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Mehta VC, Chandrasekhar SA, Quimby DL, Bhandari A, Mazo V, Glaser AD, Rose DZ, Mohanty BD. Cerebral Protection in Trans-Catheter Aortic Valve Replacement: Review and Contemporary Assessment of Randomized Trial Data. Neurohospitalist 2024; 14:157-165. [PMID: 38666284 PMCID: PMC11040624 DOI: 10.1177/19418744231225680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
As the population has aged and as aortic valve therapies have evolved, the use of trans-catheter aortic valve replacement (TAVR) has grown dramatically over the past decade. A well-known complication of percutaneous cardiac intervention is embolic phenomena, and TAVR is among the highest risk procedures for clinical and subclinical stroke. As indications for TAVR expand to lower-risk and ultimately younger patients, the long-term consequences of stroke are amplified. Cerebral embolic protection (CEP) devices have taken a on unique preventative role following the Food and Drug Administration approval of the SentinelTM Cerebral Protection System (CPS). More recently, the PROTECTED TAVR study has spurred extensive debate in the neuro-cardiac community. In this review we describe the contemporary literature regarding stroke risk associated with TAVR, the history and role of CEP devices, a PROTECTED TAVR sub-group analysis, and implications for next steps in the field. Lastly, we explore the unique need for CEP in a younger TAVR population, as well as directions for future research.
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Affiliation(s)
- Vivek C. Mehta
- Division of Cardiology, Department of Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Sanjay A. Chandrasekhar
- Division of Cardiology, Department of Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Donald L. Quimby
- Division of Cardiology, Department of Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Ajay Bhandari
- Division of Cardiology, Department of Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Victoria Mazo
- Division of Vascular Neurology, Department of Neurology, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Alexander D. Glaser
- Section of Cardiology, Department of Internal Medicine, Louisiana State University, New Orleans, LA, USA
| | - David Z. Rose
- Division of Vascular Neurology, Department of Neurology, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Bibhu D. Mohanty
- Division of Cardiology, Department of Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
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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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Sirisreetreerux N, Ponglikitmongkol K. Internuclear ophthalmoplegia as a presentation of procedural stroke: a case report. J Med Case Rep 2024; 18:79. [PMID: 38321466 PMCID: PMC10848548 DOI: 10.1186/s13256-024-04401-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 01/20/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Cardiac catheterization and endovascular procedures are extensively used in modern medicine, and procedural stroke is one of the major complications that the catheterization laboratory team may face in their everyday work. Recognizing the signs and symptoms of procedural stroke is crucial to ensuring appropriate management. We herein report a case of internuclear ophthalmoplegia that caused blurred vision, diplopia, and dizziness on lateral gaze as an unusual presentation of procedural stroke. CASE PRESENTATION A 60-year-old Thai woman underwent right partial colectomy and was diagnosed with stage IV diffuse large B-cell lymphoma. Pre-chemotherapy echocardiography revealed mild left ventricular systolic dysfunction, and she therefore underwent diagnostic catheterization. Coronary angiography revealed normal coronary arteries, leading to a diagnosis of non-ischemic cardiomyopathy. After the procedure, she immediately developed dizziness and diplopia. During the right lateral gaze, she exhibited impaired adduction of the left eye and horizontal nystagmus of the right eye. A diagnosis of left internuclear ophthalmoplegia was made. Magnetic resonance imaging revealed a tiny area exhibiting characteristics of an acute infarct in the left paramedian midbrain, including the left medial longitudinal fasciculus, which explained the clinical picture. Another region of restricted diffusion indicating an acute infarct was detected in the right inferior cerebellar hemisphere. Magnetic resonance angiography revealed no significant cerebral artery disease. The patient achieved full neurological recovery 6 weeks after symptom onset. CONCLUSION This report describes an uncommon presentation of procedural stroke that is likely to be misdiagnosed, especially by medical staff unfamiliar with internuclear ophthalmoplegia. Despite the good prognosis of internuclear ophthalmoplegia, appropriate stroke care is crucial in patients with procedural stroke because of the risk of multiple brain infarcts.
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Affiliation(s)
- Norachai Sirisreetreerux
- Cardiology Center, Chulabhorn Hospital, Chulabhorn Royal Academy, 906 Kamphaengphet 6 Road, Talat Bang Khen, Lak Si, Bangkok, 10210, Thailand.
| | - Krongkamol Ponglikitmongkol
- Department of Medicine, Chulabhorn Hospital, Chulabhorn Royal Academy, 906 Kamphaengphet 6 Road, Talat Bang Khen, Lak Si, Bangkok, 10210, Thailand
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Biancari F, Speziale G. Commentary: Sequelae of neurologic injury after cardiac surgery. J Thorac Cardiovasc Surg 2024; 167:634-635. [PMID: 35249752 DOI: 10.1016/j.jtcvs.2022.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Fausto Biancari
- Clinica Montevergine, GVM Care & Research, Mercogliano, Italy; Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
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Puthettu M, Vandenberghe S, Balafas S, Di Serio C, Singjeli G, Pagnamenta A, Demertzis S. Optimizing CO2 field flooding during sternotomy: In vitro confirmation of the Karolinska studies. PLoS One 2024; 19:e0292669. [PMID: 38194426 PMCID: PMC10775975 DOI: 10.1371/journal.pone.0292669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 09/26/2023] [Indexed: 01/11/2024] Open
Abstract
Although CO2 field-flooding was first used during cardiac surgery more than 60 years ago, its efficacy is still disputed. The invisible nature of the gas and the difficulty in determining the "safe" quantity to protect the patient are two of the main obstacles to overcome for its validation. Moreover, CO2 concentration in the chest cavity is highly sensitive to procedural aspects, such suction and hand movements. Based on our review of the existing literature, we identified four major factors that influence the intra-cavity CO2 concentration during open-heart surgery: type of delivery device (diffuser), delivery CO2 flow rate, diffuser position around the wound cavity, and its orientation inside the cavity. In this initial study, only steady state conditions were considered to establish a basic understanding on the effect of the four above-mentioned factors. Transient factors, such as suction or hand movements, will be reported separately.
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Affiliation(s)
- Mira Puthettu
- Department of Cardiac Surgery, Istituto Cardiocentro Ticino, Lugano, Switzerland
- Laboratory of Cardiovascular Engineering, Laboratories for Translational Research EOC (LRT-EOC), Bellinzona, Switzerland
| | - Stijn Vandenberghe
- Department of Cardiac Surgery, Istituto Cardiocentro Ticino, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Spyros Balafas
- University Centre for Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milano, Italy
| | - Clelia Di Serio
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- University Centre for Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milano, Italy
- Clinical Trial Unit (CTU), Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - Geni Singjeli
- Department of Cardiac Surgery, Istituto Cardiocentro Ticino, Lugano, Switzerland
| | - Alberto Pagnamenta
- Clinical Trial Unit (CTU), Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
- Department of Intensive Care, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
- Division of Pneumology, University of Geneva, Geneva, Switzerland
| | - Stefanos Demertzis
- Department of Cardiac Surgery, Istituto Cardiocentro Ticino, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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Yamaji K, Iwanaga Y, Kakehi K, Fujita K, Kawamura T, Hirase C, Ueno M, Nakazawa G. Prognostic Significance of Asymptomatic Cerebral Infarction in Patients After Cardiac Catheterization. Int Heart J 2024; 65:13-20. [PMID: 38296566 DOI: 10.1536/ihj.23-382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Recent studies have showed that asymptomatic cerebral infarction (ACI) developed in a reasonable number of patients after cardiac catheterization. However, no study has investigated the long-term prognostic impact of ACI after cardiac catheterization. We investigated whether ACI after cardiac catheterization affects long-term mortality and subsequent cardiovascular events.We retrospectively enrolled patients who underwent cardiac catheterization before cardiac surgery and cerebral diffusion-weighted magnetic resonance imaging (DWI). The incidence and clinical features of ACI were investigated. The long-term prognosis, including all-cause mortality and subsequent major cardiovascular events (MACE; all-cause mortality, stroke, acute myocardial infarction, fatal arrhythmia, and hospitalized heart failure), was also assessed.A total of 203 patients were enrolled. Of these, 10.3% had ACI diagnosed by DWI. There were no differences in baseline characteristics between patients with and without ACI, except more frequent history of symptomatic stroke in patients with ACI. In the Kaplan-Meier analysis during a median follow-up of 1009 days, the patients with ACI showed worse mortality and a slightly higher occurrence of MACE compared with those without ACI (P = 0.01 and P = 0.08, respectively). In addition, ACI was a prognostic marker independent of age, surgery type, and history of stroke.ACI after cardiac catheterization frequently developed and was also associated with long-term prognosis. It may be an independent prognostic marker in high-risk patients who underwent subsequent cardiac surgery.
