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Shuto T, Anai H, Wada T, Kawashima T, Mori K, Miyamoto S. Low-flow perfusion technique for shaggy aortic arch. Gen Thorac Cardiovasc Surg 2024; 72:439-446. [PMID: 37995016 DOI: 10.1007/s11748-023-01988-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/28/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND The most common complication of thoracic aortic disease with shaggy aorta is cerebral infarction. We have performed "low-flow perfusion" as a method of extracorporeal circulation to prevent cerebral embolism in patients with strong atherosclerotic lesions in the aortic arch. METHODS "Low-flow perfusion" is a method in which cardiopulmonary bypass is started by partial blood removal, approaching deep hypothermia while maintaining self-cardiac output. We compared the outcomes of 12 patients who underwent the "low-flow perfusion" method (Group L) with those of 12 who underwent normal extracorporeal circulation (Group N) during aortic arch surgery since 2019. RESULTS Group L consisted of 8 males with an average age of 73 years old, and Group N consisted of 6 males with an average age of 73 years old. The average time from the start of cooling to ventricular fibrillation was 9.5 min in Group L and 3.6 min in Group N (p < 0.01). The eardrum temperature when ventricular fibrillation was reached was 28.2 °C in Group L and 32.5 °C in Group N (p = 0.01). A blood flow analysis also revealed low wall shear stress on the lesser curvature of the aortic arch. CONCLUSION With this method, the intracranial temperature was sufficiently low at the time of ventricular fibrillation, and there was no need to increase the total pump flow. The low-flow perfusion method can prevent cerebral embolism by preventing atheroma destruction by the blood flow jet while maintaining the self-cardiac output during the cooling process.
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Affiliation(s)
- Takashi Shuto
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Yufu-Shi, Oita, 879-5593, Japan.
| | - Hirofumi Anai
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Yufu-Shi, Oita, 879-5593, Japan
| | - Tomoyuki Wada
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Yufu-Shi, Oita, 879-5593, Japan
| | - Takayuki Kawashima
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Yufu-Shi, Oita, 879-5593, Japan
| | - Kazuki Mori
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Yufu-Shi, Oita, 879-5593, Japan
| | - Shinji Miyamoto
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Yufu-Shi, Oita, 879-5593, Japan
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Harky A, Chow VJ, Voller C, Goyal K, Shaw M, Bhawnani A, Kenawy A, Wilson I, Lip GYH, Field M, Kuduvalli M. Stroke outcomes following cardiac and aortic surgery are improved by the involvement of a stroke team. Eur J Clin Invest 2024:e14275. [PMID: 38943528 DOI: 10.1111/eci.14275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 06/10/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVES Post-cardiac and aortic surgery stroke is often underreported. We detail our single-centre experience the following introduction of comprehensive consultant-led daily stroke service, to demonstrate the efficacy of a stroke team in recovery from stroke following cardiac and aortic surgeries. METHODS This retrospective, single-centre observational cohort study analysed consecutive patients undergoing cardiac and aortic surgery at our institution from August 2014 to December 2020. Main outcomes included stroke rate, predictors of stroke, and neurological deficit resolution or persistence at discharge and clinic follow-up. RESULTS A total of 12,135 procedures were carried out in the reference period. Among these, 436 (3.6%) suffered a stroke. Overall survival to discharge and follow-up were 86.0% and 84.0% respectively. Independent risk factors for post-operative stroke included advanced age (OR 1.033, 95% CI [1.023, 1.044], p < .001), female sex (OR 1.491, 95% [1.212, 1.827], p < .001), history of previous cardiac surgeries (OR 1.670, 95% CI [1.239, 2.218], p < .001), simultaneous coronary artery bypass graft + valve procedures (OR 1.825, 95% CI [1.382, 2.382], p < .001) and CPB time longer than 240 min (OR 3.384, 95% CI [2.413, 4.705], p < .001). Stroke patients managed by the multidisciplinary team demonstrated significantly higher rates of survival at discharge (87.3% vs. 61.9%, p = .001). CONCLUSIONS Perioperative stroke can be debilitating immediately long term. The involvement of specialist stroke teams plays a key role in reducing the long-term burden and mortality of this condition.
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Affiliation(s)
- Amer Harky
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Vanessa Jane Chow
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Calum Voller
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Kartik Goyal
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Matthew Shaw
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Anurodh Bhawnani
- Department of Cardiothoracic Anaesthesia and Intensive Care, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Ayman Kenawy
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Ian Wilson
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
| | - Mark Field
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Manoj Kuduvalli
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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3
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Navi BB, Zhang C, Kaiser JH, Liao V, Cushman M, Kasner SE, Elkind MSV, Tagawa ST, Guntupalli SR, Gaudino MFL, Lee AYY, Khorana AA, Kamel H. Cancer and the risk of perioperative arterial ischaemic events. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:345-356. [PMID: 37757472 DOI: 10.1093/ehjqcco/qcad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND AND AIMS Most cancer patients require surgery for diagnosis and treatment. This study evaluated whether cancer is a risk factor for perioperative arterial ischaemic events. METHODS The primary cohort included patients registered in the National Surgical Quality Improvement Program (NSQIP) between 2006 and 2016. The secondary cohort included Healthcare Cost and Utilization Project (HCUP) claims data from 11 US states between 2016 and 2018. Study populations comprised patients who underwent inpatient (NSQIP, HCUP) or outpatient (NSQIP) surgery. Study exposures were disseminated cancer (NSQIP) and all cancers (HCUP). The primary outcome was a perioperative arterial ischaemic event, defined as myocardial infarction or stroke diagnosed within 30 days after surgery. RESULTS Among 5 609 675 NSQIP surgeries, 2.2% involved patients with disseminated cancer. The perioperative arterial ischaemic event rate was 0.96% among patients with disseminated cancer vs. 0.48% among patients without (hazard ratio [HR], 2.01; 95% confidence interval [CI], 1.90-2.13). In Cox analyses adjusting for demographics, functional status, comorbidities, surgical specialty, anesthesia type, and clinical factors, disseminated cancer remained associated with higher risk of perioperative arterial ischaemic events (HR, 1.37; 95% CI, 1.28-1.46). Among 1 341 658 surgical patients in the HCUP cohort, 11.8% had a diagnosis of cancer. A perioperative arterial ischaemic event was diagnosed in 0.74% of patients with cancer vs. 0.54% of patients without cancer (HR, 1.35; 95% CI, 1.27-1.43). In Cox analyses adjusted for demographics, insurance, comorbidities, and surgery type, cancer remained associated with higher risk of perioperative arterial ischaemic events (HR, 1.31; 95% CI, 1.21-1.42). CONCLUSION Cancer is an independent risk factor for perioperative arterial ischaemic events.
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Affiliation(s)
- Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY 10021, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Jed H Kaiser
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Vanessa Liao
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY 10021, USA
| | - Mary Cushman
- Division of Hematology and Oncology, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT 05446, USA
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Scott T Tagawa
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine, New York, NY 10021, USA
| | - Saketh R Guntupalli
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Colorado School of Medicine at Denver, Aurora, CO 80045, USA
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York NY 10021, USA
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, University of British Columbia, BC Cancer, Vancouver, BC, Canada
| | - Alok A Khorana
- Department of Hematology and Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY 10021, USA
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Zhang X, Yang Y, Ma X, Cao H, Sun Y. Probiotics relieve perioperative postoperative cognitive dysfunction induced by cardiopulmonary bypass through the kynurenine metabolic pathway. Sci Rep 2024; 14:12822. [PMID: 38834581 DOI: 10.1038/s41598-024-59275-1] [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: 12/04/2023] [Accepted: 04/09/2024] [Indexed: 06/06/2024] Open
Abstract
Postoperative cognitive dysfunction (POCD) has become the popular critical post-operative consequences, especially cardiopulmonary bypass surgery, leading to an increased risk of mortality. However, no therapeutic effect about POCD. Probiotics are beneficial bacteria living in the gut and help to reduce the risk of POCD. However, the detailed mechanism is still not entirely known. Therefore, our research aims to uncover the effect and mechanism of probiotics in relieving POCD and to figure out the possible relationship between kynurenine metabolic pathway. 36 rats were grouped into three groups: sham operated group (S group, n = 12), Cardiopulmonary bypass group (CPB group, n = 12), and probiotics+CPB (P group, n = 12). After CPB model preparation, water maze test and Garcia score scale was performed to identify the neurological function. Immunofluorescence and Hematoxylin and eosin staining has been used for hippocampal neurons detection. Brain injury related proteins, oxidative stress factors, and inflammatory factors were detected using enzyme-linked immunosorbent assays (ELISA). Neuronal apoptosis was detected by TdT-mediated dUTP nick end-labeling (TUNEL) staining and western blot. High-performance liquid chromatography/mass spectrometry (HPLC/MS) was performed to detect the key factors of the kynurenine metabolic pathway. Our results demonstrated that probiotics improved neurological function of post-CPB rats. The administration of probiotics ameliorated memory and learning in spatial terms CPB rats (P < 0.05). Hematoxylin and eosin (H&E) staining data, S-100β and neuron-specific enolase (NSE) data convinced that probiotics agonists reduced brain damage in CPB rats (P < 0.05). Moreover, probiotics regulated inflammatory factors, meanwhile attenuated hippocampal neuronal apoptosis. Probiotics alleviated POCD in rats with CPB through regulation of kynurenine metabolic signaling pathway.
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Affiliation(s)
- Xiaodong Zhang
- Department of Anesthesiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, 441000, Hubei, China
- Postgraduate Training Base, The General Hospital of Northern Theater Command, Jinzhou Medical University, Jinzhou, 121013, Liaoning, China
| | - Yanzhang Yang
- Department of Anesthesiology, Chifeng Municipal Hospital, Chifeng, 024000, Inner Mongolia, China
| | - Xinyi Ma
- Postgraduate Training Base, The General Hospital of Northern Theater Command, Dalian Medical University, Dalian, 116051, Liaoning, China
| | - Huijuan Cao
- Department of Anesthesiology, General Hospital of Northern Theater Command, Shenyang, 110016, Liaoning, China
| | - Yingjie Sun
- Department of Anesthesiology, General Hospital of Northern Theater Command, Shenyang, 110016, Liaoning, China.
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5
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Ristow AVB, Massière B, Meirelles GV, Casella IB, Morales MM, Moreira RCR, Procópio RJ, Oliveira TF, de Araujo WJB, Joviliano EE, de Oliveira JCP. Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease. J Vasc Bras 2024; 23:e20230094. [PMID: 39099701 PMCID: PMC11296686 DOI: 10.1590/1677-5449.202300942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/16/2023] [Indexed: 08/06/2024] Open
Abstract
Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.
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Affiliation(s)
- Arno von Buettner Ristow
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Bernardo Massière
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Guilherme Vieira Meirelles
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Estadual de Campinas – UNICAMP, Hospital das Clínicas, Disciplina de Cirurgia do Trauma, Campinas, SP, Brasil.
| | - Ivan Benaduce Casella
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | - Marcia Maria Morales
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Associação Portuguesa de Beneficência de São José do Rio Preto, Serviço de Cirurgia Vascular, São José do Rio Preto, SP, Brasil.
| | - Ricardo Cesar Rocha Moreira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Pontifícia Universidade Católica do Paraná – PUC-PR, Hospital Cajurú, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil.
| | - Ricardo Jayme Procópio
- Universidade Federal de Minas Gerais – UFMG, Hospital das Clínicas, Setor de Cirurgia Endovascular, Belo Horizonte, MG, Brasil.
