atheroma and aortic injury. Anaortic techniques are an essential skillset for coronary artery surgery centers treating higher-risk patients.
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Affiliation(s)
- Fabio Ramponi
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY 10025, USA
| | - Michael Seco
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney 2065, Australia
| | - Michael P Vallely
- Department of Cardiothoracic Surgery, Monash Health, The Victorian Heart Hospital, Melbourne 3168, Australia
- Department of Surgery, Monash University, Melbourne 3168, Australia
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18
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Baron Shahaf D, Hight D, Kaiser H, Shahaf G. Association Between Risk of Stroke and Delirium After Cardiac Surgery and a New Electroencephalogram Index of Interhemispheric Similarity. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00341-5. [PMID: 37321874 DOI: 10.1053/j.jvca.2023.05.033] [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: 10/31/2022] [Revised: 05/09/2023] [Accepted: 05/19/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES Neurologic complications after surgery (stroke, delirium) remain a major concern despite advancements in surgical and anesthetic techniques. The authors aimed to evaluate whether a novel index of interhemispheric similarity, the lateral interconnection ratio (LIR), between 2 prefrontal electroencephalogram (EEG) channels could be associated with stroke and delirium following cardiac surgery. DESIGN Retrospective observational study. SETTING Single university hospital. PARTICIPANTS A total of 803 adult patients without documentation of a previous stroke, who underwent cardiac surgery with cardiopulmonary bypass (CPB) between July 2016 and January 2018. INTERVENTIONS The LIR index was calculated retrospectively from the patients' EEG database. MEASUREMENTS AND MAIN RESULTS LIR was analyzed intraoperatively every 10 seconds and compared among patients with postoperative stroke, patients with delirium, and patients without documented neurologic complications, during 5 key periods, each lasting10 minutes: (1) surgery start, (2) before CPB, (3) on CPB, (4) after CPB, and (5) surgery end. After cardiac surgery, 31 patients suffered from stroke; 48 patients were diagnosed with delirium; and 724 had no documented neurologic complications. Patients with stroke demonstrated a decrease in LIR index between the start of surgery and the postbypass period of 0.08 (0.01, 0.36 [21]; median and [interquartile range {IQR}]; valid EEG samples); whereas there was no similar decrease in the no-dysfunction group (-0.04 [-0.13, 0.04; {551}], p < 0.0001). Patients with delirium showed a decrease in LIR index between the start of surgery and the end of the surgery by 0.15 (0.02, 0.30 [12]), compared with no such decrease in the no-dysfunction group (-0.02 [-0.12, 0.08 {376}], p ≈ 0.001). CONCLUSIONS After improvement of SNR, it might be of value to further study the index decrease as an indication for risk for brain injury after surgery. The timing of decrease (after CPB or end of surgery) may provide hints regarding the injury pathophysiology and its onset.
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Affiliation(s)
| | - Darren Hight
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heiko Kaiser
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Goded Shahaf
- The Applied Neurophysiology Lab, Rambam Health Care Campus, Haifa, Israel
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Mpody C, Kola-Kehinde O, Awad H, Bhandary S, Essandoh M, Rankin D, Flores A, Harter R, Nafiu OO. Timing of Postoperative Stroke and Risk of Mortality After Noncardiac Surgery: A Cohort Study. J Clin Med Res 2023; 15:268-273. [PMID: 37303467 PMCID: PMC10251695 DOI: 10.14740/jocmr4877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/16/2023] [Indexed: 06/13/2023] Open
Abstract
Background Postoperative stroke is a devastating complication of surgery, given its association with severe long-term disability and mortality. Previous investigators have confirmed the association of stroke with postoperative mortality. However, limited data exist regarding the relationship between the timing of stroke and survival. Addressing this knowledge gap will help clinicians develop tailored perioperative strategies to reduce the incidence, severity, and mortality associated with perioperative stroke. Therefore, our objective was to determine whether the timing of postoperative stroke influenced mortality risk. Methods We performed a retrospective cohort study of patients > 18 years who underwent noncardiac surgery and developed postoperative stroke during the first 30 days of surgery (National Surgical Quality Improvement Program Pediatrics 2010 - 2021). Our primary outcome was 30-day mortality following the occurrence of postoperative stroke. We subdivided patients into two mutually exclusive groups: early and delayed stroke. Early stroke was defined as the occurrence within 7 days following surgery, consistent with a previous study. Results We identified 16,750 patients who underwent noncardiac surgery and developed stroke within 30 days of surgery. Of these, 11,173 (66.7%) had an early postoperative stroke (≤ 7 days). Perioperative physiological status, operative characteristics, and preoperative comorbidities were generally comparable between patients with early and delayed postoperative stroke. Despite the comparability in these clinical characteristics, the mortality risk was 24.9% for early and 19.4% for delayed stroke. After adjusting for perioperative physiological status, operative characteristics, and preoperative comorbidities, early stroke was associated with an increased mortality risk (adjusted odds ratio: 1.39, confidence interval: 1.29 - 1.52, P-value < 0.001). In patients with an early postoperative stroke, the most common preceding complications were bleeding requiring transfusion (24.3%), followed by pneumonia (13.2%) and renal insufficiency (11.3%). Conclusions Postoperative stroke tends to occur within 7 days following noncardiac surgery. Such timing of postoperative stroke carries a higher mortality risk, suggesting that targeted efforts to prevent stroke should focus on the first week following surgery to reduce the incidence and mortality associated with this complication. Our findings contribute to the growing understanding of stroke after noncardiac surgery and may help clinicians develop tailored perioperative neuroprotective strategies to prevent or improve treatment and outcomes of postoperative stroke.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Onaopepo Kola-Kehinde
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Hamdy Awad
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Sujatha Bhandary
- Division of Cardio-Thoracic Anesthesiology, Department of Anesthesiology, Emory University, Atlanta, GA, USA
| | - Michael Essandoh
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Demicha Rankin
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Antolin Flores
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Ronald Harter
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Olubukola O. Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
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20
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Noda K, Koga M, Toyoda K. Recognition of Strokes in the ICU: A Narrative Review. J Cardiovasc Dev Dis 2023; 10:jcdd10040182. [PMID: 37103061 PMCID: PMC10145112 DOI: 10.3390/jcdd10040182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 04/28/2023] Open
Abstract
Despite the remarkable progress in acute treatment for stroke, in-hospital stroke is still devastating. The mortality and neurological sequelae are worse in patients with in-hospital stroke than in those with community-onset stroke. The leading cause of this tragic situation is the delay in emergent treatment. To achieve better outcomes, early stroke recognition and immediate treatment are crucial. In general, in-hospital stroke is initially witnessed by non-neurologists, but it is sometimes challenging for non-neurologists to diagnose a patient's state as a stroke and respond quickly. Therefore, understanding the risk and characteristics of in-hospital stroke would be helpful for early recognition. First, we need to know "the epicenter of in-hospital stroke". Critically ill patients and patients who undergo surgery or procedures are admitted to the intensive care unit, and they are potentially at high risk for stroke. Moreover, since they are often sedated and intubated, evaluating their neurological status concisely is difficult. The limited evidence demonstrated that the intensive care unit is the most common place for in-hospital strokes. This paper presents a review of the literature and clarifies the causes and risks of stroke in the intensive care unit.
