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Zhang H, Zhang D, Qu J, Wang J, Rao C, Chen S, Zhao Y, Li H, Gao G, Liu S, Qian X, Zheng Z. Association of carotid duplex ultrasonography screening with stroke and mortality among patients undergoing coronary artery bypass grafting. J Vasc Surg 2024; 80:153-162.e4. [PMID: 38460766 DOI: 10.1016/j.jvs.2024.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/25/2024] [Accepted: 02/04/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVE Selection criteria for carotid duplex ultrasonography screening (DUS) before coronary artery bypass grafting (CABG) is primarily based on limited observational analysis, and the risks associated with carotid artery stenosis (CAS) detected by this approach to preoperative DUS are uncertain. This study aimed to determine the association of carotid DUS with stroke and mortality among patients undergoing CABG. METHODS Adult patients with coronary artery disease who underwent isolated CABG or CABG with concomitant valvular or congenital procedure were identified. CHA2DS2-VASc score was assessed before CABG, and patients were recorded as high risk if they had a score of 3 or higher. The primary outcomes were stroke and all-cause mortality. Secondary outcomes included ischemic stroke, non-ischemic stroke, transient ischemic attack, and cardiovascular mortality. RESULTS Among 8958 patients who underwent CABG, 70.9% (n = 6347) received carotid DUS preoperatively (low-risk, 57.3%; high-risk, 42.7%). In the low-risk cohort, there was no significant difference in the risk of stroke (20.7 per 1000 patient-years for CAS vs 13.1 per 1000 patient-years for no CAS; adjusted hazard ratio [aHR], 1.14; 95% confidence interval [CI], 0.78-1.68) or mortality (20.5 per 1000 patient-years for CAS vs 16.8 per 1000 patient-years for no CAS; aHR, 1.33; 95% CI, 0.97-1.83) at 15 years. In the high-risk cohort, CAS was associated with significantly higher risks of stroke at 30 days (433.2 vs 279.5 per 1000 patient-years; aHR, 1.92; 95% CI, 1.00-3.70) and mortality at 15 years (38.4 vs 32.7 per 1000 patient-years; aHR, 1.25; 95% CI, 1.01-1.57) compared with no CAS. CONCLUSIONS CAS did not impact the incidence of stroke or mortality in the low-risk cohort who underwent CABG. However, in the high-risk cohort, CAS was associated with a significant increase in the risks of 30-day stroke and 15-year mortality, indicating selective carotid DUS is necessarily recommended for these patients.
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Affiliation(s)
- Heng Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Danwei Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiac Surgery, Fujian Children's Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, People's Republic of China
| | - Jianyu Qu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jingjin Wang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Chenfei Rao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Sipeng Chen
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yan Zhao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Haojie Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Ge Gao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Sheng Liu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xiangyang Qian
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
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Ju F, Yuan X, Sun H. Left atrial appendage occlusion for patients with valvular diseases without atrial fibrillation (the OPINION Study): study protocol for a multicentre, randomised controlled trial. BMJ Open 2024; 14:e076688. [PMID: 38326254 PMCID: PMC10860065 DOI: 10.1136/bmjopen-2023-076688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is a significant cause of perioperative stroke in aortic and mitral valve surgeries. Although several large studies have evaluated surgical left atrial appendage occlusion (SLAAO) during cardiac surgeries, their retrospective nature and an uncontrolled broad spectrum of conditions leave them subject to potential residual confounding. This trial aims to test the hypothesis that opportunistic SLAAO can prevent long-term stroke after cardiac surgery in patients receiving mitral or aortic valve surgeries without a history of AF and with a CHA2DS2-VASc score of 2 or higher. METHODS AND DESIGN This study is a single-blinded, multicentre, randomised controlled trial. A total of 2118 patients planning to undergo aortic or mitral surgery without AF will be recruited and equally randomised into intervention or control arms at a 1:1 ratio. In the intervention arm, suture excision of the left atrial appendage (LAA) will be performed during the operation in addition to the original surgery plan. In the control arm, the operation will be performed according to the surgery plan without any intervention on the LAA. The primary outcome is a composite of newly occurred ischaemic stroke or transient ischaemic attack and cardiovascular mortality during a 1-year follow-up. Secondary outcomes include postoperative AF, cardiovascular mortality, newly occurred ischaemic stroke, newly occurred transient ischaemic attack, newly occurred haemorrhagic stroke, bleeding events, and AF-associated health utilisation. ETHICS AND DISSEMINATION The Ethics Committee in Fuwai Hospital approved this study. Patients will give informed consent to the study. An information leaflet will be provided to participating patients to introduce the SLAAO procedure. Patients and the public will not get involved in developing the research hypothesis, study design or any other part of this protocol. We plan to publish several papers in peer-reviewed journals about the current research and these will include a description of the study's development and the main findings of the study. TRIAL REGISTRATION NUMBER ChiCTR2100042238.
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Affiliation(s)
- Fan Ju
- Department of Cardiac Surgery, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Xicheng District, Beijing, China
| | - Xin Yuan
- Department of Cardiac Surgery, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Xicheng District, Beijing, China
| | - Hansong Sun
- Department of Cardiac Surgery, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Xicheng District, Beijing, China
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Messé SR, Overbey JR, Thourani VH, Moskowitz AJ, Gelijns AC, Groh MA, Mack MJ, Ailawadi G, Furie KL, Southerland AM, James ML, Moy CS, Gupta L, Voisine P, Perrault LP, Bowdish ME, Gillinov AM, O'Gara PT, Ouzounian M, Whitson BA, Mullen JC, Miller MA, Gammie JS, Pan S, Erus G, Browndyke JN. The impact of perioperative stroke and delirium on outcomes after surgical aortic valve replacement. J Thorac Cardiovasc Surg 2024; 167:624-633.e4. [PMID: 35483981 PMCID: PMC9996687 DOI: 10.1016/j.jtcvs.2022.01.053] [Citation(s) in RCA: 2] [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: 07/14/2020] [Revised: 12/14/2021] [Accepted: 01/23/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The effects of stroke and delirium on postdischarge cognition and patient-centered health outcomes after surgical aortic valve replacement (SAVR) are not well characterized. Here, we assess the impact of postoperative stroke and delirium on these health outcomes in SAVR patients at 90 days. METHODS Patients (N = 383) undergoing SAVR (41% received concomitant coronary artery bypass graft) enrolled in a randomized trial of embolic protection devices underwent serial neurologic and delirium evaluations at postoperative days 1, 3, and 7 and magnetic resonance imaging at day 7. Outcomes included 90-day functional status, neurocognitive decline from presurgical baseline, and quality of life. RESULTS By postoperative day 7, 25 (6.6%) patients experienced clinical stroke and 103 (28.5%) manifested delirium. During index hospitalization, time to discharge was longer in patients experiencing stroke (hazard ratio, 0.62; 95% confidence interval [CI], 0.42-0.94; P = .02) and patients experiencing delirium (hazard ratio, 0.68; 95% CI, 0.54-0.86; P = .001). At day 90, patients experiencing stroke were more likely to have a modified Rankin score >2 (odds ratio [OR], 5.9; 95% CI, 1.7-20.1; P = .01), depression (OR, 5.3; 95% CI, 1.6-17.3; P = .006), a lower 12-Item Short Form Survey physical health score (adjusted mean difference -3.3 ± 1.9; P = .08), and neurocognitive decline (OR, 7.8; 95% CI, 2.3-26.4; P = .001). Delirium was associated with depression (OR, 2.2; 95% CI, 0.9-5.3; P = .08), lower 12-Item Short Form Survey physical health (adjusted mean difference -2.3 ± 1.1; P = .03), and neurocognitive decline (OR, 2.2; 95% CI, 1.2-4.0; P = .01). CONCLUSIONS Stroke and delirium occur more frequently after SAVR than is commonly recognized, and these events are associated with disability, depression, cognitive decline, and poorer quality of life at 90 days postoperatively. These findings support the need for new interventions to reduce these events and improve patient-centered outcomes.