- Universidade Federal de Minas Gerais – UFMG, Faculdade de Medicina, Belo Horizonte, MG, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-MG, Belo Horizonte, MG, Brasil.
| | - Tércio Ferreira Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SE, Aracajú, SE, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Walter Jr. Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Edwaldo Edner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Júlio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
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Biancari F, Onorati F, Peterss S, Buech J, Mariscalco G, Lega JR, Pinto AG, Fiore A, Perrotti A, Hérve A, Rukosujew A, Demal T, Conradi L, Wisniewski K, Pol M, Kacer P, Gatti G, Mazzaro E, Vendramin I, Piani D, Rinaldi M, Ferrante L, Pruna-Guillen R, Di Perna D, Gerelli S, El-Dean Z, Nappi F, Field M, Kuduvalli M, Pettinari M, Francica A, Jormalainen M, Dell'Aquila AM, Mäkikallio T, Juvonen T, Quintana E. Nature of Neurological Complications and Outcome After Surgery for Type A Aortic Dissection. Am J Cardiol 2024; 219:85-91. [PMID: 38458584 DOI: 10.1016/j.amjcard.2024.03.001] [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: 12/28/2023] [Revised: 02/18/2024] [Accepted: 03/01/2024] [Indexed: 03/10/2024]
Abstract
Surgery for type A aortic dissection (TAAD) is frequently complicated by neurologic complications. The prognostic impact of neurologic complications of different nature has been investigated in this study. The subjects of this analysis were 3,902 patients who underwent surgery for acute TAAD from the multicenter European Registry of Type A Aortic Dissection (ERTAAD). During the index hospitalization, 722 patients (18.5%) experienced stroke/global brain ischemia. Ischemic stroke was detected in 539 patients (13.8%), hemorrhagic stroke in 76 patients (1.9%) and global brain ischemia in 177 patients (4.5%), with a few patients having had findings of more than 1 of these conditions. In-hospital mortality was increased significantly in patients with postoperative ischemic stroke (25.6%, adjusted odds ratio [OR] 2.422, 95% confidence interval [CI] 1.825 to 3.216), hemorrhagic stroke (48.7%, adjusted OR 4.641, 95% CI 2.524 to 8.533), and global brain ischemia (74.0%, adjusted OR 22.275, 95% CI 14.537 to 35.524) compared with patients without neurologic complications (13.5%). Similarly, patients who experienced ischemic stroke (46.3%, adjusted hazard ratio [HR] 1.719, 95% CI 1.434 to 2.059), hemorrhagic stroke (62.8%, adjusted HR 3.236, 95% CI 2.314 to 4.525), and global brain ischemia (83.9%, adjusted HR 12.777, 95% CI 10.325 to 15.810) had significantly higher 5-year mortality than patients without postoperative neurologic complications (27.5%). The negative prognostic effect of neurologic complications on survival vanished about 1 year after surgery. In conclusion, postoperative ischemic stroke, hemorrhagic stroke, and global cerebral ischemia increased early and midterm mortality after surgery for acute TAAD. The magnitude of risk of mortality increased with the severity of the neurologic complications, with postoperative hemorrhagic stroke and global brain ischemia being highly lethal complications.
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Affiliation(s)
- Fausto Biancari
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland; Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Sven Peterss
- LMU University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Joscha Buech
- LMU University Hospital, Ludwig Maximilian University, Munich, Germany; German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, United Kingdom
| | - Javier Rodriguez Lega
- Cardiovascular Surgery Department, University Hospital Gregorio Marañón, Madrid, Spain
| | - Angel G Pinto
- Cardiovascular Surgery Department, University Hospital Gregorio Marañón, Madrid, Spain
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, France
| | - Andrea Perrotti
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Amelié Hérve
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Andreas Rukosujew
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Till Demal
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Konrad Wisniewski
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Marek Pol
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Kacer
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Enzo Mazzaro
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Igor Vendramin
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Daniela Piani
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Mauro Rinaldi
- Cardiac Surgery, Molinette Hospital, University of Turin, Turin, Italy
| | - Luisa Ferrante
- Cardiac Surgery, Molinette Hospital, University of Turin, Turin, Italy
| | - Robert Pruna-Guillen
- Department of Cardiovascular Surgery, Hospital Clínic de Barcelona, University of Barcelona, Spain
| | - Dario Di Perna
- Department of Cardiac Surgery, Centre Hospitalier Annecy Genevois, Epagny Metz-Tessy, France
| | - Sebastien Gerelli
- Department of Cardiac Surgery, Centre Hospitalier Annecy Genevois, Epagny Metz-Tessy, France
| | - Zein El-Dean
- LMU University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Mark Field
- Liverpool Centre for Cardiovascular Sciences, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Manoj Kuduvalli
- Liverpool Centre for Cardiovascular Sciences, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Matteo Pettinari
- Department of Cardiac Surgery, Ziekenhuis Oost Limburg, Genk, Belgium
| | - Alessandra Francica
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Mikko Jormalainen
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Angelo M Dell'Aquila
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany; Department of Cardiac Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Timo Mäkikallio
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, Oulu, Finland
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clínic de Barcelona, University of Barcelona, Spain
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7
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Fong KY, Yeo S, Luo H, Kofidis T, Teoh KLK, Kang GS. Stroke prevention strategies for cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. ANZ J Surg 2024; 94:522-535. [PMID: 38529814 DOI: 10.1111/ans.18947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/15/2023] [Accepted: 03/04/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Stroke is a much-feared complication of cardiac surgery, but existing literature on preventive strategies is fragmented. Hence, a systematic review and meta-analysis of stroke prevention strategies for cardiac surgery was conducted. METHODS An electronic literature search was conducted to retrieve randomized controlled trials (RCTs) investigating perioperative interventions for cardiac surgery, with stroke as an outcome. Random-effects meta-analyses were conducted to generate risk ratios (RRs), 95% confidence intervals (95% CI), and forest plots. Descriptive analysis and synthesis of literature was conducted for interventions not amenable to meta-analysis, focusing on risks of stroke, myocardial infarction and study-defined major adverse cardiovascular events (MACE). RESULTS Fifty-six RCTs (61 894 patients) were retrieved. Many included trials were underpowered to detect differences in stroke risk. Among pharmacological therapies, only preoperative amiodarone was shown to reduce stroke risk in one trial. Concomitant left atrial appendage closure (LAAC) significantly reduced stroke risk (RR = 0.55, 95% CI = 0.36-0.84, P = 0.006) in patients with preoperative atrial fibrillation, and there was no difference in on-pump versus off-pump coronary artery bypass grafting (CABG) (RR = 0.94, 95% CI = 0.64-1.37, P = 0.735). Much controversy exists in literature on the timing of carotid endarterectomy relative to CABG in patients with severe carotid stenosis. The use of preoperative remote ischemic preconditioning was not found to reduce rates of stroke or MACE. CONCLUSION This review presents a comprehensive synthesis of existing interventions for stroke prevention in cardiac surgery, and identifies gaps in research which may benefit from future, large-scale RCTs. LAAC should be considered to reduce stroke incidence in patients with preoperative atrial fibrillation.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Selvie Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Haidong Luo
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Theodoros Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Kristine L K Teoh
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Giap Swee Kang
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
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Viikinkoski E, Aittokallio J, Lehto J, Ollila H, Relander A, Vasankari T, Jalkanen J, Gunn J, Jalkanen S, Airaksinen J, Hollmén M, Kiviniemi TO. Prolonged Systemic Inflammatory Response Syndrome After Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:709-716. [PMID: 38220516 DOI: 10.1053/j.jvca.2023.12.017] [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: 08/17/2023] [Revised: 11/25/2023] [Accepted: 12/13/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVES Cardiac surgery induces systemic inflammatory response syndrome (SIRS), leading to higher morbidity and mortality. There are no individualized predictors for worse outcomes or biomarkers for the multifactorial, excessive inflammatory response. The interest of this study was to evaluate whether a systematic use of the SIRS criteria could be used to predict postoperative outcomes beyond infection and sepsis, and if the development of an exaggerated inflammation response could be observed preoperatively. DESIGN The study was observational, with prospectively enrolled patients. SETTING This was a single institution study in a hospital setting combined with laboratory findings. PARTICIPANTS The study included a cohort of 261 volunteer patients. INTERVENTIONS Patients underwent cardiac surgery with cardiopulmonary bypass, and were followed up to 90 days. Biomarker profiling was run preoperatively. MEASUREMENTS AND MAIN RESULTS Altogether, 17 of 261 (6.4%) patients had prolonged SIRS, defined as fulfilling at least 2 criteria on 4 consecutive postoperative days. During hospitalization, postoperative atrial fibrillation (POAF) was found in 42.2% of patients, and stroke and transient ischemic attack in 3.8% of patients. Prolonged SIRS was a significant predictor of POAF (odds ratio [OR] 4.5, 95% CI 1.2-17.3), 90-day stroke (OR 4.5, 95% CI 1.1-18.0), and mortality (OR 10.7, 95% CI 1.7-68.8). Biomarker assays showed that preoperative nerve growth factor and interleukin 5 levels were associated with prolonged SIRS (OR 5.6, 95%, CI 1.4-23.2 and OR 0.7, 95%, CI 0.4-1.0, respectively). CONCLUSIONS Nerve growth factor and interleukin 5 can be used to predict prolonged systemic inflammatory response, which is associated with POAF, stroke, and mortality.
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Affiliation(s)
- Emma Viikinkoski
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Jenni Aittokallio
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Joonas Lehto
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Helena Ollila
- Turku Clinical Research Center, Turku University Hospital, Turku, Finland
| | - Arto Relander
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Tuija Vasankari
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Juho Jalkanen
- MediCity Research Laboratory, Department of Microbiology and Immunology, InFLAMES Flagship, University of Turku, Turku, Finland
| | - Jarmo Gunn
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Sirpa Jalkanen
- MediCity Research Laboratory, Department of Microbiology and Immunology, InFLAMES Flagship, University of Turku, Turku, Finland
| | - Juhani Airaksinen
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Maija Hollmén
- MediCity Research Laboratory, Department of Microbiology and Immunology, InFLAMES Flagship, University of Turku, Turku, Finland
| | - Tuomas O Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland.
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9
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de Havenon A, Zhou LW, Koo AB, Matouk C, Falcone GJ, Sharma R, Ney J, Shu L, Yaghi S, Kamel H, Sheth KN. Endovascular Treatment of Acute Ischemic Stroke After Cardiac Interventions in the United States. JAMA Neurol 2024; 81:264-272. [PMID: 38285452 PMCID: PMC10825786 DOI: 10.1001/jamaneurol.2023.5416] [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: 09/07/2023] [Accepted: 11/25/2023] [Indexed: 01/30/2024]
Abstract
Importance Ischemic stroke is a serious complication of cardiac intervention, including surgery and percutaneous procedures. Endovascular thrombectomy (EVT) is an effective treatment for ischemic stroke and may be particularly important for cardiac intervention patients who often cannot receive intravenous thrombolysis. Objective To examine trends in EVT for ischemic stroke during hospitalization of patients with cardiac interventions vs those without in the United States. Design, Setting, and Participants This cohort study involved a retrospective analysis using data for 4888 US hospitals from the 2016-2020 National Inpatient Sample database. Participants included adults (age ≥18 years) with ischemic stroke (per codes from the International Statistical Classification of Diseases, Tenth Revision, Clinical Modification), who were organized into study groups of hospitalized patients with cardiac interventions vs without. Individuals were excluded from the study if they had either procedure prior to admission, EVT prior to cardiac intervention, EVT more than 3 days after admission or cardiac intervention, or endocarditis. Data were analyzed from April 2023 to October 2023. Exposures Cardiac intervention during admission. Main Outcomes and Measures The odds of undergoing EVT by cardiac intervention status were calculated using multivariable logistic regression. Adjustments were made for stroke severity in the subgroup of patients who had a National Institutes of Health Stroke Scale (NIHSS) score documented. As a secondary outcome, the odds of discharge home by EVT status after cardiac intervention were modeled. Results Among 634 407 hospitalizations, the mean (SD) age of the patients was 69.8 (14.1) years, 318 363 patients (50.2%) were male, and 316 044 (49.8%) were female. A total of 12 093 had a cardiac intervention. An NIHSS score was reported in 218 576 admissions, 216 035 (34.7%) without cardiac intervention and 2541 (21.0%) with cardiac intervention (P < .001). EVT was performed in 23 660 patients (3.8%) without cardiac intervention vs 194 (1.6%) of those with cardiac intervention (P < .001). After adjustment for potential confounders, EVT was less likely to be performed in stroke patients with cardiac intervention vs those without (adjusted odds ratio [aOR], 0.27; 95% CI, 0.23-0.31), which remained consistent after adjusting for NIHSS score (aOR, 0.28; 95% CI, 0.22-0.35). Among individuals with a cardiac intervention, receiving EVT was associated with a 2-fold higher chance of discharge home (aOR, 2.21; 95% CI, 1.14-4.29). Conclusions and Relevance In this study, patients hospitalized with ischemic stroke and cardiac intervention may be less than half as likely to receive EVT as those without cardiac intervention. Given the known benefit of EVT, there is a need to better understand the reasons for lower rates of EVT in this patient population.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
| | - Lily W. Zhou
- Department of Neurology, The University of British Columbia, Vancouver, Canada
| | - Andrew B. Koo
- Department of Neurosurgery, Yale University, New Haven, Connecticut
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut
| | - Guido J. Falcone
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
| | - Richa Sharma
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
| | - John Ney
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Liqi Shu
- Department of Neurology, Brown University, Providence, Rhode Island
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, Rhode Island
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, New York
- Deputy Editor, JAMA Neurology
| | - Kevin N. Sheth
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
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10
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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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11
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Chatterjee S, Ad N, Badhwar V, Gillinov AM, Alexander JH, Moon MR. Anticoagulation for atrial fibrillation after cardiac surgery: Do guidelines reflect the evidence? J Thorac Cardiovasc Surg 2024; 167:694-700. [PMID: 37037415 DOI: 10.1016/j.jtcvs.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/25/2023] [Indexed: 04/12/2023]
Affiliation(s)
- Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex.