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Affiliation(s)
- Kotaro Noda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
- Department of Neurology and Neurological Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
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21
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Pierik R, Scheeren TWL, Erasmus ME, van den Bergh WM. Near-infrared spectroscopy and processed electroencephalogram monitoring for predicting peri-operative stroke risk in cardiothoracic surgery: An observational cohort study. Eur J Anaesthesiol 2023; 40:425-435. [PMID: 37067999 DOI: 10.1097/eja.0000000000001836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
BACKGROUND Stroke is a feared complication after cardiothoracic surgery, with an incidence of around 2 to 3%. Anaesthesia and postoperative sedation may obscure clinical symptoms of stroke and thus delay diagnosis and timely intervention. OBJECTIVES The objective was to assess the value of intra-operative neuromonitoring and blood pressure monitoring for predicting the occurrence of peri-operative stroke within 3 days after cardiothoracic surgery. DESIGN Single-centre retrospective observational cohort study. SETTING Academic tertiary care medical centre. PATIENTS All consecutive patients with cardiothoracic surgery and intra-operative neuromonitoring admitted postoperatively to the Intensive Care Unit (ICU) between 2008 and 2017. MAIN OUTCOME MEASURES The primary endpoint was the occurrence of any stroke confirmed by brain imaging within 3 days postcardiothoracic surgery. Areas under the curve (AUC) of intra-operative mean arterial pressure (MAP), cerebral oxygen saturation (ScO2) and bispectral index (BIS) below predefined thresholds were calculated, and the association with early stroke was tested using logistic regression analyses. RESULTS A total of 2454 patients admitted to the ICU after cardiothoracic surgery had complete intra-operative data for ScO2, BIS and MAP and were included in the analysis. In 58 patients (2.4%), a stroke was confirmed. In univariate analysis, a larger AUCMAP greater than 60 mmHg [odds ratio (OR) 1.43; 95% confidence interval (CI), 1.21 to 1.68) and larger AUCBIS<25 (OR 1.51; 95% CI, 1.24 to 1.83) were associated with the occurrence of postoperative stroke while ScO2 less than 50% or greater than 20% reduction from individual baseline was not (OR 0.91; 95% CI, 0.50 to 1.67). After multivariable analysis, AUCBIS<25 (OR 1.45; 95% CI, 1.12 to 1.87) and longer duration of MAP less than 60 mmHg (OR 1.52; 95% CI, 1.02 to 2.27) remained independently associated with stroke occurrence. CONCLUSION Cumulative intra-operative BIS values below 25 and longer duration of MAP below 60 mmHg were associated with the occurrence of peri-operative stroke within 3 days after cardiothoracic surgery. Prospective studies are warranted to evaluate a causal relationship between low BIS and stroke to establish whether avoiding intra-operative BIS values below 25 might reduce the incidence of peri-operative stroke.
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Affiliation(s)
- Ramon Pierik
- From the Department of Critical Care (RP, WMvdB), Department Anaesthesiology (TWLS) and Department of Cardiac Surgery (MEE), University Medical Center Groningen, University of Groningen, the Netherlands
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22
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Riepen B, DeAndrade D, Floyd TF, Fox A. Postoperative stroke assessment inconsistencies in cardiac surgery: Contributors to higher stroke-related mortality? J Stroke Cerebrovasc Dis 2023; 32:107057. [PMID: 36905744 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107057] [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: 01/04/2023] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 03/11/2023] Open
Abstract
OBJECTIVES In-hospital stroke mortality is surprisingly much worse than for strokes occurring outside of the hospital. Cardiac surgery patients are amongst the highest risk groups for in-hospital stroke and experience high stroke-related mortality. Variability in institutional practices appears to play an important role in the diagnosis, management, and outcome of postoperative stroke. We therefore tested the hypothesis that variability in postoperative stroke management of cardiac surgical patients exists across institutions. MATERIALS AND METHODS A 13 item survey was employed to determine postoperative stroke practice patterns for cardiac surgical patients across 45 academic institutions. RESULTS Less than half (44%) reported any formal clinical effort to preoperatively identify patients at high risk for postoperative stroke. Epiaortic ultrasonography for the detection of aortic atheroma, a proven preventative measure, was routinely practiced in only 16% of institutions. Forty-four percent (44%) reported not knowing whether a validated stroke assessment tool was utilized for the detection of postoperative stroke, and 20% reported that validated tools were not routinely used. All responders, however, confirmed the availability of stroke intervention teams. CONCLUSIONS Adoption of a best practices approach to the management of postoperative stroke is highly variable and may improve outcomes in postoperative stroke after cardiac surgery.
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Affiliation(s)
- Blair Riepen
- Department of Anesthesiology& Pain Management, The University of Texas Southwestern, Dallas, TX, USA
| | - Diana DeAndrade
- Department of Anesthesiology& Pain Management, The University of Texas Southwestern, Dallas, TX, USA
| | - Thomas F Floyd
- Department of Anesthesiology& Pain Management, The University of Texas Southwestern, Dallas, TX, USA; The Department of Cardiovascular Surgery, The University of Texas Southwestern, Dallas, TX, USA.
| | - Amanda Fox
- Department of Anesthesiology& Pain Management, The University of Texas Southwestern, Dallas, TX, USA; The McDermott Center for Human Growth and Development / Center for Human Genetics, The University of Texas Southwestern, Dallas, TX, USA
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23
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Kant S, Banerjee D, Sabe SA, Sellke F, Feng J. Microvascular dysfunction following cardiopulmonary bypass plays a central role in postoperative organ dysfunction. Front Med (Lausanne) 2023; 10:1110532. [PMID: 36865056 PMCID: PMC9971232 DOI: 10.3389/fmed.2023.1110532] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
Despite significant advances in surgical technique and strategies for tissue/organ protection, cardiac surgery involving cardiopulmonary bypass is a profound stressor on the human body and is associated with numerous intraoperative and postoperative collateral effects across different tissues and organ systems. Of note, cardiopulmonary bypass has been shown to induce significant alterations in microvascular reactivity. This involves altered myogenic tone, altered microvascular responsiveness to many endogenous vasoactive agonists, and generalized endothelial dysfunction across multiple vascular beds. This review begins with a survey of in vitro studies that examine the cellular mechanisms of microvascular dysfunction following cardiac surgery involving cardiopulmonary bypass, with a focus on endothelial activation, weakened barrier integrity, altered cell surface receptor expression, and changes in the balance between vasoconstrictive and vasodilatory mediators. Microvascular dysfunction in turn influences postoperative organ dysfunction in complex, poorly understood ways. Hence the second part of this review will highlight in vivo studies examining the effects of cardiac surgery on critical organ systems, notably the heart, brain, renal system, and skin/peripheral tissue vasculature. Clinical implications and possible areas for intervention will be discussed throughout the review.