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Affiliation(s)
- Steven R Messé
- Department of Stroke and Neurocritical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pa
| | - Jessica R Overbey
- International Center for Health Outcomes and Innovation Research (InCHOIR), The Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Vinod H Thourani
- Marcus Valve Center, Department of Cardiovascular Surgery, Piedmont Heart Institute, Atlanta, Ga
| | - Alan J Moskowitz
- International Center for Health Outcomes and Innovation Research (InCHOIR), The Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Annetine C Gelijns
- International Center for Health Outcomes and Innovation Research (InCHOIR), The Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Mark A Groh
- Asheville Heart, Mission Health and Hospitals, Asheville, NC
| | - Michael J Mack
- Cardiovascular Surgery, Baylor Scott & White Health, Plano, Tex
| | - Gorav Ailawadi
- Departments of Cardiac Surgery and Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Karen L Furie
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI
| | - Andrew M Southerland
- Division of Vascular Neurology, University of Virginia Health System, Charlottesville, Va
| | - Michael L James
- Department of Anesthesiology, Duke University Medical Center, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC
| | - Claudia Scala Moy
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Md
| | - Lopa Gupta
- International Center for Health Outcomes and Innovation Research (InCHOIR), The Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Pierre Voisine
- Department of Surgery, Institut de Cardiologie et Pneumologie de Québec, Québec, Canada
| | | | - Michael E Bowdish
- Surgery and Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Patrick T O'Gara
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass
| | - Maral Ouzounian
- Division of Cardiac Surgery, Department of Surgery, Peter Munk Cardiac Centre, UHN-Toronto General Hospital, Toronto, Ontario, Canada
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University, Columbus, Ohio
| | - John C Mullen
- Division of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Marissa A Miller
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - James S Gammie
- Department of Cardiac Surgery, Johns Hopkins Heart and Vascular Institute, Baltimore, Md
| | - Stephanie Pan
- International Center for Health Outcomes and Innovation Research (InCHOIR), The Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Guray Erus
- Department of Radiology, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pa
| | - Jeffrey N Browndyke
- Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC
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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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5
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Long term outcomes of percutaneous coronary intervention vs coronary artery bypass grafting in patients with diabetes mellitus with multi vessels diseases: A meta-analysis. IJC HEART & VASCULATURE 2023; 46:101185. [DOI: 10.1016/j.ijcha.2023.101185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 01/25/2023] [Accepted: 02/05/2023] [Indexed: 02/27/2023]
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Moscarelli M, Paparella D, Angelini GD, Giannini F, Contegiacomo G, Marchese A, Nasso G, Albertini A, Fattouch K, Speziale G. The influence of metabolic syndrome in heart valve intervention. A multi-centric study. J Card Surg 2022; 37:5063-5072. [PMID: 36413686 DOI: 10.1111/jocs.17204] [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: 09/14/2022] [Accepted: 10/29/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND The effect of metabolic syndrome (MetS), defined as insulin resistance along with two or more of: obesity, atherogenic dyslipidaemia and elevated blood pressure, on postoperative complications after isolated heart valve intervention remains controversial. We hypothesized that MetS may negatively influence the postoperative course in these patients. METHODS Patients from 10 cardiac units who underwent isolated valve intervention (mitral± $\pm $ tricuspid repair/replacement (mitral valve surgery [MVS]) or surgical aortic valve replacement (SAVR), or transcatheter aortic valve replacement (TAVR) were included. MetS was defined according to the World Health Organization criteria. Primary outcome was in-hospital mortality and overall postoperative length of stay (LOS). Relevant postoperative complications were also recorded. RESULTS From 2010 to 2019, 17,283 patients underwent valve intervention. The MVS, SVAR, and TAVR accounted for the 39.4%, 48.2%, and 12.3% respectively of the whole. MetS compared to no-MetS was associated to higher mortality in the MVS group (6.5% vs. 2%, p < .001), but not in the SAVR and TAVR group. In both surgical cohorts, MetS was associated with increased complications including red blood cells transfusion, renal failure, mechanical ventilation time, intensive care and overall postoperative LOS (11 (9) vs. 10 (6), p < .001 and 10 (6) versus 10 (5) days, p = .002, MVS and [SAVR]). No differences were found in the TAVR cohort, with similar mortality and complications. CONCLUSION MetS was associated to more postoperative complications, with higher mortality in the MVS group. In the TAVR cohort, postoperative complications and mortality rate did not differ between patients with and without MetS, however LOS was longer in the MetS group.
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Affiliation(s)
- Marco Moscarelli
- Department of Cardiovascular Surgery, GVM Care & Research, Anthea Hospital, Bari, Italy
| | - Domenico Paparella
- Department of Cardiovascular Surgery, GVM Care & Research, Santa Maria Hospital, Bari, Italy
| | | | - Francesco Giannini
- Department of Cardiovascular Surgery, GVM Care & Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | - Gaetano Contegiacomo
- Department of Cardiovascular Surgery, GVM Care & Research, Anthea Hospital, Bari, Italy
| | - Alfredo Marchese
- Department of Cardiovascular Surgery, GVM Care & Research, Santa Maria Hospital, Bari, Italy
| | - Giuseppe Nasso
- Department of Cardiovascular Surgery, GVM Care & Research, Anthea Hospital, Bari, Italy
| | - Alberto Albertini
- Department of Cardiovascular Surgery, GVM Care & Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | - Khalil Fattouch
- Department of Cardiovascular Surgery, GVM Care & Research, Maria Eleonora Hospital, Palermo, Italy
| | - Giuseppe Speziale
- Department of Cardiovascular Surgery, GVM Care & Research, Anthea Hospital, Bari, Italy
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LaPiano JB, Arnott SM, Napolitano MA, Holleran TJ, Sparks AD, Antevil JL, Trachiotis GD. Risk factors for cerebrovascular accident after isolated coronary artery bypass grafting in Veterans. J Card Surg 2022; 37:3084-3090. [PMID: 35822719 DOI: 10.1111/jocs.16751] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/20/2022] [Accepted: 06/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cerebrovascular accident (CVA) after coronary artery bypass grafting (CABG) is a devastating complication. Patient comorbidities and intraoperative elements contribute to the risk of CVA. The aim of this study is to identify risk factors for CVA in Veterans undergoing CABG. METHODS Veterans undergoing isolated CABG from 2008 to 2019 were retrospectively identified using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Thirty-day postoperative outcomes were observed. Univariate analysis followed by multivariable logistic regression identified independent risk factors for postoperative CVA. Receiver operating characteristic diagnostics identified optimal inflection points between continuous risk factors and odds of CVA. RESULTS Twenty-eight thousand seven hundred fifty-seven patients met inclusion criteria. Incidence of CVA was 1.1% (310 cases). In multivariate analysis, preoperative cerebrovascular disease had the strongest association with postoperative CVA (adjusted odds ratio = 2.29; p < .001). There was an inverse relationship between CVA incidence and ejection fraction (EF), with EF of 35%-39% conferring a 2.11 times higher risk compared to EF >55% (p < .001). CVA incidence was not different in on-pump versus off-pump cases; however, after 104 min or more on bypass patients had a 55% greater adjusted odds of CVA (p < .001). Other risk factors included poor kidney function, prior myocardial infarction, and intra-aortic balloon pump use. CONCLUSION The risk of CVA after CABG is multifactorial and involves multiple organ systems, including cardiac disease, poor renal function, and cerebrovascular disease, which was the strongest contributing risk factor. Optimization of these comorbidities and time on bypass may help improve clinical outcomes and lower the risk of this devastating complication.
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Affiliation(s)
- Jessica B LaPiano
- Division of Cardiothoracic Surgery and Heart Center, Washington D. C. Veterans Affairs Medical Center and Heart Center, Washington, District of Columbia, USA.,Department of Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Suzanne M Arnott
- Division of Cardiothoracic Surgery and Heart Center, Washington D. C. Veterans Affairs Medical Center and Heart Center, Washington, District of Columbia, USA.,Department of Surgery, George Washington University, Washington, District of Columbia, USA
| | - Michael A Napolitano
- Division of Cardiothoracic Surgery and Heart Center, Washington D. C. Veterans Affairs Medical Center and Heart Center, Washington, District of Columbia, USA.,Department of Surgery, George Washington University, Washington, District of Columbia, USA
| | - Timothy J Holleran
- Division of Cardiothoracic Surgery and Heart Center, Washington D. C. Veterans Affairs Medical Center and Heart Center, Washington, District of Columbia, USA.,Department of Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Andrew D Sparks
- Department of Statistics, George Washington University, Washington, District of Columbia, USA
| | - Jared L Antevil
- Division of Cardiothoracic Surgery and Heart Center, Washington D. C. Veterans Affairs Medical Center and Heart Center, Washington, District of Columbia, USA
| | - Gregory D Trachiotis
- Division of Cardiothoracic Surgery and Heart Center, Washington D. C. Veterans Affairs Medical Center and Heart Center, Washington, District of Columbia, USA.,Department of Surgery, George Washington University, Washington, District of Columbia, USA
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Antithrombotic Therapy in Elderly Patients with Acute Coronary Syndromes. J Clin Med 2022; 11:jcm11113008. [PMID: 35683397 PMCID: PMC9181473 DOI: 10.3390/jcm11113008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/27/2022] [Accepted: 05/10/2022] [Indexed: 02/06/2023] Open
Abstract
The treatment of acute coronary syndrome (ACS) in elderly patients continues to be a challenge because of the characteS.G.B.ristics of this population and the lack of data and specific recommendations. This review summarizes the current evidence about critical points of oral antithrombotic therapy in elderly patients. To this end, we discuss the peculiarities and differences reported referring to dual antiplatelet therapy (DAPT) in ACS management in elderly patients and what might be the best option considering these population characteristics. Furthermore, we analyze antithrombotic strategies in patients with atrial fibrillation (AF), with a particular focus on those cases that also present coronary artery disease (CAD). It is imperative to deepen our knowledge regarding the management of these challenging patients through real-world data and specifically designed geriatric studies to help resolve the questions remaining in their disease management.