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Affiliation(s)
- Kenji Yamaji
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine
- Division of Cardiology, Pref Osaka Saiseikai Izuo Hospital
| | - Yoshitaka Iwanaga
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine
- Department of Cardiology, Sakurabashi-Watanabe Hospital
| | - Kazuyoshi Kakehi
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine
| | - Kosuke Fujita
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine
| | - Takayuki Kawamura
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine
| | | | - Masafumi Ueno
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine
| | - Gaku Nakazawa
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine
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Grubman D, Ahmad Y, Leipsic JA, Blanke P, Pasupati S, Webster M, Nazif TM, Parise H, Lansky AJ. Predictors of Cerebral Embolic Debris During Transcatheter Aortic Valve Replacement: The SafePass 2 First-in-Human Study. Am J Cardiol 2023; 207:28-34. [PMID: 37722198 DOI: 10.1016/j.amjcard.2023.08.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) generates significant debris, and strategies to mitigate cerebral embolization are needed. The novel Emboliner embolic protection catheter (Emboline, Inc., Santa Cruz, California) is designed to capture all particles generated during TAVR. This first-in-human study sought to assess the safety and feasibility of the device and to characterize the distribution and histopathology of the debris generated during TAVR. The SafePass 2 study was a prospective, nonrandomized, multicenter, single-arm investigation of the Emboliner device. Primary end points included 30-day major adverse cardiac and cerebrovascular events (MACCE) and technical performance. Computed tomography angiography was analyzed by an independent core laboratory, and filters were sent for histopathology of captured debris. Predictors of particle number were identified using >150 µm and >500 µm size thresholds. Of 31 subjects enrolled, technical success was 100%, and 30-day MACCE was 6.5% (2 cerebrovascular accidents, with 1 attributed to subtherapeutic dosing of rivaroxaban along with atrial fibrillation and the other to possible previous small ischemic strokes on magnetic resonance imaging; neither MACCE event had a causal relation to the Emboliner). All filters contained debris, with a median of 191.0 particles >150 µm and 14.0 particles >500 µm. Histopathology revealed mostly acute thrombus and valve or arterial tissue with lesser amounts of calcified tissue. A history of atrial fibrillation predicted a greater number of particles >500 µm (p = 0.0259) and its presence on admission was associated with 4.1 times more particles >150 µm (p = 0.0130) and 8.1 times more particles >500 µm (p = 0.0086). Self-expanding valves were associated with twice the number of particles >150 µm (p = 0.0281). TASK score was positively correlated with number of particles >500 µm (p = 0.0337). The Emboliner device was safe and feasible. Emboli after TAVR appear more numerous than previously documented. Atrial fibrillation, higher TASK score, and self-expanding valve use conferred higher embolic burden. Notably, none of the tested computed tomography angiography features were able to identify with higher embolic risk. Larger-scale studies are needed to identify high-risk patients for selective embolic protection device use.
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Affiliation(s)
- Daniel Grubman
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Yousif Ahmad
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jonathon A Leipsic
- Department of Radiology, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada
| | - Philipp Blanke
- Department of Radiology, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada
| | | | - Mark Webster
- Department of Cardiology, Auckland City Hospital, Auckland, New Zealand
| | - Tamin M Nazif
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Helen Parise
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Alexandra J Lansky
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut.
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Baig AA, Manion C, Khawar WI, Donnelly BM, Raygor K, Turner R, Holmes DR, Iyer VS, Hopkins LN, Davies JM, Levy EI, Siddiqui AH. Cerebral emboli detection and autonomous neuromonitoring using robotic transcranial Doppler with artificial intelligence for transcatheter aortic valve replacement with and without embolic protection devices: a pilot study. J Neurointerv Surg 2023:jnis-2023-020812. [PMID: 37940386 DOI: 10.1136/jnis-2023-020812] [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: 07/13/2023] [Accepted: 09/26/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Periprocedural ischemic stroke remains a serious complication in patients undergoing transcatheter aortic valve replacement (TAVR). We used a novel robotic transcranial Doppler (TCD) system equipped with artificial intelligence (AI) for real-time continuous intraoperative neuromonitoring during TAVR to establish the safety and potential validity of this tool in detecting cerebral emboli, report the quantity and distribution of high intensity transient signals (HITS) with and without cerebral protection, and correlate HITS occurrence with various procedural steps. METHODS Consecutive patients undergoing TAVR procedures during which the robotic system was used between October 2021 and May 2022 were prospectively enrolled in this pilot study. The robotic TCD system included autonomous adjustment of the TCD probes and AI-assisted post-processing of HITS and other cerebral flow parameters. Basic demographics and procedural details were recorded. Continuous variables were analyzed by a two-sample Mann-Whitney t-test and categorical variables by a χ2 or Fisher test. RESULTS Thirty-one patients were prospectively enrolled (mean age 79.9±7.6 years; 16 men (51.6%)). Mean aortic valve stenotic area was 0.7 cm2 and mean aortic-ventricular gradient was 43 mmHg (IQR 31.5-50 mmHg). Cerebral protection was used in 16 cases (51.6%). Significantly fewer emboli were observed in the protection group than in the non-protection group (mean 470.38 vs 693.33; p=0.01). Emboli counts during valve positioning and implantation were significantly different in the protection and non-protection groups (mean 249.92 and 387.5, respectively; p=0.01). One (4%) transient ischemic attack occurred post-procedurally in the non-protection group. CONCLUSION We describe a novel real-time intraoperative neuromonitoring tool used in patients undergoing TAVR. Significantly fewer HITS were detected with protection. Valve positioning-implantation was the most significant stage for intraprocedural HITS.
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Affiliation(s)
- Ammad A Baig
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | | | - Wasiq I Khawar
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Brianna M Donnelly
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Kunal Raygor
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Ryan Turner
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - David R Holmes
- Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Vijay S Iyer
- Cardiology, Gates Vascular Institute, Buffalo, New York, USA
| | - L Nelson Hopkins
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
| | - Jason M Davies
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Neurosurgery and Bioinformatics and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Elad I Levy
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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Frederiksen H, Ashwath ML. Disseminated Melanoma: A Disappearing Left Ventricular Mass. CASE (PHILADELPHIA, PA.) 2023; 7:456-460. [PMID: 38028384 PMCID: PMC10679527 DOI: 10.1016/j.case.2023.08.003] [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] [Indexed: 12/01/2023]
Abstract
•Melanoma may lead to asymptomatic cardiac metastasis. •Resolution of the intracardiac mass occurred with nonsurgical treatment. •Echocardiography is important for screening for metastatic involvement.
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Affiliation(s)
- Hunter Frederiksen
- Division of Internal Medicine, Department of Cardiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Mahi L. Ashwath
- Division of Internal Medicine, Department of Cardiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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10
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Yang X, Wu J, Cheng H, Chen S, Wang J. DEXMEDETOMIDINE AMELIORATES ACUTE BRAIN INJURY INDUCED BY MYOCARDIAL ISCHEMIA-REPERFUSION VIA UPREGULATING THE HIF-1 PATHWAY. Shock 2023; 60:678-687. [PMID: 37647083 DOI: 10.1097/shk.0000000000002217] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
ABSTRACT Objective: Neurological complications after myocardial ischemia/reperfusion (IR) injury remain high and seriously burden patients and their families. Dexmedetomidine (Dex), an α 2 agonist, is endowed with analgesic-sedative and anti-inflammatory effects. Therefore, our study aims to explore the mechanism and effect of Dex on brain damage after myocardial IR injury. Methods C57BL/6 mice were randomly divided into sham, IR, and IR + Dex groups, and myocardial IR models were established. The impact of Dex on brain injury elicited by myocardial IR was assessed via ELISA for inflammatory factors in serum and brain; Evans blue for blood-brain barrier permeability; hematoxylin-eosin staining for pathological injury in brain; immunofluorescence for microglia activation in brain; Morris water maze for cognitive dysfunction; western blot for the expression level of HIF-1α, occludin, cleaved caspase-3, NF-κB p65, and p-NF-κB p65 in the brain. In addition, HIF-1α knockout mice were used to verify whether the neuroprotective function of Dex is associated with the HIF-1 pathway. Results: Dex was capable of reducing myocardial IR-induced brain damage including inflammatory factor secretion, blood-brain barrier disruption, neuronal edema, microglial activation, and acute cognitive dysfunction. However, the protective role of Dex was attenuated in HIF-1α knockout mice. Conclusion: Dex protects against myocardial IR-induced brain injury, and the neuroprotection of Dex is at least partially dependent on the activation of the HIF-1 pathway.