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Affiliation(s)
| | | | | | | | - Jun Feng
- Cardiothoracic Surgery Research Laboratory, Department of Cardiothoracic Surgery, Rhode Island Hospital, Lifespan, Providence, RI, United States
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24
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Current Recommendations for Perioperative Brain Health: A Scoping Review. J Neurosurg Anesthesiol 2023; 35:10-18. [PMID: 35834388 DOI: 10.1097/ana.0000000000000861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/23/2022] [Indexed: 02/07/2023]
Abstract
Perioperative complications such as stroke, delirium, and neurocognitive dysfunction are common and responsible for increased morbidity and mortality. Our objective was to characterize and synthesize the contemporary guidelines on perioperative brain health for noncardiac, non-neurologic surgery in a scoping review. We performed a structured search for articles providing recommendations on brain health published between 2016 and 2021 and included the following complications: perioperative stroke and perioperative neurocognitive disorders, the latter of which encompasses postoperative delirium and a spectrum of postoperative cognitive dysfunction. We categorized recommendations by subtopic (stroke, postoperative delirium, postoperative cognitive dysfunction), type (disclosure/ethics/policies, prevention, risk stratification, screening/diagnosis, and management), and pharmacological versus nonpharmacological strategies. We noted country of origin, specialty of the authors, evidence grade (if available), and concordance/discordance between recommendations. Eight publications provided 129 recommendations, originating from the United States (n=5), Europe (n=1), United Kingdom (n=1), and China (n=1). Three publications (37%) applied grading of evidence as follows: Grading of Recommendations, Assessment, Development, and Evaluations (GRADE): A, 30%; B, 36%; C, 30%; D, 4%. We identified 42 instances of concordant recommendations (≥2 publications) on 15 themes, including risk factor identification, risk disclosure, baseline neurocognitive testing, nonpharmacological perioperative neurocognitive disorder prevention, intraoperative monitoring to prevent perioperative neurocognitive disorders, avoidance of benzodiazepines, delaying elective surgery after stroke, and emergency imaging and rapid restoration of cerebral perfusion after perioperative stroke. We identified 19 instances of discordant recommendations on 7 themes, including the use of regional anesthesia and monitoring for perioperative stroke prevention, pharmacological perioperative neurocognitive disorder management, and postoperative stroke screening. We synthesized recommendations for clinical practice and highlighted areas where high-quality evidence is required to inform best practices in perioperative brain health.
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25
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Chen CH, Peterson MD, Mazer CD, Hibino M, Beaudin AE, Chu MWA, Dagenais F, Teoh H, Quan A, Dickson J, Verma S, Smith EE. Acute Infarcts on Brain MRI Following Aortic Arch Repair With Circulatory Arrest: Insights From the ACE CardioLink-3 Randomized Trial. Stroke 2023; 54:67-77. [PMID: 36315249 DOI: 10.1161/strokeaha.122.041612] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND to investigate the frequency and distribution of new ischemic brain lesions detected by diffusion-weighted imaging on brain magnetic resonance imaging after aortic arch surgery. METHODS This preplanned secondary analysis of the randomized, controlled ACE (Aortic Surgery Cerebral Protection Evaluation) CardioLink-3 trial compared the safety and efficacy of innominate versus axillary artery cannulation during elective proximal aortic arch surgery. Participants underwent pre and postoperative magnetic resonance imaging. New ischemic lesions were defined as lesions visible on postoperative, but not preoperative diffusion weighted imaging. RESULTS Of the 111 trial participants, 102 had complete magnetic resonance imaging data. A total of 391 new ischemic lesions were observed on diffusion-weighted imaging in 71 (70%) patients. The average number of lesions in patients with ischemic lesion were 5.5±4.9 with comparable numbers in the right (2.9±2.0) and left (3.0±2.3) hemispheres (P=0.49). Half the new lesions were in the middle cerebral artery territory; 63% of the cohort had ischemic lesions in the anterior circulation, 49% in the posterior circulation, 42% in both, and 20% in watershed areas. A probability mask of all diffusion-weighted imaging lesions revealed that the cerebellum was commonly involved. More severe white matter hyperintensity on preoperative magnetic resonance imaging (odds ratio, 1.80 [95% CI, 1.10-2.95]; P=0.02) and lower nadir nasopharyngeal temperature during surgery (odds ratio per 1°C decrease, 1.15 [95% CI, 1.00-1.32]; P=0.05) were associated with the presentation of new ischemic lesion; older age (risk ratio per 1-year increase, 1.02 [95% CI, 1.00-1.04]; P=0.03) and lower nadir temperature (risk ratio per 1°C decrease, 1.06 [95% CI, 1.00-1.14]; P=0.06) were associated with greater number of lesions. CONCLUSIONS In patients who underwent elective proximal aortic arch surgery, new ischemic brain lesions were common, and predominantly involved the middle cerebral artery territory or cerebellum. Underlying small vessel disease, lower temperature nadir during surgery, and advanced age were risk factors for perioperative ischemic lesions. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02554032.
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Affiliation(s)
- Chih-Hao Chen
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (C.-H.C., A.E.B., E.E.S.).,Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan (C.-H.C.)
| | - Mark D Peterson
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, ON, Canada (M.D.P., H.T., A.Q., S.V.).,Department of Surgery, University of Toronto, ON, Canada (M.D.P., S.V.)
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada (C.D.M., J.D.).,Departments of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada (C.D.M., J.D.).,Department of Physiology, University of Toronto, ON, Canada (C.D.M.)
| | - Makoto Hibino
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (M.H.)
| | - Andrew E Beaudin
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (C.-H.C., A.E.B., E.E.S.).,Hotchkiss Brain Institute, University of Calgary, AB, Canada (A.E.B., E.E.S.)
| | - Michael W A Chu
- Division of Cardiac Surgery, London Health Sciences Centre and the Western University, ON, Canada (M.W.A.C.)
| | - François Dagenais
- Quebec Heart and Lung Institute, Université Laval, Quebec City, QC, Canada (F.D.)
| | - Hwee Teoh
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, ON, Canada (M.D.P., H.T., A.Q., S.V.).,Division of Endocrinology and Metabolism, St. Michael's Hospital, Toronto, ON, Canada (H.T.)
| | - Adrian Quan
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, ON, Canada (M.D.P., H.T., A.Q., S.V.)
| | - Jeffrey Dickson
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada (C.D.M., J.D.).,Departments of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada (C.D.M., J.D.)
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, ON, Canada (M.D.P., H.T., A.Q., S.V.).,Department of Surgery, University of Toronto, ON, Canada (M.D.P., S.V.).,Department of Pharmacology and Toxicology, University of Toronto, ON, Canada (S.V.)
| | - Eric E Smith
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (C.-H.C., A.E.B., E.E.S.).,Hotchkiss Brain Institute, University of Calgary, AB, Canada (A.E.B., E.E.S.)
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26
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Midterm outcomes of simultaneous carotid revascularization combined with coronary artery bypass grafting. BMC Cardiovasc Disord 2022; 22:535. [PMID: 36482305 PMCID: PMC9733180 DOI: 10.1186/s12872-022-02986-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Simultaneous carotid endarterectomy (CEA) combined with coronary artery bypass grafting (CABG) has been widely used in patients with coronary heart disease complicated with severe carotid stenosis to reduce the risk of stroke and death. Carotid artery stenting (CAS) has been proven to be an alternative to CEA in recent years. We investigated the early and mid-term outcomes of simultaneous CEA or CAS combined with CABG in these patients. METHODS From January 2011 to January 2021, 88 patients who underwent simultaneous carotid revascularization combined with CABG under the same anesthesia in Beijing Anzhen Hospital were retrospectively analyzed, and this study included 25 patients who underwent CAS-CABG and 63 patients who underwent CEA-CABG. The main outcomes included all-cause death, stroke, myocardial infarction and combined adverse events. The main outcomes of the two groups were compared at 30 days after the operation and the mid-term follow-up. Univariate and multivariate Cox proportional hazards regression analyses were performed to determine the independent risk factors affecting mid-term mortality. RESULTS Within 30 days after the operation, there was no significant difference in combined adverse events between the two groups (P = 0.88). During the median follow-up period of 6.69 years (IQR, 5.82-7.57 years), 9 patients (14.30%) in the combined CEA-CABG group died, while 1 patient (4.00%) in the combined CAS-CABG group died. There were no significant differences in mid-term death (P = 0.20), stroke (P = 0.78), myocardial infarction (P = 0.88), or combined adverse events (P = 0.62) between the two groups. Univariate and multivariate Cox proportional hazards regression showed that NYHA grade IV (HR 5.01, 95% CI 1.16-21.64, P = 0.03) and previous myocardial infarction (HR 5.43, 95% CI 1.01-29.29, p = 0.04) were independent risk factors for mid-term mortality. We also found that combined CEA-CABG surgery may be associated with a higher risk of death (HR, 13.15; 95% CI 1.10-157.69, p = 0.04). CONCLUSIONS Combined CAS-CABG is a safe and effective treatment for patients with coronary heart disease complicated with severe carotid stenosis. NYHA grade IV and previous MI were independent risk factors for mid-term mortality.