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An J, Zhao L, Duan R, Sun K, Lu W, Yang J, Liang Y, Liu J, Zhang Z, Li L, Shi J. Potential nanotherapeutic strategies for perioperative stroke. CNS Neurosci Ther 2022; 28:510-520. [PMID: 35243774 PMCID: PMC8928924 DOI: 10.1111/cns.13819] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 01/24/2022] [Accepted: 02/04/2022] [Indexed: 12/12/2022] Open
Abstract
AIMS Based on the complex pathological environment of perioperative stroke, the development of targeted therapeutic strategies is important to control the development of perioperative stroke. DISCUSSIONS Recently, great progress has been made in nanotechnology, and nanodrug delivery systems have been developed for the treatment of ischemic stroke. CONCLUSION In this review, the pathological processes and mechanisms of ischemic stroke during perioperative stroke onset were systematically sorted. As a potential treatment strategy for perioperative stroke, the review also summarizes the multifunctional nanodelivery systems based on ischemic stroke, thus providing insight into the nanotherapeutic strategies for perioperative stroke.
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Affiliation(s)
- Jingyi An
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China.,Key Laboratory of Targeting Therapy and Diagnosis for Critical Diseases, Zhengzhou, China.,Key Laboratories of the Ministry of Education, Zhengzhou University, Zhengzhou, China
| | - Ling Zhao
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Ranran Duan
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ke Sun
- Department of Urinary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wenxin Lu
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Jiali Yang
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Yan Liang
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China
| | - Junjie Liu
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China.,Key Laboratory of Targeting Therapy and Diagnosis for Critical Diseases, Zhengzhou, China.,Key Laboratories of the Ministry of Education, Zhengzhou University, Zhengzhou, China
| | - Zhenzhong Zhang
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China.,Key Laboratory of Targeting Therapy and Diagnosis for Critical Diseases, Zhengzhou, China.,Key Laboratories of the Ministry of Education, Zhengzhou University, Zhengzhou, China
| | - Li Li
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jinjin Shi
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, China.,Key Laboratory of Targeting Therapy and Diagnosis for Critical Diseases, Zhengzhou, China.,Key Laboratories of the Ministry of Education, Zhengzhou University, Zhengzhou, China
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Machado RJ, Saraiva FA, Mancio J, Sousa P, Cerqueira RJ, Barros AS, Lourenço AP, Leite-Moreira AF. A systematic review and meta-analysis of randomized controlled studies comparing off-pump versus on-pump coronary artery bypass grafting in the elderly. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 63:60-68. [PMID: 34792312 DOI: 10.23736/s0021-9509.21.12012-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIM Comparison of short and mid-term outcomes between off-pump CABG (OPCAB) and on-pump CABG (ONCAB) in patients older than 65 throughout a meta-analysis of randomized clinical trials (RCTs). EVIDENCE ACQUISITION A literature search was conducted using 3 databases. RCTs reporting mortality outcomes of OPCAB versus ONCAB among the elderly were included. Data on myocardial infarction, stroke, re-revascularization, renal failure and composite endpoints after CABG were also collected. Random effects models were used to compute statistical combined measures and 95% confidence intervals (CI). EVIDENCE SYNTHESIS Five RCTs encompassing 6221 patients were included (3105 OPCAB and 3116 ONCAB). There were no significant differences on mid-term mortality (pooled HR: 1.02, 95%CI: 0.89-1.17, p=0.80) and composite endpoint incidence (pooled HR: 0.98, 95%CI: 0.88-1.09, p=0.72) between OPCAB and ONCAB. At 30-day, there were no differences in mortality, myocardial infarction, stroke and renal complications. The need for early re-revascularization was significantly higher in OPCAB (pooled OR: 3.22, 95%CI: 1.28-8.09, p=0.01), with a higher percentage of incomplete revascularization being reported for OPCAB in trials included in this pooled result (34% in OPCAB vs 29% in ONCAB, p<0.01). CONCLUSIONS Data from RCTs in elderly patients showed that OPCAB and ONCAB provide similar mid-term results. OPCAB was associated with a higher risk of early rerevascularization. As CABG on the elderly is still insufficiently explored, further RCTs, specifically designed targeting this population, are needed to establish a better CABG strategy for these patients.
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Affiliation(s)
- Rui J Machado
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Francisca A Saraiva
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jennifer Mancio
- Intensive Care and Perioperative Medicine Department, Royal Brompton and Harefield & Guys and St. Thomas NHS Foundation Trust, London, UK
| | - Patrícia Sousa
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rui J Cerqueira
- Cardiothoracic Surgery Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - António S Barros
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - André P Lourenço
- Anaesthesiology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Adelino F Leite-Moreira
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal - .,Cardiothoracic Surgery Department, Centro Hospitalar Universitário São João, Porto, Portugal
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11
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Wiberg S, Kjaergaard J, Møgelvang R, Møller CH, Kandler K, Ravn H, Hassager C, Køber L, Nilsson JC. Efficacy of a glucagon-like peptide-1 agonist and restrictive versus liberal oxygen supply in patients undergoing coronary artery bypass grafting or aortic valve replacement: study protocol for a 2-by-2 factorial designed, randomised clinical trial. BMJ Open 2021; 11:e052340. [PMID: 34740932 PMCID: PMC8573662 DOI: 10.1136/bmjopen-2021-052340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) are associated with risk of death, as well as brain, heart and kidney injury. Glucagon-like peptide-1 (GLP-1) analogues are approved for treatment of type 2 diabetes, and GLP-1 analogues have been suggested to have potential organ-protective and anti-inflammatory effects. During cardiopulmonary bypass (CPB), consensus on the optimal fraction of oxygen is lacking. The objective of this study is to determine the efficacy of the GLP-1-analogue exenatide versus placebo and restrictive oxygenation (50% fractional inspired oxygen, FiO2) versus liberal oxygenation (100% FiO2) in patients undergoing open heart surgery. METHODS AND ANALYSIS A randomised, placebo-controlled, double blind (for the exenatide intervention)/single blind (for the oxygenation strategy), 2×2 factorial designed single-centre trial on adult patients undergoing elective or subacute CABG and/or surgical AVR. Patients will be randomised in a 1:1 and 1:1 ratio to a 6-hour and 15 min infusion of 17.4 µg of exenatide or placebo during CPB and to a FiO2 of 50% or 100% during and after weaning from CPB. Patients will be followed until 12 months after inclusion of the last participant. The primary composite endpoint consists of time to first event of death, renal failure requiring renal replacement therapy, hospitalisation for stroke or heart failure. In addition, the trial will include predefined sub-studies applying more advanced measures of cardiac- and pulmonary dysfunction, renal dysfunction and cerebral dysfunction. The trial is event driven and aims at 323 primary endpoints with a projected inclusion of 1400 patients. ETHICS AND DISSEMINATION Eligible patients will provide informed, written consent prior to randomisation. The trial is approved by the local ethics committee and is conducted in accordance with Danish legislation and the Declaration of Helsinki. The results will be presented in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02673931.
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Affiliation(s)
| | | | | | | | - Kristian Kandler
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Hanne Ravn
- Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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12
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Wang KKP, Liu W, Chew STH, Ti LK, Shen L. New-Onset Atrial Fibrillation After Cardiac Surgery is a Significant Risk Factor for Long-Term Stroke: An Eight-Year Prospective Cohort Study. J Cardiothorac Vasc Anesth 2021; 35:3559-3564. [PMID: 34330576 DOI: 10.1053/j.jvca.2021.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/19/2021] [Accepted: 07/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study sought to determine the incidence and significance of new-onset atrial fibrillation as a risk factor for long-term stroke and mortality after cardiac surgery. DESIGN A prospective cohort study. SETTING Two large tertiary public hospitals. PARTICIPANTS The study comprised 3008 patients who underwent coronary artery bypass grafting and/or valve surgery from 2008 to 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS New-onset atrial fibrillation was analyzed as a risk factor for postoperative stroke using a multivariate logistic regression model after adjustment for potential confounders. A Cox regression model with time-dependent variables was used to analyze relationships between new-onset atrial fibrillation and postoperative survival. New-onset atrial fibrillation was detected in 573 (19.0%) patients. Stroke occurred in 234 (7.8%) patients during the mean postoperative follow-up period of six ± two years. The incidence of postoperative stroke in patients with new-onset atrial fibrillation (9.9%) and patients with both preoperative and postoperative atrial fibrillation (13.8%) was higher than in patients with no atrial fibrillation (6.8%) (p = 0.002). New-onset atrial fibrillation (odds ratio, 1.53; 95% confidence interval [CI], 1.08-2.18; p = 0.017) was identified as an independent risk factor for postoperative stroke. A total of 518 (17.2%) mortalities occurred within the mean postoperative follow-up period of eight ± two years. New-onset atrial fibrillation was associated with shorter survival (hazard ratio, 1.49; 95% CI, 1.22-1.81; p < 0.001) compared with patients with no atrial fibrillation. CONCLUSIONS New-onset atrial fibrillation is a significant risk factor for long-term stroke and mortality after cardiac surgery. Close monitoring and treatment of this condition may be necessary to reduce the risk of postoperative stroke and mortality.