| | - Niv Ad
- Division of Cardiac Surgery, White Oak Medical Center, Adventist HealthCare, University of Maryland, Takoma Park, Md
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - John H Alexander
- Division of Cardiology, Duke University School of Medicine & Duke Clinical Research Institute, Durham, NC
| | - Marc R Moon
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
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12
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Baron Shahaf D, Abergel E, Sivan Hoffmann R, Meirovitch E, Konstadt S, Feierman DE, Derman R, Shahaf G. Evaluating a Novel EEG-Based Index for Stroke Detection Under Anesthesia During Mechanical Thrombectomy. J Neurosurg Anesthesiol 2024; 36:60-68. [PMID: 36730962 DOI: 10.1097/ana.0000000000000889] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 08/21/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The rapid identification of acute stroke (AS) during and after anesthesia might lead to early interventions and improved outcomes. We investigated a novel 2-channel electroencephalogram (EEG)-based marker for stroke detection-the lateral interconnection ratio (LIR)-in AS patients having endovascular thrombectomy (EVT) with general anesthesia (GA) or sedation. The LIR in 2 reference groups of patients without postoperative neurological complications was used for comparison. METHODS The National Institutes of Health stroke scale score was assessed before and after thrombectomy in 100 patients having EVT with GA or sedation. The EEG was monitored during and for 4 hours following EVT in the AS group and during surgery in the 2 reference groups. We compared: (1) LIR between AS and reference groups; (2) LIR and stroke dynamics (clinical improvement or deterioration after EVT assessed by the National Institutes of Health stroke scale score); (3) the impact of stroke site (anterior vs. posterior circulation) and anesthesia type (GA vs. sedation) on the LIR. RESULTS Median (interquartile range) LIR was lower in patients with AS compared with reference patients (0.09, 0.05 to 0.16 vs. 0.39, 0.24 to 0.52, respectively; P <0.000002), and LIR increased in AS patients whose clinical status recovered after EVT compared with nonrecovered patients (0.20, 0.12 to 0.29 vs. 0.09, 0.05 to 0.11, respectively; P <0.007). The LIR might be more sensitive to anterior circulation stroke but is not impacted by anesthesia type. CONCLUSIONS We demonstrated the utility of using AS patients undergoing EVT as a platform for assessing a novel EEG marker for the identification of stroke during anesthesia. Further, large-scale studies in AS patients during EVT and in patients undergoing different surgeries and anesthesia are required to validate the LIR.
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Affiliation(s)
| | | | | | | | | | - Dennis E Feierman
- Department of Anesthesiology
- IRB, Maimonides Medical Center, Brooklyn NY
| | | | - Goded Shahaf
- Applied Neurophysiology Lab, Rambam Health Care Campus, Haifa
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13
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AlGhamdi FK, Altoijry A, AlQahtani A, Aldossary MY, AlSheikh SO, Iqbal K, Alayadhi WA. Synchronous carotid endarterectomy and coronary artery bypass graft: Four case reports. World J Clin Cases 2023; 11:8581-8588. [PMID: 38188208 PMCID: PMC10768504 DOI: 10.12998/wjcc.v11.i36.8581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/19/2023] [Accepted: 12/13/2023] [Indexed: 12/22/2023] Open
Abstract
BACKGROUND One of the major perioperative complications for coronary artery bypass graft (CABG) is stroke. The risk of perioperative stroke after CABG is approximately 2%. Carotid stenosis (CS) is considered an independent predictor of perioperative stroke risk in CABG patients. The optimal management of such patients has been a source of controversy. One of the possible surgical options is synchronous carotid endarterectomy (CEA) and CABG. Here, we have presented 4 cases of successful synchronous CEA and CABG. CASE SUMMARY Our center's experience with 4 cases of significant carotid artery stenosis, which were successfully managed with combined CEA and CABG, are detailed. The first case was a female who presented for CABG after a ST-elevation myocardial infarction. She had right internal carotid artery (ICA) occlusion and 90% left ICA stenosis. The second case was a male who was electively admitted for CABG. It was discovered that he had left ICA occlusion and 90% right ICA stenosis. The third case was a male with a history of stroke, two months prior to admission. He presented with non-ST-elevation myocardial infarction. Preoperatively, it was discovered that he had > 90% right ICA stenosis. The final case was a male who was electively admitted for CABG. It was discovered that he had bilateral > 90% ICA stenosis. We have also reviewed the current evidence and guidelines for managing CS in patients undergoing CABG. CONCLUSION Our case series demonstrated that synchronous CEA and CABG was safe. A multicenter study with additional patients is needed. It is necessary for clinicians to screen for CS in high-risk patients with features.
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Affiliation(s)
| | | | - Abdulrahman AlQahtani
- King Fahad Cardiac Center, King Saud University Medical City, Riyadh 11322, Saudi Arabia
| | - Mohammed Yousef Aldossary
- Department of General Surgery, King Saud University, Riyadh 11322, Saudi Arabia
- Department of Surgery, Dammam Medical Complex, Dammam 32245, Saudi Arabia
| | | | - Kaisor Iqbal
- Department of Surgery, King Saud University, Riyadh 11322, Saudi Arabia
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14
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Abbasi A, Li C, Dekle M, Bermudez CA, Brodie D, Sellke FW, Sodha NR, Ventetuolo CE, Eickhoff C. Interpretable machine learning-based predictive modeling of patient outcomes following cardiac surgery. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01110-8. [PMID: 38040328 PMCID: PMC11133766 DOI: 10.1016/j.jtcvs.2023.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND The clinical applicability of machine learning predictions of patient outcomes following cardiac surgery remains unclear. We applied machine learning to predict patient outcomes associated with high morbidity and mortality after cardiac surgery and identified the importance of variables to the derived model's performance. METHODS We applied machine learning to the Society of Thoracic Surgeons Adult Cardiac Surgery Database to predict postoperative hemorrhage requiring reoperation, venous thromboembolism (VTE), and stroke. We used permutation feature importance to identify variables important to model performance and a misclassification analysis to study the limitations of the model. RESULTS The study dataset included 662,772 subjects who underwent cardiac surgery between 2015 and 2017 and 240 variables. Hemorrhage requiring reoperation, VTE, and stroke occurred in 2.9%, 1.2%, and 2.0% of subjects, respectively. The model performed remarkably well at predicting all 3 complications (area under the receiver operating characteristic curve, 0.92-0.97). Preoperative and intraoperative variables were not important to model performance; instead, performance for the prediction of all 3 outcomes was driven primarily by several postoperative variables, including known risk factors for the complications, such as mechanical ventilation and new onset of postoperative arrhythmias. Many of the postoperative variables important to model performance also increased the risk of subject misclassification, indicating internal validity. CONCLUSIONS A machine learning model accurately and reliably predicts patient outcomes following cardiac surgery. Postoperative, as opposed to preoperative or intraoperative variables, are important to model performance. Interventions targeting this period, including minimizing the duration of mechanical ventilation and early treatment of new-onset postoperative arrhythmias, may help lower the risk of these complications.
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Affiliation(s)
- Adeel Abbasi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Warren Alpert School of Medicine at Brown University, Providence, RI.
| | - Cindy Li
- Brown University, Providence, RI
| | | | - Christian A Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Daniel Brodie
- Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Frank W Sellke
- Division of Cardiothoracic Surgery, Department of Surgery, Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Neel R Sodha
- Division of Cardiothoracic Surgery, Department of Surgery, Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Corey E Ventetuolo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Warren Alpert School of Medicine at Brown University, Providence, RI; Department of Health Services, Policy and Practice, Brown School of Public Health, Providence, RI
| | - Carsten Eickhoff
- Department of Computer Science, Brown University, Providence, RI; Faculty of Medicine, University of Tübingen, Tübingen, Germany; Institute for Bioinformatics and Medical Informatics, University of Tübingen, Tübingen, Germany
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15
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Sule JA, Chan XW, Sampath HK, Luo HD, Ahmed MU, Kang GS. Routine preoperative screening computed tomography of the thorax for cardiac surgery. Singapore Med J 2023:389384. [PMID: 38037774 DOI: 10.4103/singaporemedj.smj-2021-416] [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: 12/02/2023]
Abstract
Introduction This study aimed to evaluate the role of screening computed tomography (CT) of the thorax in cardiac surgery by analysing the presence of CT aortic calcifications in association with changes in operative strategy and postoperative stroke, and the CT features of emphysema with development of pneumonia. Methods All patients who underwent cardiac surgery from January 2013 to October 2017 by a single surgeon were retrospectively studied. Patients who underwent screening CT thorax before cardiac surgery (CT group) were compared to those who did not (no CT group). Multivariate subgroup analyses were performed to determine significant association with postoperative outcomes. Results A total of 392 patients were included, of which 156 patients underwent preoperative screening CT thorax. Patients in the CT group were older (63.9 vs. 59.0 years, P = 0.001), had fewer recent myocardial infarctions preoperatively (41% vs. 56.4%, P = 0.003) and had better ejection fraction (>30%; P = 0.02). Operative strategy was changed in 4.3% of patients, and 4.9% of patients suffered stroke postoperatively. The presence of CT aortic calcifications was significantly associated with change in operative strategy (P = 0.016) but not with postoperative stroke (P = 0.33). Age was an independent risk factor for change in operative strategy among patients with CT thorax (P = 0.02). Multivariate age-adjusted analysis showed only palpable plaque to be significantly associated with change in operative strategy (P < 0.001). None of the patients with CT emphysema features developed pneumonia. Conclusion The results of this study do not support routine use of preoperative screening CT thorax. Contrasted CT may be advisable in older patients and for other operative planning purposes.
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Affiliation(s)
- Jai Ajitchandra Sule
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | - Xue Wei Chan
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | - Hari Kumar Sampath
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | - Hai Dong Luo
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | - Mofassel Uddin Ahmed
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | - Giap Swee Kang
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
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16
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Gilbey T, Milne B, de Somer F, Kunst G. Neurologic complications after cardiopulmonary bypass - A narrative review. Perfusion 2023; 38:1545-1559. [PMID: 35986553 PMCID: PMC10612382 DOI: 10.1177/02676591221119312] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
Neurologic complications, associated with cardiac surgery and cardiopulmonary bypass (CPB) in adults, are common and can be devastating in some cases. This comprehensive review will not only consider the broad categories of stroke and neurocognitive dysfunction, but it also summarises other neurological complications associated with CPB, and it provides an update about risks, prevention and treatment. Where appropriate, we consider the impact of off-pump techniques upon our understanding of the contribution of CPB to adverse outcomes.
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Affiliation(s)
- Tom Gilbey
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Benjamin Milne
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Filip de Somer
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Gudrun Kunst
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, Faculty of Life Sciences and Medicine, King’s College London British Heart Foundation Centre of Excellence, London, UK
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17
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Snavely J, Thompson HJ. Nursing and Institutional Responsibilities for In-Hospital Stroke. Stroke 2023; 54:2926-2934. [PMID: 37732490 DOI: 10.1161/strokeaha.123.042868] [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: 09/22/2023]
Abstract
In-hospital stroke events occur less often than stroke outside of a health care facility; yet, the need for timely evaluation and treatment is the same regardless of geographic location. During hospitalization, nurses are generally the first to recognize possible symptoms of stroke and activate emergency protocols. Such actions in response to changes in patient condition are critical to optimal patient outcomes. A recent scientific statement from the American Heart Association notes that patients with in-hospital stroke are likely to experience delayed recognition of symptoms, less likely to receive intravenous thrombolysis therapy, and have worse outcomes compared with community-occurring stroke. The aim of this article is to expand upon that scientific statement to assist nurses and acute care hospitals in the United States and elsewhere with similar health care systems to create evidence-based, nurse-driven protocols for in-hospital stroke recognition and management.
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Affiliation(s)
- Josh Snavely
- Virginia Mason Franciscan Health, Tacoma, WA (J.S.)