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Power M, Bentley C, Benesch C. Nurse's Role in Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery. J Perianesth Nurs 2022; 37:751-759.e1. [PMID: 35835636 DOI: 10.1016/j.jopan.2022.02.002] [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: 09/24/2021] [Revised: 02/01/2022] [Accepted: 02/05/2022] [Indexed: 01/28/2023]
Abstract
Perioperative nurses have the opportunity to play a key role in prevention and recognition of stroke in patients undergoing noncardiac, nonneurological surgery and may impact this potentially devastating complication. Effective nursing care of the older adult requires a specialized knowledge base. Scientific Statements are a cornerstone of the knowledge base that informs this care. This article summarizes the recently released American Heart Association/American Stroke Association Scientific Statement entitled: Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery and discusses the nurse's role in the care of this vulnerable patient population.
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Affiliation(s)
- Martha Power
- Retired, Former Stroke Coordinator, West Virginia University Medicine, Morgantown, WV.
| | - Claire Bentley
- Department of Anesthesiology, West Virginia University Medicine, Morgantown, WV
| | - Curtis Benesch
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
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28
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Mavioglu I, Vallely MP. Minimally invasive off-pump anaortic coronary artery bypass (MACAB). J Card Surg 2022; 37:4944-4951. [PMID: 36378893 DOI: 10.1111/jocs.17180] [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: 06/21/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Minimally invasive direct coronary artery bypass has enabled coronary artery bypass graft to compete with the appeal of less invasive percutaneous coronary procedures. Favorable results of coronary artery bypass surgery performed without the use of cardiopulmonary bypass and without touching the aorta (anOPCAB) have enabled the development and use of minimally invasive methods. METHODS Between 2016 and 2021, 112 patients underwent multivessel coronary bypass surgery performed using a minimally invasive method through a small thoracotomy in the left chest with off-pump, anaortic, and all-arterial grafts (Minimally Invasive Off-Pump Anaortic Coronary Artery Bypass [MACAB]). Patient data were collected and retrospectively analyzed. Eight series from the literature using the multivessel mini-OPCAB and MACAB technique were also evaluated. RESULTS Collectively, from the literature, 2729 patients underwent an average of 2.4 bypasses with an early mortality rate of 0.7% and a stroke rate of 0.16%. In our MACAB case series, 112 patients underwent an average of 2.9 bypasses with a mortality rate of 1.8% and a stroke rate of 0%. CONCLUSION MACAB can be performed safely by experienced surgeons and reduces neurological injury and surgical trauma and may be a good alternative for multivessel stenting. Simulation systems are essential for its dissemination, and teams dedicated to coronary surgery-with subspecialty expertise-are necessary to achieve good outcomes.
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Affiliation(s)
- Ilhan Mavioglu
- Cardiovascular Surgery, Cardiac Surgical Clinic of Private Cardiac Surgeons, Istanbul, Turkey
| | - Michael P Vallely
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, New York, USA
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Armstrong PW, Bates ER, Gaudino M. Left main coronary disease: evolving management concepts. Eur Heart J 2022; 43:4635-4643. [PMID: 36173870 DOI: 10.1093/eurheartj/ehac542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/25/2022] [Accepted: 09/16/2022] [Indexed: 01/05/2023] Open
Abstract
Remarkable advances in the management of coronary artery disease have enhanced our approach to left main coronary artery (LMCA) disease. The traditional role of coronary artery bypass graft surgery has been challenged by the less invasive percutaneous coronary interventional approach. Additionally, major strides in optimal medical therapy now provide a rich menu of treatment choices in selected circumstances. Although a LMCA stenosis >70% is an acceptable threshold for revascularization, those patients with a LMCA narrowing between 40 and 69% present a more complex scenario. This review examines the relative merits of the different treatment options, addresses key diagnostic and therapeutic unknowns, and identifies future work likely to advance progress.
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Affiliation(s)
- Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, 4-120 Katz Group Centre for Pharmacy and Health Research, Edmonton, AB T6G 2E1, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, 2C2 Cardiology Walter MacKenzie Center, University of Alberta Hospital, 8440-111 St., Edmonton, AB T6G 2B7, Canada
| | - Eric R Bates
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Drive 2139 Cardiovascular Center, Ann Arbor, MI 48109, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th St, Box 110, New York, NY 10065, USA
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De Paulis R, Folino G, Scaffa R. The percutaneous coronary angioplasty gets better, but the surgical coronary artery bypass does not stay behind. Eur Heart J Suppl 2022; 24:I81-I83. [PMCID: PMC9653154 DOI: 10.1093/eurheartjsupp/suac077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Coronary artery bypass grafting remains one of the most frequently performed cardiac operations, with well-established prognostic benefits in patients with multivessel coronary artery disease and left main disease. Despite an increasingly higher patients’ risk profile, the results of this procedure have significantly improved over time, with an evident and striking decrease in operative mortality and peri-operative complications. A fair amount of technical and technological refinements has further improved the short- and long-term results of coronary artery bypass surgery. The improvements in the beating heart coronary surgery and aortic ‘no-touch’ technique, in the appropriate use of conduits (bilateral internal mammary artery, radial artery, and composite conduits configuration), and in the optimization of venous grafts’ patency are reviewed.
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Affiliation(s)
- Ruggero De Paulis
- Division of Cardiac Surgery - European Hospital, and UniCamillus University , Rome
| | - Giulio Folino
- Division of Cardiac Surgery - European Hospital, and UniCamillus University , Rome
| | - Raffaele Scaffa
- Division of Cardiac Surgery - European Hospital, and UniCamillus University , Rome
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Processed Electroencephalographic Use During Anesthesia and Outcomes: Analysis of The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg 2022; 114:1688-1694. [PMID: 34717905 DOI: 10.1016/j.athoracsur.2021.09.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 08/12/2021] [Accepted: 09/20/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND This study assessed associations between processed electroencephalographic (pEEG) use during anesthesia, surgery- and anesthesia-related risk factors, and neurologic outcomes and mortality after cardiac surgery. METHODS Drawing from The Society of Thoracic Surgeons Adult Cardiac Surgery Database and its Adult Cardiac Anesthesiology Section, we identified 42 932 records for elective, urgent, and emergency cardiac surgical procedures between July 1, 2017 and December 31, 2019. Using propensity score-weighted regression analysis, we analyzed the associations between pEEG use during anesthesia on the primary outcome, postoperative delirium (POD), and secondary outcomes of stroke, encephalopathy, coma, and operative mortality. RESULTS The rate of pEEG use during anesthesia use was 32.8% (n = 14 086), and its use was not associated with decreased odds for POD (odds ratio [OR], 0.88; 95% CI, 0.78-1.02) or encephalopathy (OR, 0.85; 95% CI, 0.70-1.03). Intraoperative pEEG monitoring use was also not associated with increased odds for stroke (OR, 1.17; 95% CI, 0.97-1.42) or coma (OR, 1.44; 95% CI, 0.82-2.52). In contrast, pEEG use during anesthesia was associated with higher odds for operative mortality (OR, 1.23; 95% CI, 1.05-1.44). This association remained significant after adjusting for POD (OR, 1.21; 95% CI, 1.03-1.41), stroke (OR, 1.21; 95% CI, 1.04-1.42), and encephalopathy (OR, 1.28; 95% CI, 1.07-1.52). CONCLUSIONS This large retrospective database study found no association between pEEG use during cardiac surgery and postoperative neurologic outcomes such as POD, stroke, encephalopathy, or coma. However, patients who underwent pEEG monitoring during anesthesia experienced higher mortality, even after adjustment for neurologic outcomes.