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Affiliation(s)
- Kevin K P Wang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Weiling Liu
- Department of Anesthesia, National University Health System, Singapore
| | - Sophia T H Chew
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore
| | - Lian Kah Ti
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Anesthesia, National University Health System, Singapore.
| | - Liang Shen
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Preoperative stroke before cardiac surgery does not increase risk of postoperative stroke. Sci Rep 2021; 11:9025. [PMID: 33907259 PMCID: PMC8079406 DOI: 10.1038/s41598-021-88441-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 04/05/2021] [Indexed: 01/04/2023] Open
Abstract
The optimal time when surgery can be safely performed after stroke is unknown. The purpose of this study was to investigate how cardiac surgery timing after stroke impacts postoperative outcomes between 2011–2017 were reviewed. Variables were extracted from the institutional Society of Thoracic Surgeons database, statewide patient registry, and medical records. Subjects were classified based upon presence of endocarditis and further grouped by timing of preoperative stroke relative to cardiac surgery: Recent (stroke within two weeks before surgery), Intermediate (between two and six weeks before), and Remote (greater than six weeks before). Postoperative outcomes were compared amongst groups. 157 patients were included: 54 in endocarditis and 103 in non-endocarditis, with 47 in Recent, 26 in Intermediate, and 84 in Remote. 30-day mortality and postoperative stroke rate were similar across the three subgroups for both endocarditis and non-endocarditis. Of patients with postoperative stroke, mortality was 30% (95% CI 4.6–66). Timing of cardiac surgery after stroke occurrence does not seem to affect postoperative stroke or mortality. If postoperative stroke does occur, subsequent stroke-related mortality is high.
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14
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Atiya M, Schorr E, Stein LK, Dhamoon AS, Dhamoon MS. Sex Differences in Ischemic Stroke Readmission Rates and Subsequent Outcomes After Coronary Artery Bypass Graft Surgery. J Stroke Cerebrovasc Dis 2021; 30:105659. [PMID: 33621823 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND PURPOSE Prior studies examining sex-related risk of readmission for ischemic stroke (IS) after coronary artery bypass grafting (CABG) did not adjust for preoperative comorbidities and used small study samples that were single-center or otherwise poorly generalizable. We assessed risk of readmission for IS after CABG for females compared to males in a nationwide sample. METHODS The 2013 Nationwide Readmissions Database contains data on 49% of all U.S. hospitalizations. We used population weighting to determine national estimates. Using all follow-up data up to 1 year after discharge from CABG hospitalization, we estimated Kaplan-Meier cumulative risk of IS, stratified by sex, using the log-rank test for significance. We created Cox proportional hazard models to calculate hazard ratios (HR) and 95% confidence intervals (CI) for IS readmission, with sex as the main independent variable. We ran unadjusted models and models adjusted for age, vascular risk factors, estimated severity of illness and risk of mortality, hospital characteristics, and income quartile of patient's zip code. RESULTS An estimated 53,270 females and 147,396 males survived index CABG admission in 2013. There was a consistently elevated cumulative risk of readmission for IS after CABG for females versus males (log-rank p-value = 0.0014). In the unadjusted Cox model, the HR of IS in females vs. males was 1.35 (95% CI 1.12-1.62, p = 0.0015). The elevated risk for females remained after adjusting for severity of illness (1.30 [1.08-1.56], p = 0.0056) and risk of mortality (1.28 [1.07-1.54], p = 0.0086). This elevated risk persisted after adjusting for multiple vascular risk factors, hospital characteristics, and income quartile of patient's zip code (1.23 [1.02-1.48], p = 0.03). CONCLUSIONS We found a 23% increased risk of readmission for IS up to 1 year after CABG for females compared to males in a fully adjusted model utilizing a large, contemporary, nationwide database. Further research would clarify mechanisms of this increased risk among women.
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Affiliation(s)
- Marianna Atiya
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emily Schorr
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laura K Stein
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amit S Dhamoon
- Department of Medicine, Upstate Medical Center, Syracuse, NY, USA
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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15
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Hasan F, Gordon C, Wu D, Huang HC, Yuliana LT, Susatia B, Marta OFD, Chiu HY. Dynamic Prevalence of Sleep Disorders Following Stroke or Transient Ischemic Attack: Systematic Review and Meta-Analysis. Stroke 2021; 52:655-663. [PMID: 33406871 DOI: 10.1161/strokeaha.120.029847] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The exact prevalence of sleep disorders following stroke or transient ischemic attack (TIA) remains unclear. We aimed to determine the prevalence of sleep-disordered breathing, insomnia, periodic leg movement during sleep, and restless leg syndrome following stroke or TIA in acute, subacute, and chronic phases and examine the moderating effects of patient characteristics (eg, age) and methodological features (eg, study quality) on the prevalence. METHODS We performed a systematic review and meta-analysis. Embase and PubMed were searched from inception to December 18, 2019. We included 64 047 adults in 169 studies (prospective, retrospective, case-control, and cross-sectional study designs) reporting the prevalence of sleep disorders following stroke or TIA. RESULTS In the acute phase, the overall prevalence of mild, moderate, and severe sleep-disordered breathing was 66.8%, 50.3%, and 31.6% (95% CIs, 63.8-69.7, 41.9-58.7, and 24.9-39.1). In the subacute phase, the prevalence of mild, moderate, and severe sleep-disordered breathing was 65.5%, 44.3%, and 36.1% (95% CIs, 58.9-71.5, 36.1-52.8, and 22.2-52.8). In the chronic phase, the summary prevalence of mild, moderate, and severe sleep-disordered breathing was 66.2%, 33.1%, and 25.1% (95% CIs, 58.6-73.1, 24.8-42.6, and 10.9-47.6). The prevalence rates of insomnia in the acute, subacute, and chronic phases were 40.7%, 42.6%, and 35.9% (95% CIs, 31.8-50.3, 31.7-54.1, and 28.6-44.0). The pooled prevalence of periodic leg movement during sleep in the acute, subacute, and chronic phases was 32.0%, 27.3%, and 48.2% (95% CIs, 7.4-73.5, 11.6-51.7, and 33.1-63.5). The summary prevalence of restless leg syndrome in the acute and chronic phases was 10.4% and 13.7% (95 CIs, 6.4-16.4 and 2.3-51.8). Age, sex, comorbidities, smoking history, and study region had significant moderating effects on the prevalence of sleep disorders. CONCLUSIONS Sleep disorders following stroke or TIA are highly prevalent over time. Our findings indicate the importance of early screening and treating sleep disorders following stroke or TIA.
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Affiliation(s)
- Faizul Hasan
- School of Nursing, College of Nursing (F.H., H.-C.H., O.F.D.M., H.-Y.C.), Taipei Medical University, Taiwan.,School of Nursing (F.H., B.S.), Politeknik Kesehatan Kemenkes Malang, Indonesia
| | - Christopher Gordon
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of Sydney, Australia (C.G.)
| | - Dean Wu
- Department of Neurology, School of Medicine, College of Medicine (D.W.), Taipei Medical University, Taiwan.,Department of Neurology, Shuang-Ho Hospital (D.W.), Taipei Medical University, Taiwan.,Research Center of Sleep Medicine, College of Medicine (D.W., H.-Y.C.), Taipei Medical University, Taiwan
| | - Hui-Chuan Huang
- School of Nursing, College of Nursing (F.H., H.-C.H., O.F.D.M., H.-Y.C.), Taipei Medical University, Taiwan
| | | | - Budi Susatia
- School of Nursing (F.H., B.S.), Politeknik Kesehatan Kemenkes Malang, Indonesia
| | - Ollyvia Freeska Dwi Marta
- School of Nursing, College of Nursing (F.H., H.-C.H., O.F.D.M., H.-Y.C.), Taipei Medical University, Taiwan.,Nursing Department, Faculty of Health Science, University of Muhammadiyah Malang, Indonesia (O.F.D.M.)