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Affiliation(s)
- Xue Yang
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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11
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Jimenez Diaz VA, Kapadia SR, Linke A, Mylotte D, Lansky AJ, Grube E, Settergren M, Puri R. Cerebral embolic protection during transcatheter heart interventions. EUROINTERVENTION 2023; 19:549-570. [PMID: 37720969 PMCID: PMC10495748 DOI: 10.4244/eij-d-23-00166] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/17/2023] [Indexed: 09/19/2023]
Abstract
Stroke remains a devastating complication of transcatheter aortic valve replacement (TAVR), with the incidence of clinically apparent stroke seemingly fixed at around 3% despite TAVR's significant evolution during the past decade. Embolic showers of debris (calcium, atheroma, valve material, foreign material) are captured in the majority of patients who have TAVR using a filter-based cerebral embolic protection device (CEPD). Additionally, in systematic brain imaging studies, the majority of patients receiving TAVR exhibit new cerebral lesions. Mechanistic studies have shown reductions in the volume of new cerebral lesions using CEPDs, yet the first randomised trial powered for periprocedural stroke within 72 hours of a transfemoral TAVR failed to meet its primary endpoint of showing superiority of the SENTINEL CEPD. The present review summarises the clinicopathological rationale for the development of CEPDs, the evidence behind these devices to date and the emerging recognition of cerebral embolisation in many non-TAVR transcatheter procedures. Given the uniqueness of each of the various CEPDs under development, specific trials tailored to their designs will need to be undertaken to broaden the CEPD field, in addition to evaluating the role of CEPD in non-TAVR transcatheter heart interventions. Importantly, the cost-effectiveness of these devices will require assessment to broaden the adoption of CEPDs globally.
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Affiliation(s)
- Victor Alfonso Jimenez Diaz
- Cardiology Department, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IISGS), SERGAS-UVIGO, Vigo, Spain
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Axel Linke
- Department of Internal Medicine and Cardiology, Heart Center Dresden University Hospital, Dresden, Germany and Technische Universität Dresden, Dresden, Germany
| | - Darren Mylotte
- Department of Cardiology, University Hospital Galway, Galway, Ireland and University of Galway, Galway, Ireland
| | | | - Eberhard Grube
- Department of Medicine II, Heart Center, University Hospital Bonn, Bonn, Germany
| | - Magnus Settergren
- Heart and Vascular Unit, Karolinska University Hospital, Stockholm, Sweden and Karolinska Institutet, Stockholm, Sweden
| | - Rishi Puri
- Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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12
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Sjölin K, Christersson C, James S, Lindbäck J, Åsberg S, Burman J. Plasma Neurofilament Light Chain Is Elevated after Transcatheter Aortic Valve Implantation. Cardiology 2023; 148:478-484. [PMID: 37517390 DOI: 10.1159/000532041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/09/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION Transcatheter aortic valve implantation (TAVI) is associated with a high incidence of new silent brain infarcts (SBIs) on postprocedural neuroimaging. A venous blood sample reflecting neuronal damage following TAVI could help identify patients with potential SBIs. We aimed to investigate if a biochemical marker of neuronal injury, neurofilament light chain (NFL), is elevated after TAVI. METHODS In this observational study, NFL was measured in plasma from 31 patients before and after TAVI. Multivariable regression analysis was performed to investigate any effect of clinical- and procedure-related factors on differences in NFL levels before and after TAVI. RESULTS Samples were collected 41 (14-81) days before and 44 (35-59) days after TAVI, median (interquartile range). Median age was 81 (77-84) years, and 35% were female. No patient had any overt procedure-related neurological complications. The geometric mean (95% confidence interval) of the NFL concentration was 30 (25-36) pg/mL before TAVI and 48 (39-61) pg/mL, after TAVI, p <0.001. None of the included variables in the multiple linear regression model were statistically significantly associated with the difference in levels before and after TAVI. CONCLUSIONS NFL levels in plasma were higher after TAVI as compared with levels before, with a mean increase of 60% (18 pg/mL). Further studies including neuroimaging and cognitive outcomes are needed to understand the potential value of measuring NFL in relation to TAVI.
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Affiliation(s)
- Karl Sjölin
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | | | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center (UCR), Uppsala University, Uppsala, Sweden
| | - Johan Lindbäck
- Uppsala Clinical Research Center (UCR), Uppsala University, Uppsala, Sweden
| | - Signild Åsberg
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
| | - Joachim Burman
- Department of Medical Sciences, Neurology, Uppsala University, Uppsala, Sweden
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13
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Christensen E, Morabito J, Kowalsky M, Tsai JP, Rooke D, Clendenen N. Year in Review 2022: Noteworthy Literature in Cardiac Anesthesiology. Semin Cardiothorac Vasc Anesth 2023; 27:123-135. [PMID: 37126462 PMCID: PMC10445401 DOI: 10.1177/10892532231173074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Last year researchers made substantial progress in work relevant to the practice of cardiac anesthesiology. We reviewed 389 articles published in 2022 focused on topics related to clinical practice to identify 16 that will impact the current and future practice of cardiac anesthesiology. We identified 4 broad themes including risk prediction, postoperative outcomes, clinical practice, and technological advances. These articles are representative of the best work in our field in 2022.
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Affiliation(s)
- Elijah Christensen
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA
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14
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Iatrogenic Strokes and Covert Brain Infarcts After Percutaneous Cardiac Procedures: An Update. Can J Cardiol 2023; 39:200-209. [PMID: 36435326 DOI: 10.1016/j.cjca.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
Millions of cardiac procedures are performed worldwide each year, making the potential complication of periprocedural iatrogenic stroke an important concern. These strokes can occur intraoperatively or within 30 days of a procedure and can be categorised as either overt or covert, occurring without obvious acute neurologic symptoms. Understanding the prevalence, risk factors, and strategies for preventing overt and covert strokes associated with cardiac procedures is imperative for reducing periprocedural morbidity and mortality. In this narrative review, we focus on the impacts of perioperative ischemic strokes for several of the most common interventional cardiac procedures, their relevance from a neurologic standpoint, and future directions for the care and research on perioperative strokes. Depending on the percutaneous procedure, the rates of periprocedural overt strokes can range from as little as 0.01% to as high as 2.9%. Meanwhile, covert brain infarctions (CBIs) occur much more frequently, with rates for different procedures ranging from 10%-84%. Risk factors include previous stroke, atherosclerotic disease, carotid stenosis, female sex, and African race, as well as other patient- and procedure-level factors. While the impact of covert brain infarctions is still a developing field, overt strokes for cardiac procedures lead to longer stays in hospital and increased costs. Potential preventative measures include screening and vascular risk factor control, premedicating, and procedural considerations such as the use of cerebral embolic protection devices. In addition, emerging treatments from the neurologic field, including neuroprotective drugs and remote ischemic conditioning, present promising avenues for preventing these strokes and merit investigation in cardiac procedures.
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15
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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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16
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Liu X, Zhou D, Fan J, Dai H, Zhu G, Chen J, Guo Y, Yidilisi A, Zhu Q, He Y, Wei Y, Liu Q, Qi X, Wang J. Cerebral Ischemic Lesions after Transcatheter Aortic Valve Implantation in Patients with Non-Calcific Aortic Stenosis. J Clin Med 2022; 11:6502. [PMID: 36362730 PMCID: PMC9655232 DOI: 10.3390/jcm11216502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 04/24/2024] Open
Abstract
Evidence for transcatheter aortic valve implantation (TAVI) is scarce among patients with non-calcific aortic stenosis, and it is not known whether aortic valve calcification is associated with new cerebral ischemic lesions (CILs) that are detected by diffusion-weighted magnetic resonance imaging. So, our study enrolled 328 patients who underwent transfemoral TAVI using a self-expanding valve between December 2016 and June 2021 from the TORCH registry (NCT02803294). A total of 34 patients were finally confirmed as non-calcific AS and the remaining 294 patients were included in the calcific AS group. Incidence of new CILs (70.6% vs. 85.7%, p = 0.022), number of lesions (2.0 vs. 3.0, p = 0.010), and lesions volume (105.0 mm3 vs. 200.0 mm3, p = 0.047) was significantly lower in the non-calcific AS group. However, the maximum and average lesion volumes were comparable between two groups. Non-calcific AS was associated with lower risk for developing new CILs by univariate logistic regression analysis [Odds ratio (OR): 0.040, 95% confident interval (CI): 0.18-0.90, p = 0.026] and multivariate analysis (OR: 0.031, 95% CI: 0.13-0.76, p = 0.010). In summary, non-calcific AS patients had a lower risk of developing new cerebral ischemic infarction after TAVI compared to calcific AS patients. However, new ischemic lesions were still found in over 70% of patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Jian’an Wang
- Department of Cardiology, Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou 310009, China
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17
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Purrman KC, Ndikumana E, Amirjamshidi H, Syposs C, Vidovich C, Boyce B, Knight P. Efficacy of Intraventricular Sponge Placement to Capture Debris in Aortic Valve Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:217-222. [PMID: 35578543 DOI: 10.1177/15569845221095876] [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] [Indexed: 11/15/2022]
Abstract
Objective: Surgical aortic valve replacement (SAVR) carries the known risk of shedding debris into the left ventricle during valve leaflet excision and annulus debridement. Embolization of this debris may have devastating effects for the patient. Although surgeons have developed methods to mitigate this risk, no data exist as to their efficacy. Herein, we present the first study that evaluates the efficacy of a technique for capturing debris during SAVR. Methods: Our group conducted a prospective case series of 20 patients who underwent SAVR using the insertion of an intraventricular surgical sponge prior to valve leaflet excision and annulus debridement to capture debris. Surgical sponges were grossly, radiographically, and histologically examined for the presence of cellular and acellular debris to determine the efficacy of this technique. Results: Of the 20 surgical sponges analyzed, 15 specimens (75%) registered positivity for cellular and/or acellular debris. Seven sponges (35%) were grossly positive, 15 sponges (75%) were radiographically positive, and 4 sponges (20%) were histologically positive for calcified debris on examination. Conclusions: This is one of the few studies to objectively evaluate a method used to capture debris in SAVR procedures. Our results demonstrate a high frequency of debris captured within intraventricular surgical sponges and confirms the efficacy of this technique. While these data are promising, numerous additional approaches exist to capture debris, and a best practice standard should exist across the specialty. In addition, this study does not address the clinical outcomes associated with this technique. To these ends, additional data and multicenter collaboration are required.