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Truckenmueller P, Fritzsching J, Schulze D, Früh A, Jacobs S, Ahlborn R, Vajkoczy P, Prinz V, Hecht N. Outcome and management of decompressive hemicraniectomy in malignant hemispheric stroke following cardiothoracic surgery. Sci Rep 2023; 13:12994. [PMID: 37563196 PMCID: PMC10415332 DOI: 10.1038/s41598-023-40202-9] [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: 04/10/2023] [Accepted: 08/07/2023] [Indexed: 08/12/2023] Open
Abstract
Management of malignant hemispheric stroke (MHS) after cardiothoracic surgery (CTS) remains difficult as decision-making needs to consider severe cardiovascular comorbidities and complex coagulation management. The results of previous randomized controlled trials on decompressive surgery for MHS cannot be generally translated to this patient population and the expected outcome might be substantially worse. Here, we analyzed mortality and functional outcome in patients undergoing decompressive hemicraniectomy (DC) for MHS following CTS and assessed the impact of perioperative coagulation management on postoperative hemorrhagic and cardiovascular complications. All patients that underwent DC for MHS resulting as a complication of CTS between June 2012 and November 2021 were included in this observational cohort study. Outcome was determined according to the modified Rankin Scale (mRS) score at 1 and 3-6 months. Clinical and demographic data, anticoagulation management and postoperative hemorrhagic and thromboembolic complications were assessed. In order to evaluate a predictive association between clinical and radiological parameters and the outcome, we used a multivariate logistic regression analysis. Twenty-nine patients undergoing DC for MHS after CTS with a female-to-male ratio of 1:1.9 and a median age of 60 (IQR 49-64) years were identified out of 123 patients undergoing DC for MHS. Twenty-four patients (83%) received pre- or intraoperative substitution. At 30 days, the in-hospital mortality rate and neurological outcome corresponded to 31% and a median mRS of 5 (5-6), which remained stable at 3-6 months [Mortality: 42%, median mRS: 5 (4-6)]. Postoperatively, 15/29 patients (52%) experienced new hemorrhagic lesions and Bayesian logistic regression predicting mortality (mRS = 6) after imputing missing data demonstrated a significantly increased risk for mortality with longer aPPT (OR = 13.94, p = .038) and new or progressive hemorrhagic lesions after DC (OR = 3.03, p = .19). Notably, all but one hemorrhagic lesion occurred before discontinued anticoagulation and/or platelet inhibition was re-initiated. Despite perioperative discontinuation of anticoagulation and/or platelet inhibition, no coagulation-associated cardiovascular complications were noted. In conclusion, Cardiothoracic surgery patients suffering MHS will likely experience severe neurological disability after DC, which should remain a central aspect during counselling and decision-making. The complex coagulation situation after CTS, however, should not per se rule out the option of performing life-saving surgical decompression.
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Affiliation(s)
- Peter Truckenmueller
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Jonas Fritzsching
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Daniel Schulze
- Institute of Medical Biometrics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anton Früh
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Stephan Jacobs
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Robert Ahlborn
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Vincent Prinz
- Department of Neurosurgery, Goethe Universität Frankfurt, Frankfurt am Main, Germany
| | - Nils Hecht
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
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Ramponi F, Seco M, Vallely MP. Defining the Role of Anaortic Coronary Artery Bypass Grafting. J Clin Med 2023; 12:4697. [PMID: 37510812 PMCID: PMC10380961 DOI: 10.3390/jcm12144697] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
As the population ages and co-morbidities become more prevalent, the complexity of patients presenting for coronary artery bypass surgery is increasing. Cardiopulmonary bypass and aortic cross-clamping in these patients carry increased risk and, indeed, in some patients, with ascending aortic disease, the risks are prohibitive. Total-arterial anaortic coronary artery surgery is a technique that provides complete surgical coronary artery revascularization without cardiopulmonary bypass and without manipulating the ascending aorta. The technique essentially eliminates the risk of cerebral embolization of aortic atheroma and aortic injury. Anaortic techniques are an essential skillset for coronary artery surgery centers treating higher-risk patients.
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Affiliation(s)
- Fabio Ramponi
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY 10025, USA
| | - Michael Seco
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney 2065, Australia
| | - Michael P Vallely
- Department of Cardiothoracic Surgery, Monash Health, The Victorian Heart Hospital, Melbourne 3168, Australia
- Department of Surgery, Monash University, Melbourne 3168, Australia
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Pearl RG, Cole SP. Development of the Modern Cardiothoracic Intensive Care Unit and Current Management. Crit Care Clin 2023; 39:559-576. [PMID: 37230556 DOI: 10.1016/j.ccc.2023.03.008] [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: 05/27/2023]
Abstract
The modern cardiothoracic intensive care unit (CTICU) developed as a result of advances in critical care, cardiology, and cardiac surgery. Patients undergoing cardiac surgery today are sicker, frailer, and have more complex cardiac and noncardiac morbidities. CTICU providers need to understand postoperative implications of different surgical procedures, complications that can occur in CTICU patients, resuscitation protocols for cardiac arrest, and diagnostic and therapeutic interventions such as transesophageal echocardiography and mechanical circulatory support. Optimum CTICU care requires a multidisciplinary team with collaboration between cardiac surgeons and critical care physicians with training and experience in the care of CTICU patients.
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Affiliation(s)
- Ronald G Pearl
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford University School of Medicine, 300 Pasteur Drive, Room H3589.
| | - Sheela Pai Cole
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford University School of Medicine, 300 Pasteur Drive, Room H3589
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Ferrante MS, Pisano C, Van Rothem J, Ruvolo G, Abouliatim I. Cerebrovascular events after cardiovascular surgery: diagnosis, management and prevention strategies. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2023; 20:118-122. [PMID: 37564967 PMCID: PMC10410632 DOI: 10.5114/kitp.2023.130020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/06/2023] [Indexed: 08/12/2023]
Abstract
Introduction Cerebrovascular events after cardiac surgery are among the most serious complications, related to a greater risk of patient mortality. This problem can occur following the formation of gas emboli during open heart surgery. Aim To address all the mechanisms that can lead to embolic events after cardiovascular surgery, how to manage them and how to possibly prevent them. Material and methods A search of the PubMed database was conducted. We reviewed the clinical literature and examined all aspects to identify the root causes that can lead to the formation of emboli. Results Among the studies reviewed, it was found that the main causes include manipulation of the aorta, inadequate deaeration after cardiac surgery, and blood-component contact of extracorporeal circulation. It has been reported that gas emboli can lead to deleterious damage such as damage to the cerebral vascular endothelium, disruption of the blood-brain barrier, complement activation, leukocyte aggregation, increased platelet adhesion, and fibrin deposition in the microvascular system. Conclusions Stroke after cardiovascular surgery is one of the most important complications, with a great impact on operative mortality and patient survival. Efforts have been made over time to understand all the pathophysiological mechanisms related to this complication, with the aim of reducing its incidence. One of the goals should be to improve both the surgical technique and the perfusion modality and minimize the formation of air bubbles or to facilitate their elimination during the cardiopulmonary bypass procedure.
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Affiliation(s)
| | - Calogera Pisano
- Cardiac Surgery Division, Tor Vergata University Hospital, Rome, Italy
| | | | - Giovanni Ruvolo
- Cardiac Surgery Division, Tor Vergata University Hospital, Rome, Italy
| | - Issam Abouliatim
- Cardiovascular and Thoracic Surgery Department, Clinique Pasteur, Toulouse, France
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Baron Shahaf D, Hight D, Kaiser H, Shahaf G. Association Between Risk of Stroke and Delirium After Cardiac Surgery and a New Electroencephalogram Index of Interhemispheric Similarity. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00341-5. [PMID: 37321874 DOI: 10.1053/j.jvca.2023.05.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 05/09/2023] [Accepted: 05/19/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES Neurologic complications after surgery (stroke, delirium) remain a major concern despite advancements in surgical and anesthetic techniques. The authors aimed to evaluate whether a novel index of interhemispheric similarity, the lateral interconnection ratio (LIR), between 2 prefrontal electroencephalogram (EEG) channels could be associated with stroke and delirium following cardiac surgery. DESIGN Retrospective observational study. SETTING Single university hospital. PARTICIPANTS A total of 803 adult patients without documentation of a previous stroke, who underwent cardiac surgery with cardiopulmonary bypass (CPB) between July 2016 and January 2018. INTERVENTIONS The LIR index was calculated retrospectively from the patients' EEG database. MEASUREMENTS AND MAIN RESULTS LIR was analyzed intraoperatively every 10 seconds and compared among patients with postoperative stroke, patients with delirium, and patients without documented neurologic complications, during 5 key periods, each lasting10 minutes: (1) surgery start, (2) before CPB, (3) on CPB, (4) after CPB, and (5) surgery end. After cardiac surgery, 31 patients suffered from stroke; 48 patients were diagnosed with delirium; and 724 had no documented neurologic complications. Patients with stroke demonstrated a decrease in LIR index between the start of surgery and the postbypass period of 0.08 (0.01, 0.36 [21]; median and [interquartile range {IQR}]; valid EEG samples); whereas there was no similar decrease in the no-dysfunction group (-0.04 [-0.13, 0.04; {551}], p < 0.0001). Patients with delirium showed a decrease in LIR index between the start of surgery and the end of the surgery by 0.15 (0.02, 0.30 [12]), compared with no such decrease in the no-dysfunction group (-0.02 [-0.12, 0.08 {376}], p ≈ 0.001). CONCLUSIONS After improvement of SNR, it might be of value to further study the index decrease as an indication for risk for brain injury after surgery. The timing of decrease (after CPB or end of surgery) may provide hints regarding the injury pathophysiology and its onset.
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Affiliation(s)
| | - Darren Hight
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heiko Kaiser
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Goded Shahaf
- The Applied Neurophysiology Lab, Rambam Health Care Campus, Haifa, Israel
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Cheng Z, Wang Y, Liu J, Ming Y, Yao Y, Wu Z, Guo Y, Du L, Yan M. A novel model for predicting a composite outcome of major complications after valve surgery. Front Cardiovasc Med 2023; 10:1132428. [PMID: 37265563 PMCID: PMC10229809 DOI: 10.3389/fcvm.2023.1132428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/28/2023] [Indexed: 06/03/2023] Open
Abstract
Background On-pump valve surgeries are associated with high morbidity and mortality. The present study aimed to reliably predict a composite outcome of postoperative complications using a minimum of easily accessible clinical parameters. Methods A total of 7,441 patients who underwent valve surgery were retrospectively analyzed. Data for 6,220 patients at West China Hospital of Sichuan University were used to develop a predictive model, which was validated using data from 1,221 patients at the Second Affiliated Hospital of Zhejiang University School of Medicine. The primary outcome was a composite of major complications: all-cause death in hospital, stroke, myocardial infarction, and severe acute kidney injury. The predictive model was constructed using the least absolute shrinkage and selection operator as well as multivariable logistic regression. The model was assessed in terms of the areas under receiver operating characteristic curves, calibration, and decision curve analysis. Results The primary outcome occurred in 129 patients (2.1%) in the development cohort and 71 (5.8%) in the validation cohort. Six variables were retained in the predictive model: New York Heart Association class, diabetes, glucose, blood urea nitrogen, operation time, and red blood cell transfusion during surgery. The C-statistics were 0.735 (95% CI, 0.686-0.784) in the development cohort and 0.761 (95% CI, 0.694-0.828) in the validation cohort. For both cohorts, calibration plots showed good agreement between predicted and actual observations, and ecision curve analysis showed clinical usefulness. In contrast, the well-established SinoSCORE did not accurately predict the primary outcome in either cohort. Conclusions This predictive nomogram based on six easily accessible variables may serve as an "early warning" system to identify patients at high risk of major complications after valve surgery. Clinical Trial Registration [www.ClinicalTrials.gov], identifier [NCT04476134].