| | - Hsiao-Yean Chiu
- School of Nursing, College of Nursing (F.H., H.-C.H., O.F.D.M., H.-Y.C.), Taipei Medical University, Taiwan.,Research Center of Sleep Medicine, College of Medicine (D.W., H.-Y.C.), Taipei Medical University, Taiwan
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16
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Zhao H, Guo F, Xu J, Zhu Y, Wen D, Duan W, Zheng M. Preoperative Imaging Risk Findings for Postoperative New Stroke in Patients With Acute Type A Aortic Dissection. Front Cardiovasc Med 2020; 7:602610. [PMID: 33330666 PMCID: PMC7734126 DOI: 10.3389/fcvm.2020.602610] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/09/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Stroke is a common postoperative complication in patients with acute type A aortic dissection (ATAAD). We aimed to explore the preoperative imaging risk findings for postoperative new stroke in patients with ATAAD. Methods: From January 2015 to December 2018, 174 patients with ATAAD who underwent preoperative aortic computed tomography angiography (CTA) and cerebral diffusion-weighted imaging (DWI) as well as postoperative brain CT were included, and divided into DWI (+) and DWI (–) groups. Pre- and intraoperative variables were collected, and logistic regression analysis was used to determine the independent risk predictors of postoperative new stroke. Results: The incidence of postoperative new stroke was 18.4% (32/174) in patients with ATAAD. Postoperative stroke was detected in 13 (31.0%) patients in the DWI (+) group and in 19 (14.4%) patients in the DWI (–) group with significant difference (P = 0.016). In the DWI (+) group, the lesions of the cerebral infarction located in the unilateral cerebral hemisphere and distributed more than three lobes (P = 0.007) were an independent risk factor for postoperative new stroke. Hypotension (P = 0.002), retrograde ascending aorta dissection with thrombosis of the false lumen (P = 0.010), aortic arch entry (P = 0.035), and coronary artery involvement (P = 0.001) were independent risk factors for postoperative stroke in the DWI (–) cohort. Conclusions: Patients with ATAAD with cerebral infarction are more likely to develop postoperative new stroke; thus, a preoperative DWI examination may be necessary. DWI lesions distributed more than 3 lobes in the unilateral hemisphere suggest a high possibility of postoperative stroke. For patients with ATAAD with normal brain, particular attention should be given to the CTA findings of false lumen thrombosis, aortic arch entry, and coronary artery involvement to avoid postoperative stroke.
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Affiliation(s)
- Hongliang Zhao
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fan Guo
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jingji Xu
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yuanqiang Zhu
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Didi Wen
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Weixun Duan
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Minwen Zheng
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Amundson B, Hormes J, Katema A, Rathakrishnan P, Edwards JK, Esper G, Binongo J, Lasanajak Y, Keeling B, Halkos M, Nahab F. Timing of Recognition for Perioperative Strokes Following Cardiac Surgery. J Stroke Cerebrovasc Dis 2020; 29:105336. [PMID: 33007681 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105336] [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: 05/24/2020] [Revised: 08/16/2020] [Accepted: 09/14/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION More than half of reported perioperative strokes following cardiac surgery are identified beyond postoperative day one. The objective of our study was to determine preoperative and intraoperative factors that are associated with stroke following cardiac surgery and to identify factors that may contribute delayed recognition of perioperative stroke. METHODS Patients undergoing coronary artery bypass surgery or isolated valve surgery from January 2, 2015 to April 28, 2017 at an academic health system were identified from the Society of Thoracic Surgeons Registry. We determined preoperative and intraoperative factors associated with perioperative stroke. Two neurologists performed retrospective chart reviews on perioperative stroke patients to determine the last seen well time and the stroke cause. RESULTS During the study period, 2795 patients underwent coronary artery bypass surgery or isolated valve surgery (mean age 64 ± 11 years, 71% male, 72% Caucasian, 9% history of stroke), of which 43 (1.5%) had a perioperative stroke; 31 (72%) patients had an embolic mechanism of stroke based on neuroimaging. In multivariable analysis, perioperative strokes were independently associated with increasing age (OR 1.04, 95% 1.01-1.07), history of stroke (OR 2.73, 95% CI 1.47-5.06), and history of thoracic aorta disease (OR 3.36, 95% CI 1.16-9.71). Strokes were identified after postoperative day one in 32 (74%) patients of which 26 (81%) had a preoperative last seen well time. CONCLUSION Given the high frequency of preoperative last seen well time in perioperative stroke patients who are identified after postoperative day one, delayed stroke recognition may contribute to the bimodal distribution in timing of perioperative stroke. Frequent neurological monitoring within 24 hours after CABG or isolated valve surgery should be considered for all patients undergoing cardiac surgery, particularly elderly patients and those with a history of stroke or thoracic aorta disease, to improve early stroke recognition.
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Affiliation(s)
- Beret Amundson
- Emory University School of Medicine, Atlanta, GA, United States
| | - Joseph Hormes
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Anna Katema
- Department of Neurology, Emory University, Atlanta, GA, United States
| | | | - J Kirk Edwards
- Department of Anesthesiology, Emory University, Atlanta, GA, United States
| | - Gregory Esper
- Department of Neurology, Emory University, Atlanta, GA, United States
| | - Jose Binongo
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, United States
| | - Yi Lasanajak
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, United States
| | - Brent Keeling
- Department of Surgery, Emory University, Atlanta, GA, United States
| | - Michael Halkos
- Department of Surgery, Emory University, Atlanta, GA, United States
| | - Fadi Nahab
- Department of Neurology & Pediatrics, Emory University, 1365 Clifton Road, Clinic B, Suite 2200, Atlanta, GA 30322, United States.
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18
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Micali LR, Bonacchi M, Weigel D, Howe R, Parise O, Parise G, Gelsomino S. The use of both internal thoracic arteries for coronary revascularization increases the estimate of post-operative lower limb ischemia in patients with peripheral artery disease. J Cardiothorac Surg 2020; 15:266. [PMID: 32977844 PMCID: PMC7519572 DOI: 10.1186/s13019-020-01315-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/21/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patients with a history of peripheral arterial disease (PAD) undergoing coronary artery bypass grafting (CABG) exhibit higher rates of complications. There are conflicting data on the survival benefits for bilateral thoracic artery (BITA) grafting compared with left internal thoracic artery (LITA) CABG in patients with PAD. The aim of the study was to explore the influence of the use of BITA grafts vs. LITA for CABG on post-operative acute lower limb ischemia (ALLI) and main post-operative complications in patients with concomitant PAD. METHODS We used a propensity-score (PS) based analysis to compare outcomes between the two surgical procedures, BITA and LITA. The inverse probability of treatment weighting PS technique was applied to adjust for pre- and intra-operative confounders, and to get optimal balancing of the pre-operative data. The primary outcome was the estimate of postoperative ALLI. Secondary outcomes included overall death and death of cardiac causes within 30 days of surgery, stroke and acute kidney disease (AKD). RESULTS The study population consisted of 1961 patients. The LITA procedure was performed in 1768 patients whereas 193 patients underwent a BITA technique. The estimate of ALLI was 14% higher in the BITA compared to the LITA (p < 0.001) group. Thirty-day mortality, cardiac death, occurrence of stroke and AKI did not differ significantly between the groups. CONCLUSIONS The use of both ITAs led to a significant increase in ALLI. This result was most likely caused by the complete disruption of the ITA collateral providing additional blood supply to the lower extremities. Based on our data, BITA should be used with extreme caution in PAD patients. Further research on this topic is necessary to confirm our findings.
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Affiliation(s)
- Linda Renata Micali
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, 6229, ER, Maastricht, The Netherlands
| | - Massimo Bonacchi
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, 6229, ER, Maastricht, The Netherlands
- Careggi Hospital, Florence, Italy
| | - Daniel Weigel
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, 6229, ER, Maastricht, The Netherlands
| | - Rosie Howe
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, 6229, ER, Maastricht, The Netherlands
| | - Orlando Parise
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, 6229, ER, Maastricht, The Netherlands
| | - Gianmarco Parise
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, 6229, ER, Maastricht, The Netherlands
| | - Sandro Gelsomino
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht - CARIM, Maastricht University Medical Center, 6229, ER, Maastricht, The Netherlands.
- Careggi Hospital, Florence, Italy.