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Affiliation(s)
- Kyle C Purrman
- Division of Cardiac Surgery, 6923University of Rochester Medical Center, NY, USA
| | - Eric Ndikumana
- Division of Cardiac Surgery, 6923University of Rochester Medical Center, NY, USA
| | - Hossein Amirjamshidi
- Division of Cardiac Surgery, 6923University of Rochester Medical Center, NY, USA
| | - Chauncey Syposs
- Division of Pathology, 6923University of Rochester Medical Center, NY, USA
| | - Courtney Vidovich
- Division of Cardiac Surgery, 6923University of Rochester Medical Center, NY, USA
| | - Brendan Boyce
- Division of Pathology, 6923University of Rochester Medical Center, NY, USA
| | - Peter Knight
- Division of Cardiac Surgery, 6923University of Rochester Medical Center, NY, USA
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18
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Antithrombotic Therapy Following Transcatheter Aortic Valve Replacement. J Clin Med 2022; 11:jcm11082190. [PMID: 35456283 PMCID: PMC9031701 DOI: 10.3390/jcm11082190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022] Open
Abstract
Due to a large technical improvement in the past decade, transcatheter aortic valve replacement (TAVR) has expanded to lower-surgical-risk patients with symptomatic and severe aortic stenosis. While mortality rates related to TAVR are decreasing, the prognosis of patients is still impacted by ischemic and bleeding complications, and defining the optimal antithrombotic regimen remains a priority. Recent randomized control trials reported lower bleeding rates with an equivalent risk in ischemic outcomes with single antiplatelet therapy (SAPT) when compared to dual antiplatelet therapy (DAPT) in patients without an underlying indication for anticoagulation. In patients requiring lifelong oral anticoagulation (OAC), the association of OAC plus antiplatelet therapy leads to a higher risk of bleeding events with no advantages on mortality or ischemic outcomes. Considering these data, guidelines have recently been updated and now recommend SAPT and OAC alone for TAVR patients without and with a long-term indication for anticoagulation. Whether a direct oral anticoagulant or vitamin K antagonist provides better outcomes in patients in need of anticoagulation remains uncertain, as recent trials showed a similar impact on ischemic and bleeding outcomes with apixaban but higher gastrointestinal bleeding with edoxaban. This review aims to summarize the most recently published data in the field, as well as describe unresolved issues.
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19
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Puthettu M, Vandenberghe S, Bagnato P, Gallo M, Demertzis S. Gaseous Microemboli in the Cardiopulmonary Bypass Circuit: Presentation of a Systematic Data Collection Protocol Applied at Istituto Cardiocentro Ticino. Cureus 2022; 14:e22310. [PMID: 35350483 PMCID: PMC8933722 DOI: 10.7759/cureus.22310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 11/05/2022] Open
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20
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Hulde N, Zittermann A, Tigges-Limmer K, Koster A, Weinrautner N, Gummert J, von Dossow V. Preoperative Risk Factors and Early Outcomes of Delirium in Valvular Open-Heart Surgery. Thorac Cardiovasc Surg 2022; 70:558-565. [PMID: 35042244 DOI: 10.1055/s-0041-1740984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Compared with coronary artery bypass grafting surgery, data regarding postoperative delirium are scant in valvular open-heart surgery. Therefore, the goal of this retrospective study was to investigate the incidence, preoperative risk factors, and early outcomes of delirium in a large group of patients undergoing valvular open-heart surgery. METHODS In 13,229 patients with isolated valvular or combined valvular and bypass surgery, the incidence of postoperative delirium was assessed until discharge. Independent risk factors of delirium were evaluated by multivariable logistic regression analysis. Moreover, we assessed the multivariable-adjusted risk of prolonged intensive care unit (ICU) stay (>48 hours) and in-hospital mortality in patients with delirium. RESULTS Overall, the incidence of postoperative delirium was 8.4%. The incidence in patients experiencing a postoperative stroke or seizure was 23.1 and 29.7%, respectively. Twelve preoperative risk factors, mostly nonmodifiable, were independently associated with the risk of delirium, including advanced age, renal impairment, stroke, the need for emergency surgery, and severe preoperative anemia (hemoglobin < 9 g/dL). Postoperative delirium was associated with an adjusted odds ratio (OR) of prolonged ICU stay of 9.48 (95% confidence interval [CI]: 7.96-11.30). Adjusted in-hospital mortality was, however, significantly lower in patients with delirium versus patients without delirium (OR, 0.56; 95% CI: 0.38-0.83). CONCLUSION In valvular open-heart surgery, postoperative delirium is a frequent neurological complication that is associated with other postoperative neurological complications and several, mostly nonmodifiable, preoperative risk factors. Although postoperative delirium was associated with a significantly increased risk of prolonged ICU stay, this did not translate into an increased short-term mortality.
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Affiliation(s)
- Nikolai Hulde
- Institute of Anesthesiology and Pain Therapy, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Armin Zittermann
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Katharina Tigges-Limmer
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Andreas Koster
- Institute of Anesthesiology and Pain Therapy, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Nicole Weinrautner
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - Vera von Dossow
- Institute of Anesthesiology and Pain Therapy, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Nordrhein-Westfalen, Germany
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21
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Asymptomatic Stroke in the Setting of Percutaneous Non-Coronary Intervention Procedures. Medicina (B Aires) 2021; 58:medicina58010045. [PMID: 35056353 PMCID: PMC8778528 DOI: 10.3390/medicina58010045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022] Open
Abstract
Advancements in clinical management, pharmacological therapy and interventional procedures have strongly improved the survival rate for cardiovascular diseases (CVDs). Nevertheless, the patients affected by CVDs are more often elderly and present several comorbidities such as atrial fibrillation, valvular heart disease, heart failure, and chronic coronary syndrome. Standard treatments are frequently not available for “frail patients”, in particular due to high surgical risk or drug interaction. In the past decades, novel less-invasive procedures such as transcatheter aortic valve implantation (TAVI), MitraClip or left atrial appendage occlusion have been proposed to treat CVD patients who are not candidates for standard procedures. These procedures have been confirmed to be effective and safe compared to conventional surgery, and symptomatic thromboembolic stroke represents a rare complication. However, while the peri-procedural risk of symptomatic stroke is low, several studies highlight the presence of a high number of silent ischemic brain lesions occurring mainly in areas with a low clinical impact. The silent brain damage could cause neuropsychological deficits or worse, a preexisting dementia, suggesting the need to systematically evaluate the impact of these procedures on neurological function.
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22
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Barbero C, Rinaldi M, Marchetto G, Valentini MC, Cura Stura E, Bosco G, Pocar M, Filippini C, Boffini M, Ricci D. Magnetic Resonance Imaging for Cerebral Micro-embolizations During Minimally Invasive Mitral Valve Surgery. J Cardiovasc Transl Res 2021; 15:828-833. [PMID: 34845626 DOI: 10.1007/s12265-021-10188-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
The role of aortic clamping techniques on the occurrence of neurological complications after right mini-thoracotomy mitral valve surgery is still debated. Brain injuries can occur also as silent cerebral micro-embolizations (SCM), which have been linked to significant deficits in physical and cognitive functions. Aims of this study are to evaluate the overall rate of SCM and to compare endoaortic clamp (EAC) with trans-thoracic clamp (TTC). Patients enrolled underwent a pre-operative, a post-operative, and a follow-up MRI. Forty-three patients were enrolled; EAC was adopted in 21 patients, TTC in 22 patients. Post-operative SCM were reported in 12 cases (27.9%). No differences between the 2 groups were highlighted (23.8% SCM in the EAC group versus 31.8% in the TTC). MRI analysis showed post-operative SCM in nearly 30% of selected patients after right mini-thoracotomy mitral valve surgery. Subgroup analysis on different types of aortic clamping showed comparable results. CLINICAL RELEVANCE: The rate of SCM reported in the present study on patients undergoing minimally invasive MVS and RAP is consistent with data in the literature on patients undergoing cardiac surgery through median sternotomy and antegrade arterial perfusion. Moreover, no differences were reported between EAC and TTC: both the aortic clamping techniques are safe, and the choice of the surgical setting to adopt can be really done according to the patient's characteristics.