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Affiliation(s)
- Zhenzhen Cheng
- Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yishun Wang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Jing Liu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Yue Ming
- Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yuanyuan Yao
- Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Zhong Wu
- Department of Cardiovascular Surgery of West China Hospital, Sichuan University, Chengdu, China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery of West China Hospital, Sichuan University, Chengdu, China
| | - Lei Du
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Mpody C, Kola-Kehinde O, Awad H, Bhandary S, Essandoh M, Rankin D, Flores A, Harter R, Nafiu OO. Timing of Postoperative Stroke and Risk of Mortality After Noncardiac Surgery: A Cohort Study. J Clin Med Res 2023; 15:268-273. [PMID: 37303467 PMCID: PMC10251695 DOI: 10.14740/jocmr4877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/16/2023] [Indexed: 06/13/2023] Open
Abstract
Background Postoperative stroke is a devastating complication of surgery, given its association with severe long-term disability and mortality. Previous investigators have confirmed the association of stroke with postoperative mortality. However, limited data exist regarding the relationship between the timing of stroke and survival. Addressing this knowledge gap will help clinicians develop tailored perioperative strategies to reduce the incidence, severity, and mortality associated with perioperative stroke. Therefore, our objective was to determine whether the timing of postoperative stroke influenced mortality risk. Methods We performed a retrospective cohort study of patients > 18 years who underwent noncardiac surgery and developed postoperative stroke during the first 30 days of surgery (National Surgical Quality Improvement Program Pediatrics 2010 - 2021). Our primary outcome was 30-day mortality following the occurrence of postoperative stroke. We subdivided patients into two mutually exclusive groups: early and delayed stroke. Early stroke was defined as the occurrence within 7 days following surgery, consistent with a previous study. Results We identified 16,750 patients who underwent noncardiac surgery and developed stroke within 30 days of surgery. Of these, 11,173 (66.7%) had an early postoperative stroke (≤ 7 days). Perioperative physiological status, operative characteristics, and preoperative comorbidities were generally comparable between patients with early and delayed postoperative stroke. Despite the comparability in these clinical characteristics, the mortality risk was 24.9% for early and 19.4% for delayed stroke. After adjusting for perioperative physiological status, operative characteristics, and preoperative comorbidities, early stroke was associated with an increased mortality risk (adjusted odds ratio: 1.39, confidence interval: 1.29 - 1.52, P-value < 0.001). In patients with an early postoperative stroke, the most common preceding complications were bleeding requiring transfusion (24.3%), followed by pneumonia (13.2%) and renal insufficiency (11.3%). Conclusions Postoperative stroke tends to occur within 7 days following noncardiac surgery. Such timing of postoperative stroke carries a higher mortality risk, suggesting that targeted efforts to prevent stroke should focus on the first week following surgery to reduce the incidence and mortality associated with this complication. Our findings contribute to the growing understanding of stroke after noncardiac surgery and may help clinicians develop tailored perioperative neuroprotective strategies to prevent or improve treatment and outcomes of postoperative stroke.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Onaopepo Kola-Kehinde
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Hamdy Awad
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Sujatha Bhandary
- Division of Cardio-Thoracic Anesthesiology, Department of Anesthesiology, Emory University, Atlanta, GA, USA
| | - Michael Essandoh
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Demicha Rankin
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Antolin Flores
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Ronald Harter
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
| | - Olubukola O. Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
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Gaudino M, Andreotti F, Kimura T. Current concepts in coronary artery revascularisation. Lancet 2023; 401:1611-1628. [PMID: 37121245 DOI: 10.1016/s0140-6736(23)00459-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 05/02/2023]
Abstract
Coronary artery revascularisation can be performed surgically or percutaneously. Surgery is associated with higher procedural risk and longer recovery than percutaneous interventions, but with long-term reduction of recurrent cardiac events. For many patients with obstructive coronary artery disease in need of revascularisation, surgical or percutaneous intervention is indicated on the basis of clinical and anatomical reasons or personal preferences. Medical therapy is a crucial accompaniment to coronary revascularisation, and data suggest that, in some subsets of patients, medical therapy alone might achieve similar results to coronary revascularisation. Most revascularisation data are based on prevalently White, non-elderly, male populations in high-income countries; robust data in women, older adults, and racial and other minorities, and from low-income and middle-income countries, are urgently needed.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA.
| | - Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Osaka, Japan
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26
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Pierik R, Scheeren TWL, Erasmus ME, van den Bergh WM. Near-infrared spectroscopy and processed electroencephalogram monitoring for predicting peri-operative stroke risk in cardiothoracic surgery: An observational cohort study. Eur J Anaesthesiol 2023; 40:425-435. [PMID: 37067999 DOI: 10.1097/eja.0000000000001836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
BACKGROUND Stroke is a feared complication after cardiothoracic surgery, with an incidence of around 2 to 3%. Anaesthesia and postoperative sedation may obscure clinical symptoms of stroke and thus delay diagnosis and timely intervention. OBJECTIVES The objective was to assess the value of intra-operative neuromonitoring and blood pressure monitoring for predicting the occurrence of peri-operative stroke within 3 days after cardiothoracic surgery. DESIGN Single-centre retrospective observational cohort study. SETTING Academic tertiary care medical centre. PATIENTS All consecutive patients with cardiothoracic surgery and intra-operative neuromonitoring admitted postoperatively to the Intensive Care Unit (ICU) between 2008 and 2017. MAIN OUTCOME MEASURES The primary endpoint was the occurrence of any stroke confirmed by brain imaging within 3 days postcardiothoracic surgery. Areas under the curve (AUC) of intra-operative mean arterial pressure (MAP), cerebral oxygen saturation (ScO2) and bispectral index (BIS) below predefined thresholds were calculated, and the association with early stroke was tested using logistic regression analyses. RESULTS A total of 2454 patients admitted to the ICU after cardiothoracic surgery had complete intra-operative data for ScO2, BIS and MAP and were included in the analysis. In 58 patients (2.4%), a stroke was confirmed. In univariate analysis, a larger AUCMAP greater than 60 mmHg [odds ratio (OR) 1.43; 95% confidence interval (CI), 1.21 to 1.68) and larger AUCBIS<25 (OR 1.51; 95% CI, 1.24 to 1.83) were associated with the occurrence of postoperative stroke while ScO2 less than 50% or greater than 20% reduction from individual baseline was not (OR 0.91; 95% CI, 0.50 to 1.67). After multivariable analysis, AUCBIS<25 (OR 1.45; 95% CI, 1.12 to 1.87) and longer duration of MAP less than 60 mmHg (OR 1.52; 95% CI, 1.02 to 2.27) remained independently associated with stroke occurrence. CONCLUSION Cumulative intra-operative BIS values below 25 and longer duration of MAP below 60 mmHg were associated with the occurrence of peri-operative stroke within 3 days after cardiothoracic surgery. Prospective studies are warranted to evaluate a causal relationship between low BIS and stroke to establish whether avoiding intra-operative BIS values below 25 might reduce the incidence of peri-operative stroke.
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Affiliation(s)
- Ramon Pierik
- From the Department of Critical Care (RP, WMvdB), Department Anaesthesiology (TWLS) and Department of Cardiac Surgery (MEE), University Medical Center Groningen, University of Groningen, the Netherlands
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27
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Sastre JA, López T, Moreno-Rodríguez MA, Reta-Ajo L, Rubia-Martín MC, Díez-Castro R. Reliability of different body temperature measurement sites during normothermic cardiac surgery. Perfusion 2023; 38:580-590. [PMID: 35133212 DOI: 10.1177/02676591211069918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Patients undergoing cardiac surgery can experience significant thermal changes during the perioperative period and, for that reason, it is essential to monitor temperatures with adequate accuracy and precision during cardiopulmonary bypass (CPB). The primary aim of the current study was to measure the discrepancies between temperatures at different body sites during normothermic or mild hypothermic CPB. METHODS 48 patients undergoing cardiac surgery participated in our study. Simultaneous temperatures were measured at nasopharynx, pulmonary artery, arterial outlet, venous inlet, forehead using a heat flux sensor, and urinary bladder at 5-min intervals throughout surgery. The Bland-Altman plot for repeated measures was used to assess concordance between methods. RESULTS The duration of surgery was 360 min (interquartile range (IQR) 300-412), while the median cross-clamp time was 135 min (IQR 101-169). During the CPB time, the average difference between arterial outlet and nasopharyngeal temperature was -0.16°C (95% limits of agreement of ±0.93). The bias between arterial outlet and the venous inflow was 0.16°C and the 95% limits of agreement were -0.63 to 0.95°C. The Bland-Altman analysis showed an average difference between oxigenator arterial outlet and bladder probe of -0.62 (95% limits of agreement of ±1.3). The average difference between arterial outlet and Tcore™ temperatures was 0.08°C (95% limits of agreement of ±1.46). 25 patients (52.08%) presented nasopharyngeal temperatures higher than 37°C in the post-CPB period, but none of them exceeded 38°C. CONCLUSIONS Perfusionists should be cautious when using the nasopharyngeal site as the only surrogate of brain temperature, even in normothermic cardiac surgery because the precision of measurements is not entirely adequate.
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Affiliation(s)
- José A Sastre
- Department of Anaesthesiology, 37479Salamanca University Hospital, Salamanca, Spain
| | - Teresa López
- Department of Anaesthesiology, 37479Salamanca University Hospital, Salamanca, Spain
| | | | - Leyre Reta-Ajo
- Cardiovascular Perfusionist, 37479Salamanca University Hospital, Salamanca, Spain
| | - María C Rubia-Martín
- Cardiovascular Perfusionist, 37479Salamanca University Hospital, Salamanca, Spain
| | - Rosa Díez-Castro
- Cardiovascular Perfusionist, 37479Salamanca University Hospital, Salamanca, Spain
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Laghlam D, Coroyer L, Martial PJ, Estagnasie P, Squara P, Nguyen LS. Risk factors and complications associated with intra-operative or post-operative identification of a PFO in cardiac surgery patients: A cohort study. Front Neurol 2023; 13:1057479. [PMID: 36703625 PMCID: PMC9871930 DOI: 10.3389/fneur.2022.1057479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/13/2022] [Indexed: 01/12/2023] Open
Abstract
Introduction It is unknown whether patent foramen ovale (PFO) reopening in the peri-operative setting of cardiac surgery affects the risk for stroke and post-operative outcomes. Methods We performed a single-center, retrospective study based on a prospectively collected database in a tertiary cardiac surgery center. Using logistic regression, we assessed risk factors of PFO finding around surgery and subsequent clinical complications. Results Between January 2007 and July 2019, 11034 patients who underwent cardiac surgery in our center were included. A total of 233 patients (2.1%) presented a finding of PFO including 138 per-operative disclosures and 95 post-operative finding for hypoxemia. In the whole cohort, the mean age was 68.4 ± 11.5 years including 73.9% of men. Post-operative PFO finding was associated with more ischemic strokes compared with per-operative finding and control group [7(7.4%) vs. 3(2.2%) vs. 236(2.2), respectively; p = 0.003]. Moreover, patients with post-operative PFO reopening experienced a higher rate of pneumonia, reintubation, and longer length of stay in the ICU. Post-operative reopening of PFO, but not per-operative finding, was independently associated with ischemic strokes {adjusted odds-ratio = 3.5, 95% confidence interval (CI) [1.6-7.8]; p = 0.002}. Other variables associated with stroke incidence included age, mitral valve surgery, and ascending aorta surgery. Per- or post-operative PFO closure was associated with reduced adverse respiratory outcomes and a trend of the lower cerebral ischemic event. Conclusion Patent foramen ovale finding incidence in peri-operative cardiac surgery care was rare (2%) but post-operative finding of PFO was associated with a increased risk of ischemic strokes, worsened respiratory outcomes, and prolonged hospitalization.
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29
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Eikelboom R, Whitlock RP, Lopes RD, Siegal D, Jaffer IH, Drakos P, Schulman S, Belley-Côté EP. How Did We Get Here? Antithrombotic Therapy after Bioprosthetic Aortic Valve Replacement: A Review. Thromb Haemost 2023; 123:6-15. [PMID: 36513278 DOI: 10.1055/s-0042-1758128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Aortic stenosis is the most common valvular disease, and more than 90% of patients who undergo aortic valve replacement receive a bioprosthetic valve. Yet optimal antithrombotic therapy after bioprosthetic aortic valve replacement remains uncertain, and guidelines provide contradictory recommendations. OBSERVATIONS Randomized studies of antithrombotic therapy after bioprosthetic aortic valve replacement are small and underpowered. Observational data present opposing, and likely confounded, results. Historically, changes to guidelines have not been informed by high-quality new data. Current guidelines from different professional bodies provide contradictory recommendations despite citing the same evidence. CONCLUSION Insufficient antithrombotic therapy after bioprosthetic aortic valve replacement has serious implications: ischemic stroke, systemic arterial thromboembolism, and clinical and subclinical valve thromboses. Unnecessarily intense antithrombotic therapy, however, increases risk of bleeding and associated morbidity and mortality. Professional bodies have used the current low-quality evidence and generated incongruent recommendations. Researchers should prioritize generating high-quality, randomized evidence evaluating the risks and benefits of antiplatelet versus anticoagulant therapy after bioprosthetic aortic valve replacement.
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Affiliation(s)
- Rachel Eikelboom
- Department of Surgery, University of Manitoba, Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Richard P Whitlock
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Renato D Lopes
- Division of Cardiology, Duke Clinical Research Institute, Duke University, Durham, North Carolina, United States
| | - Deborah Siegal
- Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Iqbal H Jaffer
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Paul Drakos
- Department of Kinesiology, McMaster University, Hamilton, Ontario, Canada
| | - Sam Schulman
- Division of Hematology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Emilie P Belley-Côté
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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30
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Feilberg Rasmussen L, Andreasen JJ, Riahi S, Lundbye‐Christensen S, Johnsen SP, Andersen G, Mortensen JK. Risk and Subtypes of Stroke Following New-Onset Postoperative Atrial Fibrillation in Coronary Bypass Surgery: A Population-Based Cohort Study. J Am Heart Assoc 2022; 11:e8032. [PMID: 36533595 PMCID: PMC9798791 DOI: 10.1161/jaha.122.027010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background New-onset postoperative atrial fibrillation (POAF) develops in approximately one-third of patients undergoing cardiac surgery and is associated with a higher incidence of ischemic stroke and increased mortality. However, it remains unknown to what extent ischemic stroke events in patients with POAF are cardioembolic and whether anticoagulant therapy is indicated. We investigated the long-term risk and pathogenesis of postoperative stroke in patients undergoing coronary artery bypass grafting experiencing POAF. Methods and Results This was a register-based cohort study. Data from the WDHR (Western Denmark Heart Registry) were linked with the DNPR (Danish National Patient Register), the Danish National Prescription Register, and the Cause of Death Register. All stroke diagnoses were verified, and ischemic stroke cases were subclassified according to pathogenesis. Furthermore, investigations of all-cause mortality and the use of anticoagulation medicine for the individual patient were performed. A total of 7813 patients without a preoperative history of atrial fibrillation underwent isolated coronary artery bypass grafting between January 1, 2010, and December 31, 2018, in Western Denmark. POAF was registered in 2049 (26.2%) patients, and a postoperative ischemic stroke was registered in 195 (2.5%) of the patients. After adjustment, there was no difference in the risk of ischemic stroke (hazard ratio [HR], 1.08 [95% CI, 0.74-1.56]) or all-cause mortality (HR, 1.09 [95% CI, 0.98-1.23]) between patients who developed POAF and non-POAF patients. Although not statistically significant, patients with POAF had a higher incidence rate (IR; per 1000 patient-years) of cardioembolic stroke (IR, 1 [95% CI, 0.6-1.6] versus IR, 0.5 [95% CI, 0.3-0.8]), whereas non-POAF patients had a higher incidence rate of large-artery occlusion stroke (IR, 1.1 [95% CI, 0.8-1.5] versus IR, 0.7 [95% CI, 0.4-1.4]). Early initiation of anticoagulation medicine was not associated with a lower risk of ischemic stroke. However, patients with POAF were more likely to die of cardiovascular causes than non-POAF patients (P<0.001). Conclusions We found no difference in the adjusted risk of postoperative stroke or all-cause mortality in POAF versus non-POAF patients. Patients with POAF after coronary artery bypass grafting presented with a higher, although not significant, proportion of ischemic strokes of the cardioembolic type.