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Moustafa B, Testai FD. Navigating Antiplatelet Treatment Options for Stroke: Evidence-Based and Pragmatic Strategies. Curr Neurol Neurosci Rep 2022; 22:789-802. [PMID: 36227497 DOI: 10.1007/s11910-022-01237-z] [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] [Accepted: 09/06/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW The benefit of using antiplatelet monotherapy in acute ischemic stroke and secondary stroke prevention is well established. In the last few years, several large randomized trials showed that the use of short-term dual antiplatelet therapy in particular stroke subtypes may reduce the risk of recurrent ischemic events. The aim of this article is to provide a critical analysis of the current evidence and recommendations for the use of antiplatelet agents for stroke prevention. RECENT FINDINGS Long-term therapy with aspirin, clopidogrel, or aspirin plus extended-release dipyridamole is recommended for secondary stroke prevention in patients with noncardioembolic ischemic stroke. Short-term dual antiplatelet therapy with aspirin and clopidogrel is superior to antiplatelet monotherapy in secondary stroke prevention when used in patients with mild noncardioembolic stroke or high-risk transient ischemic attack. Dual therapy, however, is associated with an increased risk of major bleeding, particularly when the treatment is extended for greater than 30 days. Similarly, aspirin plus ticagrelor is superior to aspirin monotherapy for the prevention of recurrent ischemic stroke, although this combination is associated with a higher risk of hemorrhagic complications when compared to other dual antiplatelet regimens. Among patients who carry CYP2C19 genetic polymorphisms associated with a slow bioactivation of clopidogrel, short-term treatment with aspirin plus ticagrelor is superior to aspirin plus clopidogrel for the reduction of recurrent stroke; however, the use of ticagrelor is associated with a higher risk of any bleeding. In patients with symptomatic intracranial stenosis, aggressive medical management in addition to dual antiplatelet therapy up to 90 days is recommended. Antiplatelet therapy has an essential role in the management of ischemic stroke. The specific antiplatelet regimen should be individualized based on the stroke characteristics, time from symptom onset, and patient-specific predisposition to develop hemorrhagic complications.
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Affiliation(s)
- Bayan Moustafa
- Mayo Clinic College of Medicine and Science, 1221 Whipple St, Eau Claire, WI, 54703, USA.
| | - Fernando D Testai
- College of Medicine, University of Illinois at Chicago, 912 S Wood St, Chicago, IL, 60612, USA
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Amin A, Etheridge GM, Amarasekara HS, Green SY, Orozco-Sevilla V, Coselli JS. Aortic arch repair: lessons learned over three decades at Baylor College of Medicine. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:393-405. [PMID: 35621061 DOI: 10.23736/s0021-9509.22.12376-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The treatment of complex aortic arch disease continues to be among the most demanding cardiovascular operations, with a considerable risk of death and stroke. Since January 1990, our single-practice service has performed over 3000 repairs of the aortic arch. Our aim was to describe the progression of our technical approach to open aortic arch repair. Our center's surgical technique has evolved considerably over the last three decades. When it comes to initial arterial cannulation, we have shifted away from femoral artery cannulation to innominate and axillary artery cannulation. During difficult repairs, this transition has made it easier to use antegrade cerebral perfusion rather than retrograde cerebral perfusion, which was commonly used in the early days. Brain protection tactics during open aortic arch procedures have evolved from profound (≤14 °C) hypothermia during circulatory arrest to moderate (22-24 °C) hypothermia. Aortic arch repair is performed through a median sternotomy and may treat acute aortic dissection, chronic aortic dissection, or degenerative aneurysm. Reoperative repair - that necessitating redo sternotomy - is common in patients undergoing aortic arch repair. The majority of repairs will include varying portions of the ascending aorta and may involve the aortic valve or the aortic root. In some patients, repair may extend into the proximal descending thoracic aorta; this includes elephant trunk, frozen elephant trunk, and antegrade hybrid approaches.
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Affiliation(s)
- Arsalan Amin
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Ginger M Etheridge
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Hiruni S Amarasekara
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Susan Y Green
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
| | - Vicente Orozco-Sevilla
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA
- Texas Heart Institute, Houston, TX, USA
- Department of Cardiovascular Surgery, CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, TX, USA
| | - Joseph S Coselli
- Baylor College of Medicine, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Houston, TX, USA -
- Texas Heart Institute, Houston, TX, USA
- Department of Cardiovascular Surgery, CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, TX, USA
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Berger T, Kreibich M, Mueller F, Breurer-Kellner L, Rylski B, Kondov S, Schröfel H, Pingpoh C, Beyersdorf F, Siepe M, Czerny M. Risk factors for stroke after total aortic arch replacement using the frozen elephant trunk technique. Interact Cardiovasc Thorac Surg 2022; 34:865-871. [PMID: 35092274 PMCID: PMC9070457 DOI: 10.1093/icvts/ivac013] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study aimed to analyse risk factors for postoperative stroke, evaluate the underlying mechanisms and report on outcomes of patients suffering a postoperative stroke after total aortic arch replacement using the frozen elephant trunk technique. METHODS Two-hundred and fifty patients underwent total aortic arch replacement via the frozen elephant trunk technique between March 2013 and November 2020 for acute and chronic aortic pathologies. Postoperative strokes were evaluated interdisciplinarily by a cardiac surgeon, neurologist and radiologist, and subclassified to each's cerebral territory. We conducted a logistic regression analysis to identify any predictors for postoperative stroke. RESULTS Overall in-hospital was mortality 10% (25 patients, 11 with a stroke). A symptomatic postoperative stroke occurred in 42 (16.8%) of our cohort. Eight thereof were non-disabling (3.3%), whereas 34 (13.6%) were disabling strokes. The most frequently affected region was the arteria cerebri media. Embolism was the primary underlying mechanism (n = 31; 73.8%). Mortality in patients with postoperative stroke was 26.2%. Logistic regression analysis revealed age over 75 (odds ratio = 3.25; 95% confidence interval 1.20-8.82; P = 0.021), a bovine arch (odds ratio = 4.96; 95% confidence interval 1.28-19.28; P = 0.021) and an acute preoperative neurological deficit (odds ratio = 19.82; 95% confidence interval 1.09-360.84; P = 0.044) as predictors for postoperative stroke. CONCLUSIONS Stroke after total aortic arch replacement using the frozen elephant trunk technique remains problematic, and most lesions are of embolic origin. Refined organ protection strategies, and sophisticated monitoring are mandatory to reduce the incidence of postoperative stroke, particularly in older patients presenting an acute preoperative neurological deficit or bovine arch.