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Affiliation(s)
- Cristina Barbero
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, University of Turin, Turin, Italy.
| | - Mauro Rinaldi
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Giovanni Marchetto
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Maria Consuelo Valentini
- Department of Neuroradiology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Erik Cura Stura
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Giovanni Bosco
- Department of Neurology, Città Della Salute E Della Scienza, University of Turin, Turin, Italy
| | - Marco Pocar
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Claudia Filippini
- Department of Anesthesia and Critical Care, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Massimo Boffini
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Davide Ricci
- Cardiac Surgery Unit, IRCCS Policlinic Hospital San Martino, Genova, Italy
- Department of Integrated Surgical and Diagnostic Sciences, University of Genova, Genova, Italy
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Riley KJ, Kao LW, Low YH, Card S, Manalo G, Fleming JP, Essandoh MK, Dalia AA, Qu JZ. Neurologic Dysfunction and Neuroprotection in Transcatheter Aortic Valve Implantation. J Cardiothorac Vasc Anesth 2021; 36:3224-3236. [PMID: 34903454 DOI: 10.1053/j.jvca.2021.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/07/2021] [Accepted: 11/08/2021] [Indexed: 11/11/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is a fast-growing procedure. Expanding to low-risk patients, it has surpassed surgical aortic valve implantation in frequency and has been associated with excellent outcomes. Stroke is a devastating complication after transcatheter aortic valve implantation. Silent brain infarcts identified by diffusion-weighted magnetic resonance imaging are present in most patients following TAVI. Postoperative delirium and cognitive dysfunction are common neurologic complications. The stroke and silent brain infarcts are likely caused by particulate emboli released during the procedure. Intravascularly positioned cerebral embolic protection devices are designed to prevent debris from entering the aortic arch vessels to avoid stroke. Despite promising design, randomized clinical trials have not demonstrated a reduction in stroke in patients receiving cerebral embolic protection devices. Similarly, the association of cerebral embolic protection devices with silent brain infarcts, postoperative delirium, and cognitive dysfunction is uncertain. Monitored anesthesia care or conscious sedation is as safe as general anesthesia and is associated with lower cost, but different anesthetic techniques have not been shown to decrease stroke risk, postoperative delirium, or cognitive dysfunction. Anesthesiologists play important roles in providing perioperative care including management of neurologic events in patients undergoing TAVI. Large randomized clinical trials are needed that focus on the correlation between perioperative interventions and neurologic outcomes.
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Affiliation(s)
- Kyle J Riley
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lee-Wei Kao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ying H Low
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Shika Card
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Gem Manalo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey P Fleming
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael K Essandoh
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jason Z Qu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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24
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Saia F, Orzalkiewicz M. How to reduce uncommon but severe transcatheter aortic valve implantation complications: stroke, thrombosis, endocarditis, cognitive decline? Eur Heart J Suppl 2021; 23:E142-E146. [PMID: 34650374 PMCID: PMC8503386 DOI: 10.1093/eurheartj/suab110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Transcatheter aortic valve implantation has become a valid alternative to surgical aortic valve replacement for patients with symptomatic severe aortic stenosis, regardless of baseline surgical risk. The incidence of periprocedural complications has steadily declined over the years, thanks to technical advancement of transcatheter heart valves, delivery systems, and increased operators' experience. Beyond the most common periprocedural complications, there are a few uncommon but potentially severe complications that more often occur during follow-up, although they may also arise in the periprocedural phase. Stroke, infective endocarditis, valve thrombosis, and cognitive decline are among them. In this brief review, we describe the incidence, predictive factors, and potential preventive measures for those events.
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Affiliation(s)
- Francesco Saia
- Cardiac Unit, Cardio-Thoracic-Vascular Department, IRCCS University Hospital of Bologna, Policlinico S. Orsola (Pav. 23), Via Massarenti, 9, 40138 Bologna, Italy
| | - Mateusz Orzalkiewicz
- Cardiac Unit, Cardio-Thoracic-Vascular Department, IRCCS University Hospital of Bologna, Policlinico S. Orsola (Pav. 23), Via Massarenti, 9, 40138 Bologna, Italy
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25
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Snyder B, 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 DOI: 10.1213/ane.0000000000005525] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [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 Snyder
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Tania Giovannetti
- Department of Psychology, Temple University, Philadelphia, Pennsylvania
| | - Thomas F Floyd
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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26
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Puthettu M, Vandenberghe S, Demertzis S. Effect of cannulation site on emboli travel during cardiac surgery. J Cardiothorac Surg 2021; 16:181. [PMID: 34162399 PMCID: PMC8220729 DOI: 10.1186/s13019-021-01564-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/06/2021] [Indexed: 11/10/2022] Open
Abstract
Background During cardiac surgery, micro-air emboli regularly enter the blood stream and can cause cognitive impairment or stroke. It is not clearly understood whether the most threatening air emboli are generated by the heart-lung machine (HLM) or by the blood-air contact when opening the heart. We performed an in vitro study to assess, for the two sources, air emboli distribution in the arterial tree, especially in the brain region, during cardiac surgery with different cannulation sites. Methods A model of the arterial tree was 3D printed and included in a hydraulic circuit, divided such that flow going to the brain was separated from the rest of the circuit. Air micro-emboli were injected either in the HLM (“ECC Bubbles”) or in the mock left ventricle (“Heart Bubbles”) to simulate the two sources. Emboli distribution was measured with an ultrasonic bubble counter. Five repetitions were performed for each combination of injection site and cannulation site, where air bubble counts and volumes were recorded. Air bubbles were separated in three categories based on size. Results For both injection sites, it was possible to identify statistically significant differences between cannulation sites. For ECC Bubbles, axillary cannulation led to a higher amount of air bubbles in the brain with medium-sized bubbles. For Heart Bubbles, aortic cannulation showed a significantly bigger embolic load in the brain with large bubbles. Conclusions These preliminary in vitro findings showed that air embolic load in the brain may be dependent on the cannulation site, which deserves further in vivo exploration.
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Affiliation(s)
- Mira Puthettu
- Foundation for Cardiovascular Research and Education (FCRE), Cardiovascular Engineering, Istituto Cardiocentro Ticino, Via ai Söi 24, 6807, Torricella-Taverne, Switzerland.
| | - Stijn Vandenberghe
- Department of Cardiac Surgery, Istituto Cardiocentro Ticino, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Stefanos Demertzis
- Department of Cardiac Surgery, Istituto Cardiocentro Ticino, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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27
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Gomes WJ, Gomes EN, Bertini A, Reis PH, Hossne NA. The Anaortic Technique with Bilateral Internal Thoracic Artery Grafting - Filling the Gap in Coronary Artery Bypass Surgery. Braz J Cardiovasc Surg 2021; 36:397-405. [PMID: 34387975 PMCID: PMC8357393 DOI: 10.21470/1678-9741-2020-0451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Coronary artery bypass grafting (CABG) has consolidated its role as the most effective procedure for treating patients with advanced atherosclerotic coronary artery disease, reducing the long-term risk of myocardial infarction and death compared to other therapies and relieving angina. Despite the recognized benefits afforded by surgical myocardial revascularization, a subset of higher-risk patients bears a more elevated risk of perioperative stroke. Stroke remains the drawback of conventional CABG and has been strongly linked to aortic manipulation (cannulation, cross-clamping, and side-biting clamping for the performance of proximal aortic anastomoses) and the use of cardiopulmonary bypass. Adoption of off-pump CABG (OPCAB) is demonstrated to lower the risk of perioperative stroke, as well as reducing the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay. However, increased risk persists owing to the need for the tangential ascending aorta clamping to construct the proximal anastomosis. The concept of anaortic (aorta no-touch) OPCAB (anOPCAB) stems from eliminating ascending aorta manipulation, virtually abolishing the risk of embolism caused by aortic wall debris into the brain circulation. The adoption of anOPCAB has been shown to further decrease the risk of postoperative stroke, especially in higher-risk patients, entailing a step forward and a refinement of outcomes provided by the primeval OPCAB technique. Therefore, anOPCAB has been the recommended technique in patients with cerebrovascular disease and/or calcification or atheromatous plaque in the ascending aorta and should be preferred in patients with high-risk factors for neurological damage and stroke.