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Affiliation(s)
- Louise Feilberg Rasmussen
- Department of Cardiothoracic SurgeryAalborg University HospitalAalborgDenmark,Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Jan J. Andreasen
- Department of Cardiothoracic SurgeryAalborg University HospitalAalborgDenmark,Department of Clinical MedicineAalborg UniversityAalborgDenmark,Atrial Fibrillation Study GroupAalborg University HospitalAalborgDenmark
| | - Sam Riahi
- Department of Clinical MedicineAalborg UniversityAalborgDenmark,Atrial Fibrillation Study GroupAalborg University HospitalAalborgDenmark,Department of CardiologyAalborg University HospitalAalborgDenmark
| | - Søren Lundbye‐Christensen
- Atrial Fibrillation Study GroupAalborg University HospitalAalborgDenmark,Unit of Clinical BiostatisticsAalborg University HospitalAalborgDenmark
| | - Søren P. Johnsen
- Department of Clinical MedicineAalborg UniversityAalborgDenmark,Danish Center for Clinical Health Services ResearchAalborg UniversityAalborgDenmark
| | - Grethe Andersen
- Department of Neurology, Danish Stroke CentreAarhus University HospitalAarhusDenmark,Department of Clinical Medicine, Faculty of HealthAarhus UniversityAarhusDenmark
| | - Janne K. Mortensen
- Department of Neurology, Danish Stroke CentreAarhus University HospitalAarhusDenmark,Department of Clinical Medicine, Faculty of HealthAarhus UniversityAarhusDenmark
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31
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De Paulis R, Folino G, Scaffa R. The percutaneous coronary angioplasty gets better, but the surgical coronary artery bypass does not stay behind. Eur Heart J Suppl 2022; 24:I81-I83. [PMID: 36380805 PMCID: PMC9653154 DOI: 10.1093/eurheartjsupp/suac077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Coronary artery bypass grafting remains one of the most frequently performed cardiac operations, with well-established prognostic benefits in patients with multivessel coronary artery disease and left main disease. Despite an increasingly higher patients' risk profile, the results of this procedure have significantly improved over time, with an evident and striking decrease in operative mortality and peri-operative complications. A fair amount of technical and technological refinements has further improved the short- and long-term results of coronary artery bypass surgery. The improvements in the beating heart coronary surgery and aortic 'no-touch' technique, in the appropriate use of conduits (bilateral internal mammary artery, radial artery, and composite conduits configuration), and in the optimization of venous grafts' patency are reviewed.
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Affiliation(s)
- Ruggero De Paulis
- Division of Cardiac Surgery - European Hospital, and UniCamillus University, Rome
| | - Giulio Folino
- Division of Cardiac Surgery - European Hospital, and UniCamillus University, Rome
| | - Raffaele Scaffa
- Division of Cardiac Surgery - European Hospital, and UniCamillus University, Rome
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Moustafa B, Testai FD. Navigating Antiplatelet Treatment Options for Stroke: Evidence-Based and Pragmatic Strategies. Curr Neurol Neurosci Rep 2022; 22:789-802. [PMID: 36227497 DOI: 10.1007/s11910-022-01237-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW The benefit of using antiplatelet monotherapy in acute ischemic stroke and secondary stroke prevention is well established. In the last few years, several large randomized trials showed that the use of short-term dual antiplatelet therapy in particular stroke subtypes may reduce the risk of recurrent ischemic events. The aim of this article is to provide a critical analysis of the current evidence and recommendations for the use of antiplatelet agents for stroke prevention. RECENT FINDINGS Long-term therapy with aspirin, clopidogrel, or aspirin plus extended-release dipyridamole is recommended for secondary stroke prevention in patients with noncardioembolic ischemic stroke. Short-term dual antiplatelet therapy with aspirin and clopidogrel is superior to antiplatelet monotherapy in secondary stroke prevention when used in patients with mild noncardioembolic stroke or high-risk transient ischemic attack. Dual therapy, however, is associated with an increased risk of major bleeding, particularly when the treatment is extended for greater than 30 days. Similarly, aspirin plus ticagrelor is superior to aspirin monotherapy for the prevention of recurrent ischemic stroke, although this combination is associated with a higher risk of hemorrhagic complications when compared to other dual antiplatelet regimens. Among patients who carry CYP2C19 genetic polymorphisms associated with a slow bioactivation of clopidogrel, short-term treatment with aspirin plus ticagrelor is superior to aspirin plus clopidogrel for the reduction of recurrent stroke; however, the use of ticagrelor is associated with a higher risk of any bleeding. In patients with symptomatic intracranial stenosis, aggressive medical management in addition to dual antiplatelet therapy up to 90 days is recommended. Antiplatelet therapy has an essential role in the management of ischemic stroke. The specific antiplatelet regimen should be individualized based on the stroke characteristics, time from symptom onset, and patient-specific predisposition to develop hemorrhagic complications.
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Affiliation(s)
- Bayan Moustafa
- Mayo Clinic College of Medicine and Science, 1221 Whipple St, Eau Claire, WI, 54703, USA.
| | - Fernando D Testai
- College of Medicine, University of Illinois at Chicago, 912 S Wood St, Chicago, IL, 60612, USA
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Jonsson K, Barbu M, Nielsen SJ, Hafsteinsdottir B, Gudbjartsson T, Jensen EM, Silverborn M, Jeppsson A. Perioperative stroke and survival in coronary artery bypass grafting patients: a SWEDEHEART study. Eur J Cardiothorac Surg 2022; 62:ezac025. [PMID: 35079766 PMCID: PMC9643741 DOI: 10.1093/ejcts/ezac025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/11/2021] [Accepted: 01/14/2022] [Indexed: 03/06/2024] Open
Abstract
OBJECTIVES Perioperative stroke is a severe complication of cardiac surgery. We assessed the incidence of stroke over time, the association between stroke and mortality and identified preoperative factors independently associated with perioperative stroke, in a large nationwide cardiac surgery population. METHODS All patients who underwent coronary artery bypass grafting in Sweden 2006-2017 were included in a registry-based observational cohort study based on prospectively collected data. Multivariable logistic and Cox regression models were used to assess associations between perioperative stroke and mortality and to identify factors associated with stroke. The median follow-up was 6 years (range 0-12). RESULTS There were 441 perioperative strokes in 36 898 patients. The mean incidence was 1.2% and decreased marginally over time [adjusted odds ratio (OR) 0.97 per year (95% confidence interval 0.94-1.00), P = 0.035]. Stroke patients had a higher overall mortality risk during follow-up [adjusted hazard ratio 2.30 (2.00-2.64), P < 0.001], with the highest risk during the first 30 postoperative days [adjusted hazard ratio (7.29 (5.58-9.54), P < 0.001]. The strongest independent preoperative factors associated with stroke were prior cardiac surgery [adjusted OR 2.89 (1.40-5.96)], critical preoperative condition [adjusted OR 2.55 (1.73-3.76)], previous stroke [adjusted OR 1.77 (1.35-2.33)], preoperative angina requiring intravenous nitrates [adjusted OR 1.67 (1.28-2.17)], peripheral vascular disease [OR 1.63 (1.25-2.13)] and advanced age [OR 1.05 (1.03-1.06) per year]. CONCLUSIONS The incidence of perioperative stroke after coronary artery bypass grafting has remained stable. Patients with perioperative stroke had a markedly higher adjusted risk of death early after surgery. The risk declined over time but remained higher during the entire follow-up period.
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Affiliation(s)
- Kristjan Jonsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mikael Barbu
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiology, Blekinge Hospital, Karlskrona, Sweden
| | - Susanne J Nielsen
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Tomas Gudbjartsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Cardiothoracic Surgery, Landspitali, Reykjavik, Iceland
| | - Elin M Jensen
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Cardiothoracic Surgery, Landspitali, Reykjavik, Iceland
| | - Martin Silverborn
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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Worku B, Gulkarov I, Mack C. Embolization during cardiac surgery; to prevent or intercept. J Card Surg 2022; 37:2732-2733. [PMID: 35765996 DOI: 10.1111/jocs.16722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Berhane Worku
- Department of Cardiothoracic Surgery, New York Presbyterian Weill Cornell Medical Center, New York, New York, USA.,Department of Cardiothoracic Surgery, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
| | - Iosif Gulkarov
- Department of Cardiothoracic Surgery, New York Presbyterian Weill Cornell Medical Center, New York, New York, USA.,Department of Cardiothoracic Surgery, New York Presbyterian Queens Hospital, Queens, New York, USA
| | - Charles Mack
- Department of Cardiothoracic Surgery, New York Presbyterian Weill Cornell Medical Center, New York, New York, USA.,Department of Cardiothoracic Surgery, New York Presbyterian Queens Hospital, Queens, New York, USA
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35
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Spanjersberg AJ, Ottervanger JP, Nierich AP, Hoogendoorn M, Bruinsma GJBB. Mortality Reduction After a Preincision Safety Check Before Cardiac Surgery: Is It the Aorta? J Cardiothorac Vasc Anesth 2022; 36:2954-2960. [PMID: 35288024 DOI: 10.1053/j.jvca.2022.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/13/2022] [Accepted: 01/29/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The introduction and use of a preincision safety check were associated with lower mortality after mixed adult cardiac surgery; however, an explanatory mechanism is lacking. Stroke, one of the most severe complications after cardiac surgery, with high mortality, may be reduced by adapting the surgical handling of the ascending aorta. This study assessed the prevalence and predictors of this adaptation after a preincision safety check and the subsequent effect on outcome. DESIGN A prospective, single-center, observational study comparing adaptation with no-adaptation. The primary outcome measure was 30-day mortality. Multivariate analyses were performed to determine independent predictors of adaptation. To study the effect of adaptation on outcome, a propensity score-matched cohort was constructed in a 1:3 intervention:control ratio. SETTING At Isala Zwolle (NL), a large, nonacademic teaching hospital. PARTICIPANTS All consecutive cardiac surgery procedures from 2012 until 2015, including 4,752 surgeries. INTERVENTIONS The adaptation of surgical handling of the ascending aorta. MEASUREMENTS AND MAIN RESULTS In 283 cardiac surgeries (5.9%), adaptation was indicated. The most important independent predictors for adaptation were extracardiac atherosclerosis, current smoking, and increasing age. In the propensity score-matched cohort consisting of 1,069 procedures, there were no significant differences in outcome. After correction for propensity score, the hazard ratio of adaptation for 30-day mortality was 1.8 (0.85-3.79). CONCLUSIONS The adaptation of aortic surgical handling after a preincision safety check was necessary for 5.9% of cardiac surgeries, with extracardiac atherosclerosis as the strongest predictor. Outcome was not significantly different between patients with and without adaptation. Although promising, it remains unclear whether adaptation may fully explain mortality reduction after the use of a preincision safety check.