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19
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Independent Predictors of Perioperative Stroke-Related Mortality after Cardiac Surgery. J Stroke Cerebrovasc Dis 2020; 29:104711. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.104711] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/24/2020] [Accepted: 01/26/2020] [Indexed: 11/18/2022] Open
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Synchronous Carotid Endarterectomy and Coronary Artery Bypass Graft versus Staged Carotid Artery Stenting and Coronary Artery Bypass Graft for Patients with Concomitant Severe Coronary and Carotid Stenosis: A Systematic Review and Meta-analysis. Ann Vasc Surg 2020; 62:463-473.e4. [DOI: 10.1016/j.avsg.2019.06.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 06/02/2019] [Accepted: 06/05/2019] [Indexed: 11/18/2022]
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Jayaraman DK, Mehla S, Joshi S, Rajasekaran D, Goddeau RP. Update in the Evaluation and Management of Perioperative Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:76. [DOI: 10.1007/s11936-019-0779-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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22
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Diamond J, Madhavan MV, Sabik JF, Serruys PW, Kappetein AP, Leon MB, Taggart DP, Berland J, Morice MC, Gersh BJ, Kandzari DE, Dressler O, Stone GW. Left Main Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Prior Cerebrovascular Disease: Results From the EXCEL Trial. JACC Cardiovasc Interv 2019; 11:2441-2450. [PMID: 30573053 DOI: 10.1016/j.jcin.2018.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/13/2018] [Accepted: 09/04/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVES The aim of this study was to determine whether high-risk patients with left main coronary artery disease (LMCAD) and prior cerebrovascular disease (CEVD) preferentially benefit from revascularization by percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG). BACKGROUND Patients with known CEVD requiring revascularization are often referred to PCI rather than CABG. There is a paucity of data regarding the impact of CEVD in patients with LMCAD undergoing revascularization. METHODS In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, patients with LMCAD and low or intermediate SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) scores were randomized to PCI with everolimus-eluting stents versus CABG. The effects of prior CEVD, defined as prior stroke, transient ischemic attack, or carotid artery disease, on 30-day and 3-year event rates were assessed. RESULTS Prior CEVD was present in 233 of 1,898 patients (12.3%). These patients were older and had higher rates of comorbidities, including hypertension, diabetes, peripheral vascular disease, anemia, chronic kidney disease, and prior PCI, compared with those without prior CEVD. Patients with prior CEVD had higher rates of stroke at 30 days (2.2% vs. 0.8%; p = 0.05) and 3 years (6.4% vs. 2.2%; p = 0.0003) and higher 3-year rates of the primary endpoint of all-cause death, stroke, or myocardial infarction (25.0% vs. 13.6%; p < 0.0001). The relative effects of PCI versus CABG on the 30-day and 3-year rates of stroke (pinteraction = 0.65 and 0.16, respectively) and the 3-year rates of the primary composite endpoint (pinteraction = 0.14) were consistent in patients with and those without prior CEVD. CONCLUSIONS Patients with LMCAD and prior CEVD compared with those without CEVD have higher rates of stroke and reduced event-free survival after revascularization. Data from the EXCEL trial do not a priori support a preferential role of PCI over CABG in patients with known CEVD.
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Affiliation(s)
- Jamie Diamond
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Mahesh V Madhavan
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Joseph F Sabik
- Department of Surgery, UH Cleveland Medical Center, Cleveland, Ohio
| | - Patrick W Serruys
- Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Arie Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Martin B Leon
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | | | | | - Marie-Claude Morice
- Ramsay Générale de Santé - Institut Cardiovasculaire Paris Sud, Massy, France
| | | | | | - Ovidiu Dressler
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Gregg W Stone
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York.
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23
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Tzoumas A, Giannopoulos S, Texakalidis P, Charisis N, Machinis T, Koullias GJ. Synchronous versus Staged Carotid Endarterectomy and Coronary Artery Bypass Graft for Patients with Concomitant Severe Coronary and Carotid Artery Stenosis: A Systematic Review and Meta-analysis. Ann Vasc Surg 2019; 63:427-438.e1. [PMID: 31629126 DOI: 10.1016/j.avsg.2019.09.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/13/2019] [Accepted: 09/17/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Due to the systemic nature of atherosclerosis, arteries at different sites are commonly simultaneously affected. As a result, severe coronary artery disease (CAD) requiring coronary artery bypass grafting (CABG) frequently coexists with significant carotid stenosis that warrants revascularization. To compare simultaneous carotid endarterectomy (CEA) and CABG versus staged CEA and CABG for patients with concomitant CAD and carotid artery stenosis in terms of perioperative outcomes. METHODS This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. A meta-analysis was conducted with the use of a random effects model. The I2 statistic was used to assess for heterogeneity. RESULTS Eleven studies comprising 44,895 patients were included in this meta-analysis (21,710 in the synchronous group and 23,185 patients in the staged group). The synchronous CEA and CABG group had a statistically significant lower risk for myocardial infarction (MI) (odds ratio [OR] 0.15, 95% CI 0.04-0.61, I2 = 0%) and higher risk for stroke (OR 1.51, 95% CI 1.34-1.71, I2 = 0%) and death (OR 1.33, 95% CI 1.01-1.75, I2 = 47.8%). Transient ischemic attacks (TIAs) (OR 1.27, 95% CI 1.00-1.61, I2 = 0.0%), postoperative bleeding (OR 0.82, 95% CI 0.22-3.05, I2 = 0.0%), and pulmonary complications (OR 1.52, 95% CI 0.24-9.60, I2 = 67.5%) were similar between the 2 groups. CONCLUSIONS Patients in the simultaneous CEA and CABG group had a significantly higher risk of 30-day mortality and stroke and lower risk for MI as compared to staged CEA and CABG group. The rates of TIA, postoperative bleeding, and pulmonary complications were similar between the 2 groups. Future randomized trials or prospective cohorts are needed to validate our results.
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Affiliation(s)
- Andreas Tzoumas
- Department of Internal Medicine, Medical School Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Pavlos Texakalidis
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA
| | - Nektarios Charisis
- Division of Surgical Oncology, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
| | - Theofilos Machinis
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA
| | - George J Koullias
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY
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24
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Andreasen C, Jørgensen ME, Gislason GH, Martinsson A, Sanders RD, Abdulla J, Jensen PF, Torp-Pedersen C, Køber L, Andersson C. Association of Timing of Aortic Valve Replacement Surgery After Stroke With Risk of Recurrent Stroke and Mortality. JAMA Cardiol 2019; 3:506-513. [PMID: 29710128 DOI: 10.1001/jamacardio.2018.0899] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Timing of surgical aortic valve replacement (SAVR) in patients with aortic valve stenosis and previous stroke for the risk of recurrent stroke is insufficiently investigated. Objective To evaluate the association of time elapsed between previous stroke and SAVR with the risk of recurrent perioperative stroke, major adverse cardiovascular events (MACE), and mortality among patients with aortic valve stenosis. Design, Setting, and Participants This cohort study using data from Danish administrative registries included all patients with aortic valve stenosis older than 18 years who underwent SAVR between 1996 and 2014 (n = 14 030). Patients who received simultaneous mitral, tricuspid, or pulmonary valve surgery and patients with endocarditis 1 year prior to surgery were excluded. Data were analyzed from March 2017 to January 2018. Exposures Time elapsed between prior stroke and SAVR (<3 months, 3-<12 months, ≥12 months, and no prior stroke). Main Outcomes and Measures Thirty-day risks of MACE, ischemic stroke, and all-cause mortality reported as absolute events and multivariable adjusted odds ratios with 95% confidence intervals. Restricted cubic spline regression models were additionally applied on the subgroup with prior stroke. Results Of the 14 030 included patients, 616 patients (190 [30.8%] women; mean [SD] age, 72.0 [9.1] years) with prior stroke underwent surgery, and 13 414 (4837 [36.1%] women; mean [SD] age, 69.8 [10.8] years) without prior stroke underwent surgery. The absolute risk of ischemic stroke was significantly increased in patients with stroke less than 3 months prior to surgery compared with patients with no prior stroke (18.4% [37 of 201] vs 1.2% [160 of 13 219]; odds ratio, 14.69; 95% CI, 9.69-22.27). Likewise, compared with patients without stroke, patients with stroke less than 3 months prior surgery were at significantly increased risk of MACE (23.3% [53 of 227] vs 5.7% [768 of 13 414]; odds ratio, 4.57; 95% CI, 3.24-6.44) but not all-cause mortality (6.8% [50 of 730] vs 3.6% [374 of 10 370]; odds ratio, 1.45; 95% CI, 0.83-2.54). Spline analyses supported a declining risk over time, reaching nadir after 2 to 4 months. Conclusions and Relevance Previous stroke is a major risk factor of recurrent ischemic stroke and MACE in patients undergoing SAVR, especially if time elapsed between previous stroke and surgery is less than 3 months.