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Affiliation(s)
- Walter J Gomes
- Cardiovascular Surgery Discipline, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Eduardo N Gomes
- Affiliated Hospitals of Associação Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, São Paulo, Brazil
| | - Ayrton Bertini
- Affiliated Hospitals of Associação Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, São Paulo, Brazil
| | - Pedro H Reis
- Affiliated Hospitals of Associação Paulista para o Desenvolvimento da Medicina (SPDM), São Paulo, São Paulo, Brazil
| | - Nelson A Hossne
- Cardiovascular Surgery Discipline, Hospital São Paulo, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
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28
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Woldendorp K, Indja B, Bannon PG, Fanning JP, Plunkett BT, Grieve SM. Silent brain infarcts and early cognitive outcomes after transcatheter aortic valve implantation: a systematic review and meta-analysis. Eur Heart J 2021; 42:1004-1015. [PMID: 33517376 DOI: 10.1093/eurheartj/ehab002] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/16/2020] [Accepted: 01/08/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Silent brain infarcts (SBIs) are frequently identified after transcatheter aortic valve implantation (TAVI), when patients are screened with diffusion-weighted magnetic resonance imaging (DW-MRI). Outside the cardiac literature, SBIs have been correlated with progressive cognitive dysfunction; however, their prognostic utility after TAVI remains uncertain. This study's main goals were to explore (i) the incidence of and potential risk factors for SBI after TAVI; and (ii) the effect of SBI on early post-procedural cognitive dysfunction (PCD). METHODS AND RESULTS A systematic literature review was performed to identify all publications reporting SBI incidence, as detected by DW-MRI after TAVI. Silent brain infarct incidence, baseline characteristics, and the incidence of early PCD were evaluated via meta-analysis and meta-regression models. We identified 39 relevant studies encapsulating 2408 patients. Out of 2171 patients who underwent post-procedural DW-MRI, 1601 were found to have at least one new SBI (pooled effect size 0.76, 95% CI: 0.72-0.81). The incidence of reported stroke with focal neurological deficits was 3%. Meta-regression noted that diabetes, chronic renal disease, 3-Tesla MRI, and pre-dilation were associated with increased SBI risk. The prevalence of early PCD increased during follow-up, from 16% at 10.0 ± 6.3 days to 26% at 6.1 ± 1.7 months and meta-regression suggested an association between the mean number of new SBI and incidence of PCD. The use of cerebral embolic protection devices (CEPDs) appeared to decrease the volume of SBI, but not their overall incidence. CONCLUSIONS Silent brain infarcts are common after TAVI; and diabetes, kidney disease, and pre-dilation increase overall SBI risk. While higher numbers of new SBIs appear to adversely affect early neurocognitive outcomes, long-term follow-up studies remain necessary as TAVI expands to low-risk patient populations. The use of CEPD did not result in a significant decrease in the occurrence of SBI.
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Affiliation(s)
- Kei Woldendorp
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia.,Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia.,Baird Institute of Applied Heart and Lung Research, 100 Carillon Avenue, Sydney, NSW 2042, Australia
| | - Ben Indja
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia
| | - Paul G Bannon
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia.,Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia.,Baird Institute of Applied Heart and Lung Research, 100 Carillon Avenue, Sydney, NSW 2042, Australia
| | - Jonathon P Fanning
- The Prince Charles Hospital, Critical Care Research Group, Brisbane, QLC 4032, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD 4072, Australia
| | - Brian T Plunkett
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia.,Baird Institute of Applied Heart and Lung Research, 100 Carillon Avenue, Sydney, NSW 2042, Australia
| | - Stuart M Grieve
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia.,Sydney Translational Imaging Laboratory, Charles Perkins Centre, University of Sydney, NSW 2006, Australia.,Department of Radiology, Royal Prince Alfred Hospital, Camperdown, Sydney, NSW 2050, Australia
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29
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Johansen MC, Gottesman RF. Cerebrovascular Disease and Cognitive Outcome in Patients with Cardiac Disease. Semin Neurol 2021; 41:463-472. [PMID: 33851395 DOI: 10.1055/s-0041-1726330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The pace of understanding cognitive decline and dementia has rapidly accelerated over the past decade, with constantly evolving insights into the vascular contributions to cognitive impairment and dementia (VCID). Notably, more overlap has been discovered in the pathophysiology between what was previously understood to be Alzheimer's disease and VCID, leading to a heightened emphasis on disease prevention through early and aggressive control of vascular risk factors. One particularly vulnerable population may be those with cardiac disease, as they are at risk for cerebrovascular disease, which itself can lead to dementia, and increasing evidence supports cognitive impairment in disease processes such as heart failure and atrial fibrillation, independent of ischemic stroke, suggesting other potential mechanisms. In this article, we review the evidence supporting the relationship between cardiac disease, cerebrovascular disease, and cognitive decline and discuss the ongoing and future research efforts aimed at defining the important relationship between these entities.
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Affiliation(s)
- Michelle C Johansen
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca F Gottesman
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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30
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Benesch C, Glance LG, Derdeyn CP, Fleisher LA, Holloway RG, Messé SR, Mijalski C, Nelson MT, Power M, Welch BG. Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association. Circulation 2021; 143:e923-e946. [PMID: 33827230 DOI: 10.1161/cir.0000000000000968] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.
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31
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Guo J, Zhou C, Yue L, Yan F, Shi J. Incidence and Risk Factors for Silent Brain Infarction After On-Pump Cardiac Surgery: A Meta-analysis and Meta-regression of 29 Prospective Cohort Studies. Neurocrit Care 2021; 34:657-668. [PMID: 32648193 DOI: 10.1007/s12028-020-01048-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Silent brain infarction (SBI) happens at a considerable rate after on-pump cardiac surgery. Though termed silent, SBI is related to unfavorable clinical outcomes including higher incidence of future stroke and neurocognitive impairment in the general population. The risk factors of SBI have not been fully identified in both individual studies and several meta-analyses addressing the topic. In this meta-analysis, we aimed to conduct meta-regression analysis for the first time to explore risk factors for SBI after on-pump cardiac surgery. METHODS This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Medline, Embase, Central, Web of Science, and Wiley databases were searched for relevant studies. Preoperative patient baseline characteristics and intraoperative surgical parameters were extracted from included studies. For meta-regression, a P value of less than 0.1 was considered statistically significant in both univariable and multivariable analyses. RESULTS Twenty-nine studies with 1478 patients were included in this meta-analysis. The summarized SBI rate after on-pump cardiac surgery was 37% (95% CI 0.27-0.47, P < 0.0001). Heterogeneity between studies was significant (I2 = 94.9%, P < 0.0001). In multivariable meta-regression, we found that age (coefficient 0.014, 95% CI 0.001-0.029, P = 0.043), diabetes (coefficient 0.006, 95% CI - 0.001 to 0.013, P = 0.075), and proportion of CABG (coefficient - 0.001, 95% CI - 0.003 to 0.0003, P = 0.096) were significantly associated with SBI incidence. CONCLUSION From the meta-regression, we concluded that advanced age and diabetes were related to increased SBI incidence after on-pump cardiac surgery, while CABG procedure alone was associated with less SBI onset. Studies with more accurate diagnoses of SBI are required to add more conclusive evidence to the field.
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Affiliation(s)
- Jingfei Guo
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, No. 167 Beilishi Street, Xicheng District, Beijing, 100037, China
| | - Chenghui Zhou
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, No. 167 Beilishi Street, Xicheng District, Beijing, 100037, China
| | - Liu Yue
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, No. 167 Beilishi Street, Xicheng District, Beijing, 100037, China
| | - Fuxia Yan
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, No. 167 Beilishi Street, Xicheng District, Beijing, 100037, China
| | - Jia Shi
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, No. 167 Beilishi Street, Xicheng District, Beijing, 100037, China.
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32
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Kussman BD, Imaduddin SM, Gharedaghi MH, Heldt T, LaRovere K. Cerebral Emboli Monitoring Using Transcranial Doppler Ultrasonography in Adults and Children: A Review of the Current Technology and Clinical Applications in the Perioperative and Intensive Care Setting. Anesth Analg 2021; 133:379-392. [PMID: 33764341 DOI: 10.1213/ane.0000000000005417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Transcranial Doppler (TCD) ultrasonography is the only noninvasive bedside technology for the detection and monitoring of cerebral embolism. TCD may identify patients at risk of acute and chronic neurologic injury from gaseous or solid emboli. Importantly, a window of opportunity for intervention-to eliminate the source of the emboli and thereby prevent subsequent development of a clinical or subclinical stroke-may be identified using TCD. In this review, we discuss the application of TCD sonography in the perioperative and intensive care setting in adults and children known to be at increased risk of cerebral embolism. The major challenge for evaluation of emboli, especially in children, is the need to establish the ground truth and define true emboli identified by TCD. This requires the development and validation of a predictive TCD emboli monitoring technique so that appropriately designed clinical studies intended to identify specific modifiable factors and develop potential strategies to reduce pathologic cerebral embolic burden can be performed.