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Affiliation(s)
- Alexander J Spanjersberg
- Division Cardiothoracic Anesthesiology, Department of Anesthesiology and Intensive Care, Isala Heart Centre, Isala Zwolle, The Netherlands.
| | | | - Arno P Nierich
- Division Cardiothoracic Anesthesiology, Department of Anesthesiology and Intensive Care, Isala Heart Centre, Isala Zwolle, The Netherlands
| | - Marga Hoogendoorn
- Division Cardiothoracic Anesthesiology, Department of Anesthesiology and Intensive Care, Isala Heart Centre, Isala Zwolle, The Netherlands
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36
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Gerdisch M, Lehr E, Dunnington G, Johnkoski J, Barksdale A, Parikshak M, Ryan P, Youssef S, Fletcher R, Barnhart G. Mid‐term outcomes of concomitant Cox‐Maze IV: Results from a multicenter prospective registry. J Card Surg 2022; 37:3006-3013. [PMID: 35870185 PMCID: PMC9543802 DOI: 10.1111/jocs.16777] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/26/2022] [Accepted: 05/12/2022] [Indexed: 11/29/2022]
Abstract
Background Benefits of concomitant atrial fibrillation (AF) surgical treatment are well established. Cardiac societies support treating AF during cardiac surgery with a class I recommendation. Despite these guidelines, adoption has been inconsistent. We report results of routine performance of concomitant Cox‐Maze IV (CMIV) from participating centers using a standardized, prospective registry. Methods Nine surgeons at four cardiac surgery programs enrolled 807 patients undergoing concomitant CMIV surgery over 12 years. Lesions were created using bipolar radiofrequency clamps and cryoablation probes. Follow‐up occurred at 3‐ and 6‐months, then annually for 3 years. Freedom from AF was defined as no episode >30 s of atrial arrhythmia. Results Sixty‐four percent of patients were male, mean age 69 years, mean left atrial size 4.6 cm, mean preoperative AF duration 4.0 years, mean EuroSCORE 6.4, and mean CHADS2 score 3.1. Thirty‐day postoperative mortality and neurologic event rates were 3.3% and 1.3%, respectively. New pacemaker implant rate was 6.3%. Freedom from AF rates at 1‐ and 3‐years stratified by preoperative AF type were: paroxysmal 94.6% and 87.5%, persistent 82.1% and 81.9%, and longstanding persistent 84.1% and 78.1%. At 3‐year follow up, 84% of patients were off antiarrhythmic drugs and 74% of sinus rhythm patients were off oral anticoagulants. Conclusions Routine CMIV is safe and effective. Acceptable outcomes can be achieved across multiple centers and multiple operators even in a moderate risk patient population undergoing more complex procedures. Surgeons and institutions should be encouraged by all cardiac societies to adopt the CMIV procedure to maximize patient benefit.
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Affiliation(s)
- Marc Gerdisch
- Franciscan Health Indianapolis Indianapolis Indiana USA
| | - Eric Lehr
- Swedish Medical Center Seattle Washington USA
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Lau M, Chan DTL, Bhatia I, Au TWK. Hybrid approach for cerebral protection in open-heart surgery: Case series. J Card Surg 2022; 37:2727-2731. [PMID: 35766011 DOI: 10.1111/jocs.16725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/02/2022] [Accepted: 05/19/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Stroke remains one of the most important complications of cardiac surgery and occurs in 2.2% after open-heart procedure. It is associated with significant morbidity and mortality. The use of a cerebral protection system during transcatheter aortic valve implantation may be associated with a lower risk of periprocedural strokes, and mortality at 30 days. The aim of the present study was to assess the safety and feasibility of this device in patients at high risk for stroke during open cardiac surgery. METHODS We present six patients with a high risk of perioperative stroke who underwent placement of Sentinel cerebral protection system during various open-heart operations between 2018 and 2021. RESULTS The system was successfully deployed, and debris was retrieved in all patients. There was no device-related complication or development of ischemic stroke postoperatively. One patient suffered from intracranial hemorrhage due to peri-operative coagulopathy. CONCLUSIONS We demonstrated the feasibility and safety of this hybrid approach with a high debris capture rate. It encourages further study to evaluate the benefits of the Sentinel cerebral protection system in reducing stroke and mortality in selected patients undergoing open-heart surgery.
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Affiliation(s)
- Ming Lau
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR
| | - Daniel T L Chan
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR
| | - Inderjeet Bhatia
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR
| | - Timmy W K Au
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR
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38
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Ji L, Li F. Potential Markers of Neurocognitive Disorders After Cardiac Surgery: A Bibliometric and Visual Analysis. Front Aging Neurosci 2022; 14:868158. [PMID: 35721025 PMCID: PMC9199578 DOI: 10.3389/fnagi.2022.868158] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/20/2022] [Indexed: 12/11/2022] Open
Abstract
Background Identifying useful markers is essential for diagnosis and prevention of perioperative neurocognitive disorders (PNDs). Here, we attempt to understand the research basis and status, potential hotspots and trends of predictive markers associated with PNDs after cardiac surgery via bibliometric analysis. Methods A total of 4,609 original research articles and reviews that cited 290 articles between 2001 and 2021 were obtained from the Web of Science Core Collection (WoSCC) as the data source. We used the software CiteSpace to generate and analyze visual networks of bibliographic information, including published years and journals, collaborating institutions, co-cited references, and co-occurring keywords. Results The number of annual and cumulative publications from 2001 to 2021 has been increasing on the whole. The Harvard Medical School was a very prolific and important institution in this field. The journal of Ann Thorac Surg (IF 4.33) had the most publications, while New Engl J Med was the most cited journal. Neuron-specific enolase (NSE), S100b and kynurenic acid (KYNA) were frequently discussed as possible markers of PNDs in many references. Cardiopulmonary bypass (CPB) was a keyword with high frequency (430) and sigma (6.26), and inflammation was the most recent burst keyword. Conclusion Potential markers of PNDs has received growing attention across various disciplines for many years. The research basis mainly focuses on three classic biomarkers of S100b, NSE, and KYNA. The most active frontiers are the inflammation-related biomarkers (e.g., inflammatory cells, cytokines, or mediators) and surgery-related monitoring parameters (e.g., perfusion, oxygen saturation, and the depth of anesthesia).
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90-Day Patient-Centered Outcomes after Totally Endoscopic Cardiac Surgery: A Prospective Cohort Study. J Clin Med 2022; 11:jcm11092674. [PMID: 35566800 PMCID: PMC9103144 DOI: 10.3390/jcm11092674] [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] [Received: 04/05/2022] [Revised: 04/29/2022] [Accepted: 05/08/2022] [Indexed: 01/27/2023] Open
Abstract
Over the past years, minimally invasive procedures have been developed to reduce surgical trauma after cardiac surgery. The value of patient-centered outcomes, including the quality of recovery after hospital discharge, is increasingly recognized. Identifying meaningful changes in postoperative function that might have a negative impact on patients without noticeable complications can provide a more comprehensive understanding of the impact on the patient’s life. In total, 209 patients were included in this trial. Of these, 193 patients underwent totally endoscopic cardiac surgery, 8 underwent cardiac surgery through a sternotomy, and 8 underwent transcatheter aortic valve implantation. Patients who previously underwent cardiac surgery were excluded. Quality of life was determined through the Short Form 36 and European Quality of Life-5 Dimensions questionnaires before the surgery and 14, 30, and 90 days afterward. In patients who underwent totally endoscopic cardiac surgery, the quality of life improved over the three time periods. The different domains of the questionnaire evolved in a positive manner. However, 14 days postoperatively, a decline in quality of life was noted, followed by a return to baseline at 30 days and an increase at 90 days. In conclusion, totally endoscopic cardiac surgery improves the quality of life 90 days after surgery.
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40
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Fatima R, Dhingra NK, Ribeiro R, Bisleri G, Yanagawa B. Routine left atrial appendage occlusion in patients undergoing cardiac surgery: a narrative review. Curr Opin Cardiol 2022; 37:165-172. [PMID: 34723850 DOI: 10.1097/hco.0000000000000925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW New evidence suggests a greater prevalence of protracted postoperative atrial fibrillation (POAF) than previously recognized. The left atrial appendage (LAA) is the most common source of embolism in patients with nonvalvular atrial fibrillation. In this review, we ask whether there is evidence to support routine LAA occlusion (LAAO) in patients without preexisting atrial fibrillation undergoing cardiac surgery. RECENT FINDINGS Overall, available studies are small, inconsistent and have varying proportions of patients with and without preexisting atrial fibrillation. There is considerable discrepancy with respect to the efficacy of LAAO in reducing the risk of POAF-related stroke. Only one study reported a lower rate of stroke in the LAAO group compared with no LAAO. Two studies included a subgroup analysis of patients that developed POAF and report a significantly higher rate of stroke in patients that developed POAF and did not undergo LAAO. There are three clinical trials ongoing that are investigating prophylactic LAAO in patients undergoing cardiac surgery: ATLAS, LAA-CLOSURE and LAACS-2. SUMMARY There is currently insufficient evidence to recommend routine addition of LAAO to lower the risk of postoperative stroke. Ongoing clinical trials will provide important insight into the role of routine LAAO in all patients undergoing cardiac surgery.
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Affiliation(s)
- Rubab Fatima
- Kingston General Hospital, Queen's University, Kingston
| | - Nitish K Dhingra
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Roberto Ribeiro
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gianluigi Bisleri
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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41
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Kasim A, Elbaz-Greener G, Shalabi A, Kachel E, Grosman-Rimon L, Jerdev M, amir O, Carasso S. High Mitral Annulus Calcium Score in Pre-Operative Chest Computerized Tomography and Adverse Outcomes in Mitral Valve Surgery. Vasc Health Risk Manag 2021; 17:801-807. [PMID: 34916798 PMCID: PMC8670886 DOI: 10.2147/vhrm.s338880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/03/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Severe mitral annulus calcification (MAC) is believed to bear high operative and post-operative risk during mitral valve replacement (MVR) surgery, including longer surgery time, post-surgical valvular leaks and increased rate of embolic phenomena. We hypothesized that quantification of mitral calcium in pre-operative chest computerized tomography (CCT), performed to assess aortic root before cross-clamping may help in risk assessment of adverse intraoperative and postoperative outcomes in patients undergoing MVR. METHODS We included patients who underwent MVR between the years 2015 and 2018 at Poriya medical center. Preoperative CCT was performed using Philips iCT 256 and Agatston mitral annulus calcium score (MACS) was retrospectively calculated using Philips Intellispace portal version 8.0. Patients were divided into MACS quintiles; 1-3 quintiles were grouped (Low MACS) and compared to the 4-5 quintiles (High MACS) group for demographic, clinical operative and post-operative parameters. RESULTS A total of 66 patients had MVR, out of which 61% were males, with mean age of 64±9. Concomitant coronary or valvular procedures were done in 60% of patients. The median MACS was 43. High MACS (≥854) was not associated with longer bypass or cross clamp times. No differences in the MVR results were found between the groups. There were 6 post-operative embolic events; 1 mesenteric and 5 cerebral, which were not associated with MACS. CONCLUSION MACS did not seem to be related to adverse outcomes in MVR. Due to a low event rate and probable pre-selection of patients without extreme mitral annulus calcifications our results should be confirmed in larger prospective study.
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Affiliation(s)
- Alexandra Kasim
- Department of Radiology, B Padeh Medical Center, Poriya, Israel
| | - Gabby Elbaz-Greener
- Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Amjad Shalabi
- Cardiovascular Institute, B Padeh Medical Center, Poriya, Israel
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
- Department of Cardiac Surgery, B Padeh Medical Center, Poriya, Israel
| | - Erez Kachel
- Cardiovascular Institute, B Padeh Medical Center, Poriya, Israel
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
- Department of Cardiac Surgery, B Padeh Medical Center, Poriya, Israel
| | - Liza Grosman-Rimon
- Cardiovascular Institute, B Padeh Medical Center, Poriya, Israel
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Michael Jerdev
- Cardiovascular Institute, B Padeh Medical Center, Poriya, Israel
| | - offer amir
- Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Cardiovascular Institute, B Padeh Medical Center, Poriya, Israel
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Shemy Carasso
- Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Cardiovascular Institute, B Padeh Medical Center, Poriya, Israel
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
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42
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Contemporary Neuroprotection Strategies during Cardiac Surgery: State of the Art Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312747. [PMID: 34886474 PMCID: PMC8657178 DOI: 10.3390/ijerph182312747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 12/30/2022]
Abstract
Open-heart surgery is the leading cause of neuronal injury in the perioperative state, with some patients complicating with cerebrovascular accidents and delirium. Neurological fallout places an immense burden on the psychological well-being of the person affected, their family, and the healthcare system. Several randomised control trials (RCTs) have attempted to identify therapeutic and interventional strategies that reduce the morbidity and mortality rate in patients that experience perioperative neurological complications. However, there is still no consensus on the best strategy that yields improved patient outcomes, such that standardised neuroprotection protocols do not exist in a significant number of anaesthesia departments. This review aims to discuss contemporary evidence for preventing and managing risk factors for neuronal injury, mechanisms of injury, and neuroprotection interventions that lead to improved patient outcomes. Furthermore, a summary of existing RCTs and large observational studies are examined to determine which strategies are supported by science and which lack definitive evidence. We have established that the overall evidence for pharmacological neuroprotection is weak. Most neuroprotective strategies are based on animal studies, which cannot be fully extrapolated to the human population, and there is still no consensus on the optimal neuroprotective strategies for patients undergoing cardiac surgery. Large multicenter studies using universal standardised neurological fallout definitions are still required to evaluate the beneficial effects of the existing neuroprotective techniques.