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Affiliation(s)
- Tim Berger
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Felix Mueller
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Lara Breurer-Kellner
- Department of Neurology, Faculty of Medicine, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Holger Schröfel
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Clarence Pingpoh
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, University Heart Centre, University Hospital Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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Advances in Neuroimaging and Monitoring to Defend Cerebral Perfusion in Noncardiac Surgery. Anesthesiology 2022; 136:1015-1038. [PMID: 35482943 DOI: 10.1097/aln.0000000000004205] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Noncardiac surgery conveys a substantial risk of secondary organ dysfunction and injury. Neurocognitive dysfunction and covert stroke are emerging as major forms of perioperative organ dysfunction, but a better understanding of perioperative neurobiology is required to identify effective treatment strategies. The likelihood and severity of perioperative brain injury may be increased by intraoperative hemodynamic dysfunction, tissue hypoperfusion, and a failure to recognize complications early in their development. Advances in neuroimaging and monitoring techniques, including optical, sonographic, and magnetic resonance, have progressed beyond structural imaging and now enable noninvasive assessment of cerebral perfusion, vascular reserve, metabolism, and neurologic function at the bedside. Translation of these imaging methods into the perioperative setting has highlighted several potential avenues to optimize tissue perfusion and deliver neuroprotection. This review introduces the methods, metrics, and evidence underlying emerging optical and magnetic resonance neuroimaging methods and discusses their potential experimental and clinical utility in the setting of noncardiac surgery.
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36
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Cerebral circulation II: pathophysiology and monitoring. BJA Educ 2022; 22:282-288. [DOI: 10.1016/j.bjae.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2022] [Indexed: 11/23/2022] Open
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Hobbes B, Akseer S, Pikula A, Huszti E, Devereaux PJ, Horlick E, Abrahamyan L. Risk of Perioperative Stroke in Patients with Patent Foramen Ovale: A Systematic Review and Meta-Analysis. Can J Cardiol 2022; 38:1189-1200. [PMID: 35247468 DOI: 10.1016/j.cjca.2022.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Patent foramen ovale (PFO) is a common congenital cardiac abnormality. Risk of stroke increases perioperatively; however, the association of PFO with perioperative stroke risk remains unclear. We conducted a systematic review to inform the risk of perioperative stroke in patients with PFO undergoing surgery. METHODS EMBASE, MEDLINE, and Cochrane databases were searched from inception to January 2020. We described methods used for establishing PFO and perioperative stroke diagnosis. We conducted meta-analyses to obtain pooled estimates for risk of stroke in patients with and without PFO in different surgical populations. RESULTS Ten articles with a total of 20,858,011 patients met the eligibility criteria. Prevalence of PFO ranged from 0.06-1.4% based on ICD code diagnosis and 10.4-40.4% based on echocardiography diagnosis. Perioperative stroke was observed in 0-25% of patients with PFO, and 0-16.7% without PFO. Studies that use echocardiography to diagnose PFO found no association between PFO and perioperative stroke. Studies that used ICD codes, found strong association but were highly heterogenous. PFO was not associated with a risk of perioperative stroke in cardiac and transplant surgeries. While the adjusted odds ratios for stroke were substantial for orthopedic, general, genitourinary, neuro, and thoracic surgeries (with PFO status established based on ICD codes), data heterogeneity and quality of data create significant uncertainty. CONCLUSION In conclusion, PFO is likely a risk factor for perioperative stroke in select types of surgeries. However, this is based on a very low-quality evidence. Rigorous, prospective studies are needed to further investigate this relationship.
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Affiliation(s)
- Benjamin Hobbes
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Selai Akseer
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
| | - Aleksandra Pikula
- Division of Neurology, Toronto Western Hospital, University Health Network (UHN), Toronto, ON, Canada
| | - Ella Huszti
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada; Biostatistics Research Unit, UHN, Toronto, Ontario, Canada
| | - P J Devereaux
- Population Health Research Institute, Hamilton, ON, Canada; Departments of Medicine, and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Eric Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre (PMCC), UHN, Toronto, Ontario, Canada
| | - Lusine Abrahamyan
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, UHN, Toronto, Ontario, Canada.
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Guo Y, Li P. Recent highlights in periopeative neurological disorders, from bench to bedside. CNS Neurosci Ther 2022; 28:467-469. [PMID: 35146923 PMCID: PMC8928913 DOI: 10.1111/cns.13771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/10/2021] [Indexed: 12/20/2022] Open
Abstract
Perioperative neurological disorders are important causes of postoperative disability and even perioperative death, bringing a huge challenge to the vulnerable and increasing aging population. Perioperative neurological disorders usually contain ischemic stroke, hemorrhagic stroke, and neurocognitive disorders during the perioperative period. Although a few prevention and treatment strategies have been developed for each disorder, there is still a lack of effective treatments and the underlying mechanisms are far from well‐understood. This special issue is dedicated to introducing the recent advances in new strategies towards the management of perioperative neurological disorders. The issue collects research articles and reviews focusing on the neuroprotection mechanisms and application of novel technologies in perioperative neurological disorders, including machine learning and nano‐delivery system. These works help to shed lights on developing novel therapeutic targets of perioperative neurological disorders in the pursuit of better recovery and prognosis of the surgical patients.
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Affiliation(s)
- Yunlu Guo
- Department of Anesthesiology, State Key Laboratory of Oncogenes and Related Genes, Renji Hospital, Shanghai Cancer Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Peiying Li
- Department of Anesthesiology, State Key Laboratory of Oncogenes and Related Genes, Renji Hospital, Shanghai Cancer Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Nouh A, Amin-Hanjani S, Furie KL, Kernan WN, Olson DM, Testai FD, Alberts MJ, Hussain MA, Cumbler EU. Identifying Best Practices to Improve Evaluation and Management of In-Hospital Stroke: A Scientific Statement From the American Heart Association. Stroke 2022; 53:e165-e175. [PMID: 35137601 DOI: 10.1161/str.0000000000000402] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This scientific statement describes a path to optimizing care for patients who experience an in-hospital stroke. Although these patients are in a monitored environment, their evaluation and treatment are often delayed compared with patients presenting to the emergency department, contributing to higher rates of morbidity and mortality. Reducing delays and optimizing treatment for patients with in-hospital stroke could improve outcomes. This scientific statement calls for the development of hospital systems of care and targeted quality improvement for in-hospital stroke. We propose 5 core elements to optimize in-hospital stroke care: 1. Deliver stroke training to all hospital staff, including how to activate in-hospital stroke alerts. 2. Create rapid response teams with dedicated stroke training and immediate access to neurological expertise. 3. Standardize the evaluation of patients with potential in-hospital stroke with physical assessment and imaging. 4. Address barriers to treatment potentially, including interfacility transfer to advanced stroke treatment. 5. Establish an in-hospital stroke quality oversight program delivering data-driven performance feedback and driving targeted quality improvement efforts. Additional research is needed to better understand how to reduce the incidence, morbidity, and mortality of in-hospital stroke.
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Cummings S, Kasner SE, Mullen M, Olsen A, McGarvey M, Weimer J, Jackson B, Desai N, Acker M, Messé SR. Delays in the Identification and Assessment of in-Hospital Stroke Patients. J Stroke Cerebrovasc Dis 2022; 31:106327. [PMID: 35123276 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106327] [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: 08/06/2021] [Revised: 01/07/2022] [Accepted: 01/15/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES In-hospital stroke is associated with poor outcomes. Reasons for delays, use of interventions, and presence of large vessel occlusion are not well characterized. MATERIALS AND METHODS A retrospective single center cohort of 97 patients with in-hospital stroke was analyzed to identify factors associated with delays from last known normal to symptom identification and to stroke team alerting. Stroke interventions and presence of large vessel occlusion were also assessed. RESULTS Strokes were predominantly on surgery services (70%), ischemic (82%), and severe (median NIHSS 16; interquartile range [IQR] 6-24). There were long delays from last known normal to symptom identification (median 5.1 hours, IQR 1.0-19.7 hours), symptom identification to stroke team alerting (median 2.1 hours, IQR 0.5-9.9 hours), and total time from last known normal to alerting (median 11.4 [IQR 2.7-34.2] hours). In univariable analysis, being on a surgical service, in an ICU, intubated, and higher NIHSS were associated with delays. In multivariable analysis only intubation was independently associated with time from last known normal to symptom identification (coefficient 20 hours, IQR 0.2 - 39.8, p=0.047). Interventions were given to 17/80 (21%) ischemic stroke patients; 3 (4%) received IV tPA and 14 (18%) underwent thrombectomy. Vascular imaging occurred in 57/80 (71%) ischemic stroke patients and 21/57 (37%) had large vessel occlusion. CONCLUSIONS Hospitalized patients with stroke experience long delays from symptom identification to stroke team alerting. Intubation was strongly associated with delay to symptom identification. Although stroke severity was high and large vessel occlusion common, many patients did not receive acute interventions.