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Affiliation(s)
- Charlotte Andreasen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Gentofte, Denmark
| | - Mads Emil Jørgensen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Gentofte, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Gentofte, Denmark.,The Danish Heart Foundation, Copenhagen, Denmark.,The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | - Robert D Sanders
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison
| | - Jawdat Abdulla
- Division of Cardiology, Department of Medicine, Glostrup University Hospital, Copenhagen, Denmark
| | - Per Føge Jensen
- The Multidisciplinary Pain Center, Department of Anaesthesia, Copenhagen University Hospital Herlev and Gentofte, Gentofte, Denmark
| | - Christian Torp-Pedersen
- Department of Health, Science, and Technology, Aalborg University, Aalborg, Denmark.,The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Charlotte Andersson
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Gentofte, Denmark
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Salehi Ravesh M, Rusch R, Friedrich C, Teickner C, Berndt R, Haneya A, Cremer J, Pühler T. Impact of patients´ age on short and long-term outcome after carotid endarterectomy and simultaneous coronary artery bypass grafting. J Cardiothorac Surg 2019; 14:109. [PMID: 31202278 PMCID: PMC6570883 DOI: 10.1186/s13019-019-0928-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 06/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate whether age has an effect on short and long-term outcome in patients who undergo simultaneous coronary artery bypass grafting (CABG) and carotid endarterectomy. METHODS From 2005 to 2017, 186 consecutive elective patients underwent CABG and synchronous endarterectomy at our institution. Patients were retrospectively classified according to age into 2 groups: patients above 70 years (elderly group: n = 97, 76.1 ± 3.9 years) and patients below 70 years (younger group: n = 89, 63.2 ± 4.8 years). RESULTS The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, 4.4% vs. 2.5%; p < 0.001) and Society of Thoracic Surgeons (STS) score (0.7% vs. 1.6%; p < 0.001) were significantly higher in the elderly group. Otherwise, there was no difference between the two groups concerning important preoperative risk factors or the intraoperative data. Postoperatively, the incidence of temporary dialysis was significantly higher in the elderly group (14.4% vs. 3.4%; p = 0.009). The rate of tracheotomy (16.5% vs. 2.2%; p = 0.001), of re-intubation (7.9% vs. 18.6%; p = 0.033) and drainage loss (600 ml vs. 800 ml; p = 0.035) was significantly higher in this elderly group. Neurological complications and 30-day mortality were comparable. Long-term survival was satisfactory for both groups. Nevertheless, 5-year survival rates (63% vs. 85%) were significantly lower in the elderly group (p = 0.003). Logistic regression analysis identified chronic obstructive pulmonary disease (COPD) and arrhythmia as significant risk factors for 30-day-mortality, but not age. CONCLUSIONS CABG in combination with synchronous endarterectomy can also be performed with satisfactory results in elderly patients.
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Affiliation(s)
- Mona Salehi Ravesh
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller-Street 3, Building 41, 24105, Kiel, Germany.
| | - Rene Rusch
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller street 3, Building 18, Kiel, Germany
| | - Christine Friedrich
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller street 3, Building 18, Kiel, Germany
| | - Christoph Teickner
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller street 3, Building 18, Kiel, Germany
| | - Rouven Berndt
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller street 3, Building 18, Kiel, Germany
| | - Assad Haneya
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller street 3, Building 18, Kiel, Germany
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller street 3, Building 18, Kiel, Germany
| | - Thomas Pühler
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Arnold-Heller street 3, Building 18, Kiel, Germany
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Sperna Weiland NH, Hermanides J, Hollmann MW, Preckel B, Stok WJ, van Lieshout JJ, Immink RV. Novel method for intraoperative assessment of cerebral autoregulation by paced breathing. Br J Anaesth 2019; 119:1141-1149. [PMID: 29028933 DOI: 10.1093/bja/aex333] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2017] [Indexed: 11/14/2022] Open
Abstract
Background Cerebral autoregulation (CA) is the mechanism that maintains constancy of cerebral blood flow (CBF) despite variations in blood pressure (BP). Patients with attenuated CA have been shown to have an increased incidence of peri-operative stroke. Studies of CA in anaesthetized subjects are rare, because a simple and non-invasive method to quantify the integrity of CA is not available. In this study, we set out to improve non-invasive quantification of CA during surgery. For this purpose, we introduce a novel method to amplify spontaneous BP fluctuations during surgery by imposing mechanical positive pressure ventilation at three different frequencies and quantify CA from the resulting BP oscillations. Methods Fourteen patients undergoing sevoflurane anaesthesia were included in the study. Continuous non-invasive BP and transcranial Doppler-derived CBF velocity (CBF V ) were obtained before surgery during 3 min of paced breathing at 6, 10, and 15 bpm and during surgery from mechanical positive pressure ventilation at identical frequencies. Data were analysed using frequency domain analysis to obtain CBF V -to-BP phase lead as a continuous measure of CA efficacy. Group averages were calculated. Values are means ( sd ), and P <0.05 was used to indicate statistical significance. Results Preoperative vs intraoperative CBF V -to-BP phase lead was 43 (9) vs 45 (8)°, 25 (8) vs 24 (10)°, and 4 (6) vs -2 (12)° during 6, 10, and 15 bpm, respectively (all P =NS). Conclusions During surgery, cerebral autoregulation indices were similar to values determined before surgery. This indicates that CA can be quantified reliably and non-invasively using this novel method and confirms earlier evidence that CA is unaffected by sevoflurane anaesthesia. Clinical trial registration NCT03071432.
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Affiliation(s)
- N H Sperna Weiland
- Department of Anaesthesiology.,Department of Medical Biology, Laboratory for Clinical Cardiovascular Physiology
| | | | | | | | - W J Stok
- Department of Medical Biology, Laboratory for Clinical Cardiovascular Physiology
| | - J J van Lieshout
- Department of Medical Biology, Laboratory for Clinical Cardiovascular Physiology.,Department of Internal Medicine, Academic Medical Centre AMC Amsterdam, University of Amsterdam, PO Box 22660, 1100DD Amsterdam, The Netherlands.,MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, UK
| | - R V Immink
- Department of Anaesthesiology.,Department of Medical Biology, Laboratory for Clinical Cardiovascular Physiology
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Yoshitani K, Kawaguchi M, Ishida K, Maekawa K, Miyawaki H, Tanaka S, Uchino H, Kakinohana M, Koide Y, Yokota M, Okamoto H, Nomura M. Guidelines for the use of cerebral oximetry by near-infrared spectroscopy in cardiovascular anesthesia: a report by the cerebrospinal Division of the Academic Committee of the Japanese Society of Cardiovascular Anesthesiologists (JSCVA). J Anesth 2019; 33:167-196. [DOI: 10.1007/s00540-019-02610-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 01/02/2019] [Indexed: 11/29/2022]
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28
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Muresanu DF, Sharma A, Patnaik R, Menon PK, Mössler H, Sharma HS. Exacerbation of blood-brain barrier breakdown, edema formation, nitric oxide synthase upregulation and brain pathology after heat stroke in diabetic and hypertensive rats. Potential neuroprotection with cerebrolysin treatment. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2019; 146:83-102. [DOI: 10.1016/bs.irn.2019.06.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Ko SB. Perioperative stroke: pathophysiology and management. Korean J Anesthesiol 2018; 71:3-11. [PMID: 29441169 PMCID: PMC5809704 DOI: 10.4097/kjae.2018.71.1.3] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 11/19/2017] [Indexed: 01/01/2023] Open
Abstract
Although perioperative stroke is uncommon during low-risk non-vascular surgery, if it occurs, it can negatively impact recovery from the surgery and functional outcome. Based on the Society for Neuroscience in Anesthesiology and Critical Care Consensus Statement, perioperative stroke includes intraoperative stroke, as well as postoperative stroke developing within 30 days after surgery. Factors related to perioperative stroke include age, sex, a history of stroke or transient ischemic attack, cardiac surgery (aortic surgery, mitral valve surgery, or coronary artery bypass graft surgery), and neurosurgery (external carotid-internal carotid bypass surgery, carotid endarterectomy, or aneurysm clipping). Concomitant carotid and cardiac surgery may further increase the risk of perioperative stroke. Preventive strategies should be individualized based on patient factors, including cerebrovascular reserve capacity and the time interval since the previous stroke.