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Affiliation(s)
- Barry D Kussman
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Syed M Imaduddin
- Department of Electrical Engineering and Computer Science, the Institute for Medical Engineering and Science, and the Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Mohammad Hadi Gharedaghi
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Thomas Heldt
- Department of Electrical Engineering and Computer Science, the Institute for Medical Engineering and Science, and the Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Kerri LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts.,Department of Neurology, Harvard Medical School, Boston, Massachusetts
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33
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Ramponi F, Seco M, Brereton RJL, Gaudino MFL, Puskas JD, Calafiore AM, Vallely MP. Toward stroke-free coronary surgery: The role of the anaortic off-pump bypass technique. J Card Surg 2021; 36:1499-1510. [PMID: 33502822 DOI: 10.1111/jocs.15372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/06/2021] [Accepted: 01/13/2021] [Indexed: 11/26/2022]
Abstract
Surgical coronary revascularization remains the preferred strategy in a significant portion of patients with coronary artery disease due to superior long-term outcomes. However, there is a significant risk of perioperative neurologic injury that has influenced guideline recommendations. These complications occur in 1%-5% of patients, ranging from overt neurologic deficits with permanent disability, to subtle cerebral defects noted on neuroimaging that may result in slow cognitive and functional decline. The primary mechanism by which these events occur is thromboembolism from manipulation of the ascending aorta. This occurs during cardiopulmonary bypass, aortic cross-clamping, and partial occlusion clamping (side clamp). Elderly patients and patients with aortic atheroma are, therefore, at significantly increased risk. Initial surgical techniques addressed this by aggressively debriding or replacing the ascending aorta during coronary artery bypass grafting (CABG). Strategies then moved toward minimizing aortic manipulation through pump-assisted beating heart surgery and off-pump surgery with partial occlusion clamping or proximal anastomosis devices. Finally, anaortic off-pump CABG aims to avoid all manipulation of the ascending aorta through advanced off-pump grafting techniques combined with in situ and composite grafts. This has been demonstrated to result in the greatest reduction in risk. Establishing successful anaortic off-pump CABG programs requires subspecialization and focused interest groups dedicated to advancing CABG outcomes.
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Affiliation(s)
- Fabio Ramponi
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael Seco
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, New York, USA
| | | | - Michael P Vallely
- Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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34
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Ordóñez-Velasco LM, Hernández-Leiva E. Factors associated with delirium after cardiac surgery: A prospective cohort study. Ann Card Anaesth 2021; 24:183-189. [PMID: 33884974 PMCID: PMC8253013 DOI: 10.4103/aca.aca_43_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background: Delirium is a frequent complication after cardiac surgery and is associated with a higher incidence of morbidity and mortality and a prolonged hospital stay. However, knowledge of the variables involved in its occurrence is still limited; therefore, in this study, we evaluated the perioperative risk factors independently associated with this complication. Methods: This study was conducted in a referral tertiary care university hospital with a cardiovascular focus. A total of 311 consecutive adult patients undergoing any type of cardiac surgery were evaluated. The subjects were examined at regular intervals in the postoperative period using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) tool. Results: The incidence of postoperative delirium (PD) was 10%. Among the 18 pre-, intra- and postoperative variables evaluated, the logistic regression analysis showed that low education level, history of diabetes or stroke, type of surgery, prolonged extracorporeal circulation, or red blood cell transfusion in the intra- or postoperative period were independently associated with delirium after cardiac surgery. An increased body mass index was identified as a protective factor. Conclusions: The aforementioned risk factors are significantly and independently associated with the presentation of PD. Because some of these factors can be treated or avoided, the results of this study are highly relevant to reduce the risk of this complication and improve the care of patients undergoing cardiac surgery.
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Affiliation(s)
- Lina Maria Ordóñez-Velasco
- Intensivist at Cardiovascular Intensive Care Unit. Instituto de Cardiología - Fundación Cardioinfantil, Colombia
| | - Edgar Hernández-Leiva
- Department of Cardiology, Head of the Cardiac Surgical Intensive Care Unit, Instituto de Cardiología - Fundación Cardioinfantil, Colombia
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35
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Browne A, Spence J, Power P, Copland I, Mian R, Gagnon S, Kennedy S, Sharma M, Lamy A. Perioperative covert stroke in patients undergoing coronary artery bypass graft surgery. JTCVS OPEN 2020; 4:1-11. [PMID: 36004290 PMCID: PMC9390707 DOI: 10.1016/j.xjon.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 12/19/2022]
Abstract
Objectives Covert stroke is a complication of coronary artery bypass graft surgery that is increasingly recognized as a serious problem. In noncardiac surgery settings, covert stroke is associated with the development of delirium, long-term cognitive decline, and future clinical stroke. Therefore, we sought to determine the feasibility of conducting a large, prospective cohort study of the influence of covert stroke on neurocognitive outcomes in patients undergoing coronary artery bypass graft surgery. Methods NeuroVISION Cardiac pilot was a prospective cohort study enrolling patients aged ≥21 years undergoing isolated coronary artery bypass graft surgery to receive diffusion-weighted magnetic resonance imaging of the brain after surgery to identify patients with covert stroke. Patients were screened for postoperative delirium in-hospital and were administered questionnaires of cognitive and global function (once before and twice after surgery). Regional cerebral oxygen saturation was recorded during surgery using near-infrared spectroscopy. Results Between March 27, 2017, and February 11, 2018, 50 of 66 patients enrolled (76%) completed the brain magnetic resonance imaging (1 patient per week). Among the 49 patients included in the analysis, 19 (39%; 95% confidence interval, 26%-53%) experienced perioperative covert stroke and 3 (6%) had a clinical stroke within 30 days of surgery. Postoperative delirium occurred in 5 (26%) patients with covert stroke and in 3 (10%) patients who did not experience covert stroke. Conclusions The NeuroVISION Cardiac pilot study established the feasibility of conducting a large, prospective cohort study of the determinants and consequences of covert stroke in patients undergoing coronary artery bypass graft surgery.
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Affiliation(s)
- Austin Browne
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jessica Spence
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Anesthesia, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Patricia Power
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Ingrid Copland
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Rajibul Mian
- Department of Statistics, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Stephanie Gagnon
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Shauna Kennedy
- Department of Radiology, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Mukul Sharma
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Neurology, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - André Lamy
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada
- Address for reprints: André Lamy, MD, Department of Perioperative Medicine, Population Health Research Institute, DBCVSRI Room C1-112, 20 Copeland Ave, Hamilton, Ontario L8L 2X2 Canada.
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36
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Freedman B, Kamel H, Van Gelder IC, Schnabel RB. Atrial fibrillation: villain or bystander in vascular brain injury. Eur Heart J Suppl 2020; 22:M51-M59. [PMID: 33664640 PMCID: PMC7916423 DOI: 10.1093/eurheartj/suaa166] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) and stroke are inextricably connected, with classical Virchow pathophysiology explaining thromboembolism through blood stasis in the fibrillating left atrium. This conceptualization has been reinforced by the remarkable efficacy of oral anticoagulant (OAC) for stroke prevention in AF. A number of observations showing that the presence of AF is neither necessary nor sufficient for stroke, cast doubt on the causal role of AF as a villain in vascular brain injury (VBI). The requirement for additional risk factors before AF increases stroke risk; temporal disconnect of AF from a stroke in patients with no AF for months before stroke during continuous ECG monitoring but manifesting AF only after stroke; and increasing recognition of the role of atrial cardiomyopathy and atrial substrate in AF-related stroke, and also stroke without AF, have led to rethinking the pathogenetic model of cardioembolic stroke. This is quite separate from recognition that in AF, shared cardiovascular risk factors can lead both to non-embolic stroke, or emboli from the aorta and carotid arteries. Meanwhile, VBI is now expanded to include dementia and cognitive decline: research is required to see if reduced by OAC. A changed conceptual model with less focus on the arrhythmia, and more on atrial substrate/cardiomyopathy causing VBI both in the presence or absence of AF, is required to allow us to better prevent AF-related VBI. It could direct focus towards prevention of the atrial cardiomyopathy though much work is required to better define this entity before the balance between AF as villain or bystander can be determined.
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Affiliation(s)
- Ben Freedman
- Heart Research Institute, Charles Perkins Centre and Concord Hospital Department of Cardiology, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Renate B Schnabel
- University Heart and Vascular Centre, Department of Cardiology, Hamburg, Germany; German Centre for Cardiovascular Research (DZHK e.V.), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Indja B, Woldendorp K, Vallely MP, Grieve SM. Silent Brain Infarcts Following Cardiac Procedures: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2020; 8:e010920. [PMID: 31017035 PMCID: PMC6512106 DOI: 10.1161/jaha.118.010920] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Silent brain infarcts (SBI) are increasingly being recognized as an important complication of cardiac procedures as well as a potential surrogate marker for studies on brain injury. The extent of subclinical brain injury is poorly defined. Methods and Results We conducted a systematic review and meta‐analysis utilizing studies of SBIs and focal neurologic deficits following cardiac procedures. Our final analysis included 42 studies with 49 separate intervention groups for a total of 2632 patients. The prevalence of SBIs following transcatheter aortic valve implantation was 0.71 (95% CI 0.64‐0.77); following aortic valve replacement 0.44 (95% CI 0.31‐0.57); in a mixed cardiothoracic surgery group 0.39 (95% CI 0.28‐0.49); coronary artery bypass graft 0.25 (95% CI 0.15‐0.35); percutaneous coronary intervention 0.14 (95% CI 0.10‐0.19); and off‐pump coronary artery bypass 0.14 (0.00‐0.58). The risk ratio of focal neurologic deficits to SBI in aortic valve replacement was 0.22 (95% CI 0.15‐0.32); in off‐pump coronary artery bypass 0.21 (95% CI 0.02‐2.04); with mixed cardiothoracic surgery 0.15 (95% CI 0.07‐0.33); coronary artery bypass graft 0.10 (95% CI 0.05‐0.18); transcatheter aortic valve implantation 0.10 (95% CI 0.07‐0.14); and percutaneous coronary intervention 0.06 (95% CI 0.03‐0.14). The mean number of SBIs per patient was significantly higher in the transcatheter aortic valve implantation group (4.58 ± 2.09) compared with both the aortic valve replacement group (2.16 ± 1.62, P=0.03) and the percutaneous coronary intervention group (1.88 ± 1.02, P=0.03). Conclusions SBIs are a very common complication following cardiac procedures, particularly those involving the aortic valve. The high frequency of SBIs compared with strokes highlights the importance of recording this surrogate measure in cardiac interventional studies. We suggest that further work is required to standardize reporting in order to facilitate the use of SBIs as a routine outcome measure.