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43
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Vallely MP, Seco M, Ramponi F, Puskas JD. Total-arterial, anaortic, off-pump coronary artery surgery: Why, when, and how. JTCVS Tech 2021; 10:140-148. [PMID: 34977717 PMCID: PMC8691864 DOI: 10.1016/j.xjtc.2021.09.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/27/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Michael P. Vallely
- Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Michael Seco
- Department of Cardiothoracic Surgery, The Children's Hospital at Westmead, Sydney, Australia
| | - Fabio Ramponi
- Department of Cardiothoracic Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - John D. Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, NY
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Effect of routine preoperative screening for aortic calcifications using noncontrast computed tomography on stroke rate in cardiac surgery: the randomized controlled CRICKET study. Eur Radiol 2021; 32:2611-2619. [PMID: 34783875 PMCID: PMC8921026 DOI: 10.1007/s00330-021-08360-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/30/2021] [Accepted: 09/24/2021] [Indexed: 11/04/2022]
Abstract
Objectives To evaluate if routine screening for aortic calcification using unenhanced CT lowers the risk of stroke and alters the surgical approach in patients undergoing general cardiac surgery compared with standard of care (SoC). Methods In this prospective, multicenter, randomized controlled trial, adult patients scheduled for cardiac surgery from September 2014 to October 2019 were randomized 1:1 into two groups: SoC alone, including chest radiography, vs. SoC plus preoperative noncontrast CT. The primary endpoint was in-hospital perioperative stroke. Secondary endpoints were preoperative change of the surgical approach, in-hospital mortality, and postoperative delirium. The trial was halted halfway for expected futility, as the conditional power analysis showed a chance < 1% of finding the hypothesized effect. Results A total of 862 patients were evaluated (SoC-group: 433 patients (66 ± 11 years; 74.1% male) vs. SoC + CT-group: 429 patients (66 ± 10 years; 69.9% male)). The perioperative stroke rate (SoC + CT: 2.1%, 9/429 vs. SoC: 1.2%, 5/433, p = 0.27) and rate of changed surgical approach (SoC + CT: 4.0% (17/429) vs. SoC: 2.8% (12/433, p = 0.35) did not differ between groups. In-hospital mortality and postoperative delirium were comparable between groups. In the SoC + CT group, aortic calcification was observed on CT in the ascending aorta in 28% (108/380) and in the aortic arch in 70% (265/379). Conclusions Preoperative noncontrast CT in cardiac surgery candidates did not influence the surgical approach nor the incidence of perioperative stroke compared with standard of care. Aortic calcification is a frequent finding on the CT scan in these patients but results in major surgical alterations to prevent stroke in only few patients. Key Points • Aortic calcification is a frequent finding on noncontrast computed tomography prior to cardiac surgery. • Routine use of noncontrast computed tomography does not often lead to a change of the surgical approach, when compared to standard of care. • No effect was observed on perioperative stroke after cardiac surgery when using routine noncontrast computed tomography screening on top of standard of care. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-08360-4.
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Impact of Lipoprotein(a) Levels on Perioperative Outcomes in Cardiac Surgery. Cells 2021; 10:cells10112829. [PMID: 34831051 PMCID: PMC8616553 DOI: 10.3390/cells10112829] [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] [Received: 08/20/2021] [Revised: 10/08/2021] [Accepted: 10/19/2021] [Indexed: 11/17/2022] Open
Abstract
Altered lipid metabolism has been shown to be of major importance in a range of metabolic diseases, with particular importance in cardiovascular disease (CVD). As a key metabolic product, altered lipoprotein(a) (Lp(a)) levels may be associated with adverse clinical outcomes in high-risk cardiovascular patients undergoing cardiac surgery. We aimed to investigate the impact of the important metabolite Lp(a) on complications and clinical outcomes in high-risk patients. A prospective observational cohort study was performed. Data were derived from the Bern Perioperative Biobank (ClinicalTrials.gov NCT04767685), and included 192 adult patients undergoing elective cardiac surgery. Blood samples were collected at 24 h preoperatively, before induction of general anaesthesia, upon weaning from cardiopulmonary bypass (CPB), and the first morning after surgery. Clinical endpoints included stroke, myocardial infarction, and mortality within 30 days after surgery or within 1 year. Patients were grouped according to their preoperative Lp(a) levels: <30 mg/dL (n = 121; 63%) or >30 mg/dL (n = 71, 37%). The groups with increased vs. normal Lp(a) levels were comparable with regard to preoperative demographics and comorbidities. Median age was 67 years (interquartile range (IQR) 60.0, 73.0), with median body mass index (BMI) of 23.1 kg/m2 (23.7, 30.4), and the majority of patients being males (75.5%). Over the observational interval, Lp(a) levels decreased in all types of cardiac surgery after CPB (mean decline of approximately -5 mg/dL). While Lp(a) levels decreased in all patients following CPB, this observation was considerably pronounced in patients undergoing deep hypothermic circulatory arrest (DHCA) (decrease to preoperative Lp(a) levels by -35% (95% CI -68, -1.7), p = 0.039). Increased Lp(a) levels were neither associated with increased rates of perioperative stroke or major adverse events in patients undergoing cardiac surgery, nor with overall mortality in the perioperative period, or at one year after surgery. Other than for cohorts in neurology and cardiology, elevated Lp(a) might not be a risk factor for perioperative events in cardiac surgery.
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Milne B, Gilbey T, Gautel L, Kunst G. Neuromonitoring and Neurocognitive Outcomes in Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2021; 36:2098-2113. [PMID: 34420812 DOI: 10.1053/j.jvca.2021.07.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/28/2021] [Accepted: 07/15/2021] [Indexed: 12/30/2022]
Abstract
Neurocognitive dysfunction after cardiac surgery can present with diverse clinical phenotypes, which include postoperative delirium, postoperative cognitive dysfunction, and stroke, and it presents a significant healthcare burden for both patients and providers. Neurologic monitoring during cardiac surgery includes several modalities assessing cerebral perfusion and oxygenation (near-infrared spectroscopy, transcranial Doppler and jugular venous bulb saturation monitoring) and those that measure cerebral function (processed and unprocessed electroencephalogram), reflecting an absence of a single, definitive neuromonitor. This narrative review briefly describes the technologic basis of these neuromonitoring modalities, before exploring their use in clinical practice, both as tools to predict neurocognitive dysfunction, and with a bundle of interventions designed to optimize cerebral oxygen supply, with the aim of reducing postoperative delirium and cognitive dysfunction following cardiac surgery.
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Affiliation(s)
- Benjamin Milne
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Thomas Gilbey
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Livia Gautel
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, UK; School of Biological Sciences in Edinburgh, University of Edinburgh, Edinburgh, UK; School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, UK; School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK.
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Surgical Aortic Mitral Curtain Replacement: Systematic Review and Metanalysis of Early and Long-Term Results. J Clin Med 2021; 10:jcm10143163. [PMID: 34300329 PMCID: PMC8305575 DOI: 10.3390/jcm10143163] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 12/31/2022] Open
Abstract
The Commando procedure is challenging, and aims to replace the mitral valve, the aortic valve and the aortic mitral curtain, when the latter is severely affected by pathological processes (such as infective endocarditis or massive calcification). Given the high complexity, it is seldomly performed. We aim to review the literature on early (hospitalization and up to 30 days) and long-term (at least 3 years of follow-up) results. Bibliographical research was performed on PubMed and Cochrane with a dedicated string. Papers regarding double valve replacement or repair in the context of aortic mitral curtain disease were included. The metaprop function was used to assess early survival and complications (pacemaker implantation, stroke and bleeding). Nine papers (540 patients, median follow-up 41 (IQR 24.5–51.5) months) were included in the study. Pooled proportion of early mortality, stroke, pacemaker implant and REDO for bleeding were, respectively 16.2%, 7.8%, 25.1% and 13.1%. The long-term survival rate ranged from 50% to 92.2%. Freedom from re-intervention was as high as 90.9% when the endocarditis was not the first etiology and 78.6% in case of valvular infection (one author had 100%). Freedom from IE recurrences reached 85% at 10 years. Despite the high mortality, the rates of re-intervention and infective endocarditis recurrences following the Commando procedure are satisfactory and confirm the need for an aggressive strategy to improve long-term outcomes.
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Kobayashi K, Kitamura T, Kohira S, Inoue N, Fukunishi T, Miyaji K. Near-infrared spectroscopy device selection affects intervention management for cerebral desaturation during cardiopulmonary bypass surgery. Gen Thorac Cardiovasc Surg 2021; 70:11-15. [PMID: 34091814 DOI: 10.1007/s11748-021-01659-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 05/26/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Currently, several near-infrared spectroscopy oximetry devices are used for detecting cerebral ischemia during cardiopulmonary bypass (CPB) surgery. We investigated whether two different models of near-infrared spectroscopy oximetry devices affect the assessment of cerebral ischemia and its management during CPB. METHODS From January 2017 to August 2017, 70 adult cardiovascular surgery cases were randomly assigned to 1 of 2 different near-infrared spectroscopy oximetry devices. The devices were INVOS 5100C (Medtronic, Minneapolis, MN, USA) (group I; n = 35) and FORE-SIGHT ELITE (CAS Medical Systems, Branford, CT, USA) (group F; n = 35). RESULTS There were no significant differences in patient characteristics. The rSO2 values were significantly higher for patients in group F than for patients in group I. Scalp-Cortex distance showed negative correlations with the mean rSO2 values in group I (P = 0.01). Interventions for low rSO2 during CPB for groups I and F were increase perfusion flow (13:5; P = 0.03), blood transfusion (7:1; P = 0.02), and both (6:1; P = 0.04), respectively. The Scalp-Cortex distance in group I was significantly longer in patients who required intervention than in patients who did not (17.1 ± 2.5 vs 15.1 ± 1.6 mm; P = 0.007). CONCLUSIONS It is inappropriate to use the same intervention criteria for different near-infrared spectroscopy oximetry devices. Moreover, brain atrophy influence rSO2 values depending on device selection. It is important to note that inappropriate device selection may misguide perfusionists into performing unnecessary or excessive intervention during CPB.
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Affiliation(s)
- Kensuke Kobayashi
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan.
| | - Tadashi Kitamura
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan
| | - Satoshi Kohira
- Department of Medical Engineering, Kitasato University Hospital, Sagamihara, Japan
| | - Nobuyuki Inoue
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan
| | - Takuma Fukunishi
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan
| | - Kagami Miyaji
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0375, Japan
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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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Mohamed MO, Hirji S, Mohamed W, Percy E, Braidley P, Chung J, Aranki S, Mamas MA. Incidence and predictors of postoperative ischemic stroke after coronary artery bypass grafting. Int J Clin Pract 2021; 75:e14067. [PMID: 33534146 DOI: 10.1111/ijcp.14067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/26/2021] [Accepted: 01/29/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Data on the incidence and outcomes of ischemic stroke in patients undergoing coronary artery bypass grafting (CABG) in the current era are limited. The goal of this study was to examine contemporary trends, predictors, and outcomes of ischemic stroke following CABG in a large nationally representative database over a 12-year-period. METHODS The National Inpatient Sample was used to identify all adult (≥18 years) patients who underwent CABG between 2004 and 2015. The incidence and predictors of post-CABG ischemic stroke were assessed and in-hospital outcomes of patients with and without post-CABG stroke were compared. RESULTS Out of 2 569 597 CABG operations, ischemic stroke occurred in 47 279 (1.8%) patients, with a rising incidence from 2004 (1.2%) to 2015 (2.3%) (P < .001). Patient risk profiles increased over time in both cohorts, with higher Charlson comorbidity scores observed amongst stroke patients. Stroke was independently associated with higher rates of in-hospital mortality (3-fold), longer lengths of hospital stay (~6 more days), and higher total hospitalisation cost (~$80 000 more). Age ≥60 years and female sex (OR 1.33, 95% CI 1.31-1.36) were the strongest predictors of stroke (both P < .001). Further, on-pump CABG was not an independent predictor of stroke (P = .784). CONCLUSION In this nationally representative study we have shown that the rates of postoperative stroke complications following CABG have increased over time to commensurate with a parallel increase in overall baseline patient risks. Given the adverse impact of stroke on in-hospital morbidity and mortality after CABG, further studies are warranted to systematically delineate factors contributing to this striking trend.
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Affiliation(s)
- Mohamed O Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Newcastle, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Walid Mohamed
- University Hospitals of Leicester NHS Foundation Trust, Leicester, UK
| | - Edward Percy
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Joshua Chung
- Department of Cardiac Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Sary Aranki
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Newcastle, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
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