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Affiliation(s)
- Stephanie Cummings
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael Mullen
- Department of Neurology, Temple University Hospital, Philadelphia, PA, United States
| | - Andrew Olsen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael McGarvey
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - James Weimer
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, PA, United States
| | - Ben Jackson
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Nimesh Desai
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael Acker
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Steven R Messé
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States.
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Zhang YJ, Guo WJ, Tang ZY, Lin HB, Hong P, Wang JW, Huang XX, Li FX, Xu SY, Zhang HF. Isoflurane Attenuates Cerebral Ischaemia-Reperfusion Injury via the TLR4-NLRP3 Signalling Pathway in Diabetic Mice. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:2650693. [PMID: 35419168 PMCID: PMC9001073 DOI: 10.1155/2022/2650693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/11/2022] [Indexed: 02/05/2023]
Abstract
Ischaemic stroke is a severe disease worldwide. Restoration of blood flow after ischaemic stroke leads to cerebral ischaemia-reperfusion injury (CIRI). Various operations, such as cardiac surgery with deep hypothermic circulatory arrest, predictably cause cerebral ischaemia. Diabetes is related to the occurrence of perioperative stroke and exacerbates neurological impairment after stroke. Therefore, the choice of anaesthetic drugs has certain clinical significance for patients with diabetes. Isoflurane (ISO) exerts neuroprotective and anti-neuroinflammatory effects in patients without diabetes. However, the role of ISO in cerebral ischaemia in the context of diabetes is still unknown. Toll-like receptor 4 (TLR4) and NOD-like receptor pyrin domain-containing protein 3 (NLRP3) inflammasome activation play important roles in microglia-mediated neuroinflammatory injury. In this study, we treated a diabetic middle cerebral artery occlusion mouse model with ISO. We found that diabetes exacerbated cerebral ischaemia damage and that ISO exerted neuroprotective effects in diabetic mice. Then, we found that ISO decreased TLR4-NLRP3 inflammasome activation in microglia and the excessive autophagy induced by CIRI in diabetic mice. The TLR4-specific agonist CRX-527 reversed the neuroprotective effects of ISO. In summary, our study indicated that ISO exerts neuroprotective effects against the neuroinflammation and autophagy observed during diabetic stroke via the TLR4-NLRP3 signalling pathway.
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Affiliation(s)
- Ya-Jun Zhang
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
- Department of Anesthesiology, Dalian Municipal Maternal and Child Health Care Hospital, Dalian, Liaoning, China
| | - Wen-Jing Guo
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Zi-Yuan Tang
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Hong-Bin Lin
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Pu Hong
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Jing-Wei Wang
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
- Department of Anesthesiology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Xuan-Xuan Huang
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Feng-Xian Li
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Shi-Yuan Xu
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Hong-Fei Zhang
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
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Vallely MP, Seco M, Ramponi F, Puskas JD. Total-arterial, anaortic, off-pump coronary artery surgery: Why, when, and how. JTCVS Tech 2021; 10:140-148. [PMID: 34977717 PMCID: PMC8691864 DOI: 10.1016/j.xjtc.2021.09.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/27/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Michael P Vallely
- Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Michael Seco
- Department of Cardiothoracic Surgery, The Children's Hospital at Westmead, Sydney, Australia
| | - Fabio Ramponi
- Department of Cardiothoracic Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, NY
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Abstract
Surgery and anesthesia carry risks of ischemic, hemorrhagic, hypoxic, and metabolic complications, all of which can result in neurologic symptoms and deficits. Patients with underlying cardiovascular and cerebrovascular risk factors are particularly vulnerable. In this article the authors review the neurologic complications of surgery and anesthesia, with a focus on the role of the neurologic consultant in preoperative evaluation and risk stratification and diagnosis and management of postoperative complications.
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Affiliation(s)
- Daniel Talmasov
- Department of Neurology, New York University School of Medicine, 222 East 41st Street, 14th Floor, New York, NY 10017, USA
| | - Joshua P Klein
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Room 4018, 60 Fenwood Road, Boston 02115, MA, USA.
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Nicoara A, Song P, Bollen BA, Paone G, Abernathy JJ, Taylor MA, Habib RH, Del Rio JM, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2021 Update on Echocardiography. Ann Thorac Surg 2021; 113:13-24. [PMID: 34536378 DOI: 10.1016/j.athoracsur.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/05/2021] [Accepted: 09/07/2021] [Indexed: 11/01/2022]
Abstract
The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) is the world's premier clinical outcomes registry for adult cardiac surgery and a driving force for quality improvement in cardiac surgery. Echocardiographic data provide a wealth of hemodynamic, structural, and functional data and have been part of STS ACSD data collection since its inception. An increasing body of evidence suggests that the use of echocardiography in patients undergoing cardiac surgery has a positive impact on postoperative outcomes. In this report, we describe and summarize the type and rate of reporting of echocardiography-related variables in the STS ACSD, including the Adult Cardiac Anesthesiology Module, from July 2017 to December 2019 for the most frequently performed cardiac surgical procedures. With this review, we aim to increase awareness of the importance of collecting accurate and consistent echocardiography data in the STS ACSD and to highlight opportunities for growth and improvement.
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Affiliation(s)
- Alina Nicoara
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Pinping Song
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Gaetano Paone
- Department of Surgery, Emory University, Atlanta, Georgia
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute/Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | | | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Lincoln, Nebraska
| | - G Burkhard Mackensen
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Department of Anesthesiology Vanderbilt University, Nashville, Tennessee.
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Mestres CA, Pereda D. Commentary: Stroke gives me confusion. JTCVS OPEN 2021; 7:193-194. [PMID: 36003688 PMCID: PMC9390155 DOI: 10.1016/j.xjon.2021.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 12/04/2022]
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Wakabayashi R. A Call for Real-Time Bispectral Index and Electroencephalogram Monitoring in a Patient Undergoing Aortic Surgery. J Cardiothorac Vasc Anesth 2021; 36:2558-2562. [PMID: 34551884 DOI: 10.1053/j.jvca.2021.08.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 11/11/2022]
Abstract
A 77-year-old woman underwent replacement of the ascending aorta and aortic valve. Before separation from cardiopulmonary bypass, the pump flow was reduced to 0-to-1.1 L/min/m2 for four minutes at a tympanic temperature of 34.3°C to perform additional sutureing for aorta-graft anastomosis. Postoperative magnetic resonance imaging revealed watershed cerebral infarction. An offline scalogram of intraoperative electroencephalograms obtained from the bispectral index monitor, which was generated by using continuous wavelet transform with complex Morlet wavelets, readily visualized the process of development of cerebral infarction preceding a significant decrease of regional cerebral oxygen saturation during the low-flow period of cardiopulmonary bypass. The present case demonstrated the possible importance of real-time bispectral index and electroencephalogram monitoring in patients undergoing cardiovascular surgery, especially those undergoing high-risk procedures under hypothermic circulatory arrest.