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Affiliation(s)
- Ben Indja
- 1 Sydney Translational Imaging Laboratory Heart Research Institute Charles Perkins Centre The University of Sydney Camperdown Sydney NSW Australia.,2 Sydney Medical School The University of Sydney Camperdown Sydney NSW Australia
| | - Kei Woldendorp
- 2 Sydney Medical School The University of Sydney Camperdown Sydney NSW Australia.,4 Department of Cardiothoracic Surgery Royal Prince Alfred Hospital Camperdown Sydney NSW Australia
| | - Michael P Vallely
- 2 Sydney Medical School The University of Sydney Camperdown Sydney NSW Australia.,3 Sydney Heart and Lung Surgeons Camperdown Sydney NSW Australia
| | - Stuart M Grieve
- 1 Sydney Translational Imaging Laboratory Heart Research Institute Charles Perkins Centre The University of Sydney Camperdown Sydney NSW Australia.,2 Sydney Medical School The University of Sydney Camperdown Sydney NSW Australia.,5 Department of Radiology Royal Prince Alfred Hospital Camperdown Sydney NSW Australia
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38
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Affiliation(s)
- Thomas Raphael Meinel
- Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology (J.K.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology (L.R.), Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (T.R.M., U.F.), Inselspital, Bern University Hospital, University of Bern, Switzerland
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Nishijima S, Nakamura Y, Yoshiyama D, Yasumoto Y, Kuroda M, Nakayama T, Tsuruta R, Ito Y, Shikata F, Takeda T, Kato N. Silent brain infarction after minimally invasive cardiac surgery with retrograde perfusion. J Card Surg 2020; 35:1927-1932. [PMID: 32667074 DOI: 10.1111/jocs.14866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM There is no report on silent brain infarction (SBI) after minimally invasive cardiac surgery (MICS) with retrograde perfusion. Thus, the current study aimed to investigate the incidence of SBI after MICS using magnetic resonance imaging (MRI). METHODS This study included 174 patients who underwent MICS with retrograde perfusion between July 2014 and July 2018. Preoperative computed tomography (CT) angiography was routinely performed and vascular pathology was evaluated for patient selection. Postoperative MRI was performed to investigate the occurrence of SBI. RESULTS Out of the total 174 patients, 26 (14.9%) presented with SBI. A total of 61 SBI lesions were found in the 26 patients; of these, 34 (56%) SBI lesions were in the right hemisphere and 27 (44%) in the left hemisphere. SBIs were primarily observed in the posterior cerebral artery territory. Multivariate analysis revealed aortic stenosis to be the only risk factor of SBI. CONCLUSIONS Retrograde perfusion via femoral cannulation may not increase the incidence of SBI in selected MICS patients based on preoperative CT findings.
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Affiliation(s)
- Shuhei Nishijima
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Chiba, Japan
| | - Yoshitsugu Nakamura
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Chiba, Japan
| | - Daiki Yoshiyama
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Chiba, Japan
| | - Yuto Yasumoto
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Chiba, Japan
| | - Miho Kuroda
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Chiba, Japan
| | - Taisuke Nakayama
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Chiba, Japan
| | - Ryo Tsuruta
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Chiba, Japan
| | - Yujiro Ito
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Chiba, Japan
| | - Fumiaki Shikata
- Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Chiba, Japan
| | - Tetsuji Takeda
- Department of Neuro Surgery, Chiba-Nishi General Hospital, Matsudo, Chiba, Japan
| | - Nobuyuki Kato
- Department of Radiology, Chiba-Nishi General Hospital, Matsudo, Chiba, Japan
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40
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Haussig S, Linke A, Mangner N. Cerebral Protection Devices during Transcatheter Interventions: Indications, Benefits, and Limitations. Curr Cardiol Rep 2020; 22:96. [PMID: 32651654 PMCID: PMC7351861 DOI: 10.1007/s11886-020-01335-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Purpose of Review Stroke remains a devastating complication of cardiovascular interventions. This review is going to discuss stroke rates and outcomes in different cardiovascular procedures with a highlight on the current evidence for the use of cerebral protection devices (CPD). Recent Findings Depending on the quality of neurological assessment, stroke occurs in up to 9.1% after TAVI, 3.9% after mitral clipping, 3.1% in LAAO patients, 0.4% after PCIs, and 1.8% after catheter ablation. CPDs are available for routine use. They are easy to use in most anatomies, feasible, and safe. Data on clinical impact and stroke reduction from RCTs are still missing. Summary Most evidence for the routine use of CPDs exists in TAVI patients, who are at the highest risk. The PROTECTED TAVI RCT will shed more light on the clinical impact of CPD-use in TAVI patients. In other cardiovascular procedures like mitral clipping, PCIs, and ablation, the current data do not support the routine use of CPDs in these patients.
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Affiliation(s)
- Stephan Haussig
- Herzzentrum Dresden, University Clinic, Department of Internal Medicine and Cardiology, Technische Universität Dresden, Fetscherstr, 76, 01307, Dresden, Germany.
| | - Axel Linke
- Herzzentrum Dresden, University Clinic, Department of Internal Medicine and Cardiology, Technische Universität Dresden, Fetscherstr, 76, 01307, Dresden, Germany
| | - Norman Mangner
- Herzzentrum Dresden, University Clinic, Department of Internal Medicine and Cardiology, Technische Universität Dresden, Fetscherstr, 76, 01307, Dresden, Germany
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41
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Jayaraman DK, Mehla S, Joshi S, Rajasekaran D, Goddeau RP. Update in the Evaluation and Management of Perioperative Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:76. [DOI: 10.1007/s11936-019-0779-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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42
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Welton T, Indja BE, Maller JJ, Fanning JP, Vallely MP, Grieve SM. Replicable brain signatures of emotional bias and memory based on diffusion kurtosis imaging of white matter tracts. Hum Brain Mapp 2019; 41:1274-1285. [PMID: 31773802 PMCID: PMC7268065 DOI: 10.1002/hbm.24874] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 12/31/2022] Open
Abstract
Diffusion MRI (dMRI) is sensitive to anisotropic diffusion within bundles of nerve axons and can be used to make objective measurements of brain networks. Many brain disorders are now recognised as being caused by network dysfunction or are secondarily associated with changes in networks. There is therefore great potential in using dMRI measures that reflect network integrity as a future clinical tool to help manage these conditions. Here, we used dMRI to identify replicable, robust and objective markers that meaningfully reflect cognitive and emotional performance. Using diffusion kurtosis analysis and a battery of cognitive and emotional tests, we demonstrated strong relationships between white matter structure across networks of anatomically and functionally specific brain regions with both emotional bias and emotional memory performance in a large healthy cohort. When the connectivity of these regions was examined using diffusion tractography, the terminations of the identified tracts overlapped precisely with cortical loci relating to these domains, drawn from an independent spatial meta‐analysis of available functional neuroimaging literature. The association with emotional bias was then replicated using an independently acquired healthy cohort drawn from the Human Connectome Project. These results demonstrate that, even in healthy individuals, white matter dMRI structural features underpin important cognitive and emotional functions. Our robust cross‐correlation and replication supports the potential of structural brain biomarkers from diffusion kurtosis MRI to characterise early neurological changes and risk in individuals with a reduced threshold for cognitive dysfunction, with further testing required to demonstrate clinical utility.
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Affiliation(s)
- Thomas Welton
- Sydney Translational Imaging Laboratory, Heart Research Institute, The University of Sydney, Camperdown, New South Wales, Australia
| | - Ben E Indja
- Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia
| | - Jerome J Maller
- Sydney Translational Imaging Laboratory, Heart Research Institute, The University of Sydney, Camperdown, New South Wales, Australia.,GE Healthcare, Richmond, Victoria, Australia
| | - Jonathon P Fanning
- Faculty of Medicine, The University of Queensland, Brisbane, New South Wales, Australia.,The Critical Care Research Group, The Prince Charles Hospital, Brisbane, New South Wales, Australia
| | - Michael P Vallely
- Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Cardiothoracic Surgery, The Northern Beaches Hospital, Sydney, New South Wales, Australia
| | - Stuart M Grieve
- Sydney Translational Imaging Laboratory, Heart Research Institute, The University of Sydney, Camperdown, New South Wales, Australia.,Department of Radiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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