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Affiliation(s)
- Ryo Wakabayashi
- Department of Anesthesiology and Resuscitology, Shinshu University School of Medicine, Nagano, Japan.
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Sultan I, Brown JA, Serna-Gallegos D, Thirumala PD, Balzer JR, Paras S, Fleseriu C, Crammond DJ, Anetakis KM, Kilic A, Navid F, Gleason TG. Intraoperative neurophysiologic monitoring during aortic arch surgery. J Thorac Cardiovasc Surg 2021; 165:1971-1981.e2. [PMID: 34384591 DOI: 10.1016/j.jtcvs.2021.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/16/2021] [Accepted: 07/09/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the ability of intraoperative neurophysiologic monitoring (IONM) during aortic arch reconstruction with hypothermic circulatory arrest (HCA) to predict early (<48 hours) adverse neurologic events (ANE; stroke or transient ischemic attack) and operative mortality. METHODS This was an observational study of aortic arch surgeries requiring HCA from 2010 to 2018. Patients were monitored with electroencephalogram (EEG) and somatosensory evoked potentials (SSEP). Baseline characteristics and postoperative outcomes were compared according to presence or absence of IONM changes, which were defined as any acute variation in SSEP or EEG, compared with baseline. Multivariable logistic regression analysis was used to assess the association of IONM changes with operative mortality and early ANE. RESULTS A total of 563 patients underwent aortic arch reconstruction with HCA and IONM. Of these, 119 (21.1%) patients had an IONM change, whereas 444 (78.9%) did not. Patients with IONM changes had increased operative mortality (22.7% vs 4.3%) and increased early ANE (10.9% vs 2.9%). In multivariable analysis, SSEP changes were correlated with early ANE (odds ratio [OR], 4.68; 95% confidence interval [CI], 1.51-14.56; P = .008), whereas EEG changes were not (P = .532). Permanent SSEP changes were correlated with early ANE (OR, 4.56; 95% CI, 1.51-13.77; P = .007), whereas temperature-related SSEP changes were not (P = .997). Finally, any IONM change (either SSEP or EEG) was correlated with operative mortality (OR, 5.82; 95% CI, 2.72-12.49; P < .001). CONCLUSIONS Abnormal IONM events during aortic arch reconstruction with HCA portend worse neurologic outcomes and operative mortality and have a negative predictive value of 97.1%. SSEP might be more sensitive than EEG for predicting early ANE, especially when SSEP changes are permanent.
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Affiliation(s)
- Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | | | - Jeffrey R Balzer
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Stephanie Paras
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Cara Fleseriu
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pa
| | | | - Arman Kilic
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Forozan Navid
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Surgery, University of Maryland, College Park, Md
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48
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Snyder BD, Simone SM, Giovannetti T, Floyd TF. Cerebral Hypoxia: Its Role in Age-Related Chronic and Acute Cognitive Dysfunction. Anesth Analg 2021; 132:1502-1513. [PMID: 33780389 PMCID: PMC8154662 DOI: 10.1213/ane.0000000000005525] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Postoperative cognitive dysfunction (POCD) has been reported with widely varying frequency but appears to be strongly associated with aging. Outside of the surgical arena, chronic and acute cerebral hypoxia may exist as a result of respiratory, cardiovascular, or anemic conditions. Hypoxia has been extensively implicated in cognitive impairment. Furthermore, disease states associated with hypoxia both accompany and progress with aging. Perioperative cerebral hypoxia is likely underdiagnosed, and its contribution to POCD is underappreciated. Herein, we discuss the various disease processes and forms in which hypoxia may contribute to POCD. Furthermore, we outline hypoxia-related mechanisms, such as hypoxia-inducible factor activation, cerebral ischemia, cerebrovascular reserve, excitotoxicity, and neuroinflammation, which may contribute to cognitive impairment and how these mechanisms interact with aging. Finally, we discuss opportunities to prevent and manage POCD related to hypoxia.
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Affiliation(s)
- Brina D. Snyder
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Dallas, TX
| | | | | | - Thomas F. Floyd
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Dallas, TX
- Department of Cardiothoracic Surgery, UT Southwestern Medical Center, Dallas, TX
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49
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Ito M, Shimada H, Ogata T, Teratani H, Tsuboi Y, Inoue T, Wada H. Association of carotid ultrasonography with perioperative stroke after thoracic aortic aneurysm treatment: a retrospective study. J Med Ultrason (2001) 2021; 48:307-313. [PMID: 33881652 DOI: 10.1007/s10396-021-01096-0] [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: 01/08/2021] [Accepted: 04/01/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to verify whether carotid ultrasonography (CUS) findings could be associated with the occurrence of perioperative stroke after thoracic aortic aneurysm (TAA) treatment. METHODS Patients with TAAs who were treated by either total arch replacement or thoracic endovascular aortic repair (TEVAR) were retrospectively enrolled. Left subclavian artery (LSA) embolization and bypass surgery of the left common carotid artery (CCA) to the LSA before TEVAR were additionally performed for some patients. CUS was performed before TAA treatment to evaluate carotid atherosclerosis and flow velocities of bilateral cervical arteries. After dividing patients into those with and without perioperative stroke, their background, atherosclerotic risk factors, history of stroke, TAA location and size, treatment procedures, and CUS parameters were compared between the two groups. RESULTS Of the 60 patients (18 women, 42 men; mean age 73.5 ± 10.2 years) with TAA, four (7.5%) developed perioperative stroke. There were no significant differences in the patients' characteristics and their TAAs between those with and without perioperative stroke. For the CUS parameters, end-diastolic velocity (EDV) of bilateral CCAs was significantly decreased in perioperative stroke patients (with vs without stroke; right: 9.2 ± 1.8 vs. 14.5 ± 4.6 cm/s, P = 0.025, left: 9.1 ± 0.3 vs. 15.0 ± 4.5 cm/s, P = 0.012), whereas the resistance index (RI) of bilateral CCAs was significantly elevated (right: 0.76 vs. 0.87, P = 0.008, left: 0.76 vs. 0.87, P < 0.001). CONCLUSIONS Lower EDV and higher RI of bilateral CCAs were significantly associated with perioperative stroke after TAA treatment. Thus, CUS findings may help predict the occurrence of perioperative stroke.
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Affiliation(s)
- Michiko Ito
- Department of Clinical Laboratory, Fukuoka University Hospital, Fukuoka, Japan
| | - Hirofumi Shimada
- Department of Clinical Laboratory, Fukuoka University Hospital, Fukuoka, Japan
| | - Toshiyasu Ogata
- Department of Neurology, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Hiromitsu Teratani
- Department of Cardiovascular Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoshio Tsuboi
- Department of Neurology, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Tooru Inoue
- Department of Neurosurgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hideichi Wada
- Department of Cardiovascular Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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50
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Affiliation(s)
- Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (M.F.K.).,The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (M.F.K.)
| | - Dawn M Bravata
- Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Health Services Research and Development, Department of Veterans Affairs, Indianapolis, IN (D.M.B.).,Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, IN (D.M.B.).,Medicine Service, Richard L. Roudebush VA Medical Center, Indianapolis, IN (D.M.B.).,Departments of Medicine and of Neurology, Indiana University School of Medicine, Indianapolis (D.M.B.).,William M. Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, IN (D.M.B.)
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