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Affiliation(s)
- Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
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30
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Zhou ZF, Zhang FJ, Huo YF, Yu YX, Yu LN, Sun K, Sun LH, Xing XF, Yan M. Intraoperative tranexamic acid is associated with postoperative stroke in patients undergoing cardiac surgery. PLoS One 2017; 12:e0177011. [PMID: 28552944 PMCID: PMC5446127 DOI: 10.1371/journal.pone.0177011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 04/20/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Stroke is a devastating and potentially preventable complication of cardiac surgery. Tranexamic acid (TXA) is a commonly antifibrinolytic agent in cardiac surgeries with cardiopulmonary bypass (CPB), however, there is concern that it might increase incidence of stroke after cardiac surgery. In this retrospective study, we investigated whether TXA usage could increase postoperative stroke in cardiac surgery. METHODS A retrospective study was conducted from January 1, 2010, to December 31, 2015, in 2,016 patients undergoing cardiac surgery, 664 patients received intravenous TXA infusion and 1,352 patients did not receive any antifibrinolytic agent. Univariate and propensity-weighted multivariate regression analysis were applied for data analysis. RESULTS Intraoperative TXA administration was associated with postoperative stroke (1.7% vs. 0.5%; adjusted OR, 4.11; 95% CI, 1.33 to 12.71; p = 0.014) and coma (adjusted OR, 2.77; 95% CI, 1.06 to 7.26; p = 0.038) in cardiac surgery. As subtype analysis was performed, TXA administration was still associated with postoperative stroke (1.7% vs. 0.3%; adjusted OR, 5.78; 95% CI, 1.34 to 27.89; p = 0.018) in patients undergoing valve surgery or multi-valve surgery only, but was not associated with postoperative stroke (1.7% vs. 1.3%; adjusted OR, 5.21; 95% CI, 0.27 to 101.17; p = 0.276) in patients undergoing CABG surgery only. However, TXA administration was not associated with postoperative mortality (adjusted OR, 1.31; 95% CI, 0.56 to 3.71; p = 0.451), seizure (adjusted OR, 1.13; 95% CI, 0.42 to 3.04; p = 0.816), continuous renal replacement therapy (adjusted OR, 1.36; 95% CI, 0.56 to 3.28; p = 0.495) and resternotomy for postoperative bleeding (adjusted OR, 1.55; 95% CI, 0.55 to 4.30; p = 0.405). No difference was found in postoperative ventilation time (adjusted B, -1.45; SE, 2.33; p = 0.535), length of intensive care unit stay (adjusted B, -0.12; SE, 0.25; p = 0.633) and length of hospital stay (adjusted B, 0.48; SE, 0.58; p = 0.408). CONCLUSIONS Based on the 5-year experience of TXA administration in cardiac surgery with CPB, we found that postoperative stroke was associated with intraoperative TXA administration in patients undergoing cardiac surgery, especially in those undergoing valve surgeries only. This study may suggest that TXA should be administrated according to clear indications after evaluating the bleeding risk in patients undergoing cardiac surgery, especially in those with high stroke risk.
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Affiliation(s)
- Zhen-feng Zhou
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Feng-jiang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | | | - Yun-xian Yu
- Department of Epidemiology and Health Statistics, School of Public Health, Zhejiang University, Hangzhou, China
| | - Li-na Yu
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Kai Sun
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Li-hong Sun
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Xiu-fang Xing
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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O'Neill DE, Knudtson ML, Kieser TM, Graham MM. Considerations in Cardiac Revascularization for the Elderly Patient: Age Isn't Everything. Can J Cardiol 2016; 32:1132-9. [DOI: 10.1016/j.cjca.2016.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/04/2016] [Accepted: 05/04/2016] [Indexed: 02/04/2023] Open
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33
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Sun Z, Yue Y, Leung C, Chan M, Gelb A. Clinical diagnostic tools for screening of perioperative stroke in general surgery: a systematic review. Br J Anaesth 2016; 116:328-38. [DOI: 10.1093/bja/aev452] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Silvay G, Zafirova Z. Ten Years Experiences With Preoperative Evaluation Clinic for Day Admission Cardiac and Major Vascular Surgical Patients: Model for "Perioperative Anesthesia and Surgical Home". Semin Cardiothorac Vasc Anesth 2015; 20:120-32. [PMID: 26620138 DOI: 10.1177/1089253215619236] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Admission on the day of surgery for elective cardiac and noncardiac surgery is the prevalent practice in North America and Canada. This approach realizes medical, psychological and logistical benefits, and its success is predicated on an effective outpatient preoperative evaluation. The establishment of a highly functional preoperative clinic with a comprehensive set up and efficient logistical pathways is invaluable. This notion in recent years has included the entire perioperative period, and the concept of a perioperative anesthesia/surgical home (PASH) is gaining popularity. The anesthesiologists as perioperative physicians can organize and lead the entire process from the preoperative evaluation, through the hosptial discharge. The functions of the PASH include preoperative optimization of medical conditions and psychological preparation of the patients and their support system; the care in the operating room and intensive care unit; pain management; respiratory therapy; cardiac rehabilitation; and specialized nutrition. Along with oversight of the medical issues, the preoperative visit is an opportune time for counseling, clarification of expectations and discussion of research, as well as for utilization of various informatics systems to consolidate the pertinent information and distribute it to relevant health care providers. We review the scientific foundation and practical applications of a preoperative visit and share our experience with the development of the preoperative evaluation clinic, designed specifically for cardiac and major vascular patients scheduled for day admission surgery. The ultimate goal of preoperative evaluation clinic is to ensure a safe, efficient, and cost-effective perioperative care for patients undergoing a complex type of surgery.
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Affiliation(s)
- George Silvay
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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35
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Predictors associated with stroke after coronary artery bypass grafting: A systematic review. J Neurol Sci 2015. [DOI: 10.1016/j.jns.2015.07.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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36
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Luchowski P, Wojczal J, Buraczynska K, Kozlowicz M, Stazka J, Rejdak K. Predictors of intracranial cerebral artery stenosis in patients before cardiac surgery and its impact on perioperative and long-term stroke risk. Neurol Neurochir Pol 2015; 49:395-400. [PMID: 26652874 DOI: 10.1016/j.pjnns.2015.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 09/06/2015] [Accepted: 09/14/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of this prospective study was to determine the prevalence of stenosis within intracranial and extracranial arteries in patients before coronary artery bypass surgery (CABG), to evaluate the influence of intracranial artery stenosis on neurological outcome and to identify preoperative risk factors for these patients. METHODS One hundred and seventy-five patients (71% males, mean age=66.1) scheduled for CABG were enrolled for extracranial Doppler duplex sonography, transcranial color-coded duplex sonography (TCCS) and transcranial Doppler (TCD) examination. RESULTS Twenty-six patients (14.7%) had extracranial stenosis or occlusion and 13 patients (7.3%) intracranial vascular disease. Six patients (3.5%) had both extra- and intracranial artery disease. The presence of peripheral artery disease and diabetes mellitus was a strong risk factor for extracranial artery stenosis but not for intracranial artery stenosis, which occurred independently also of typical atherosclerotic risk factors like age >70, male sex, hypertension, hyperlipidemia, hyperhomocysteinemia, smoking habit, obesity (BMI>30) and waist to hip ratio >1. Functional neurological outcome of the patients with intracranial arterial disease evaluated 7 days after CABG was the same as the patients without extra- and intracranial stenosis. However, 12-months neurological follow-up revealed significantly more ischemic strokes in patients with intracranial artery stenosis compared to patients without intracranial stenosis (p=0.015). CONCLUSION The occurrence of intracranial artery stenosis in CABG patients cannot be predicted by well-known atherosclerotic risk factors and seems not to be associated with perioperative stroke.
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Affiliation(s)
- Piotr Luchowski
- Department of Neurology, Medical University of Lublin, Lublin, Poland.
| | - Joanna Wojczal
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | - Kinga Buraczynska
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | - Michal Kozlowicz
- Department of Cardiosurgery, Medical University of Lublin, Lublin, Poland
| | - Janusz Stazka
- Department of Cardiosurgery, Medical University of Lublin, Lublin, Poland
| | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, Lublin, Poland
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37
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Tzimas P, Petrou A, Laou E, Milionis H, Mikhailidis D, Papadopoulos G. Impact of metabolic syndrome in surgical patients: should we bother? Br J Anaesth 2015; 115:194-202. [DOI: 10.1093/bja/aev199] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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38
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Oi K, Arai H. Stroke associated with coronary artery bypass grafting. Gen Thorac Cardiovasc Surg 2015; 63:487-95. [PMID: 26153474 DOI: 10.1007/s11748-015-0572-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Indexed: 01/04/2023]
Abstract
While coronary artery bypass grafting (CABG) has been playing a significant role in the revascularization for ischemic heart disease, neurological complications associated with CABG have been a primary concern. Stroke, although the incidence is low, is one of the most devastating complication of CABG. Many studies have identified the risk factors for stroke with CABG, such as prior stroke, carotid artery stenosis, aortic atherosclerosis, atrial fibrillation and cardiopulmonary bypass. Various rational approaches focusing on individual risk factor have been proposed for the stroke. Prophylactic carotid revascularization is an important strategy, and the diagnosis of carotid stenosis has to be established correctly. Prevention of emboli from aortic plaque is also an essential issue. Intraoperative monitoring with transesophageal or epiaortic ultrasound is useful to identify mobile atheromatous plaques and to select appropriate aortic manipulations. Maintenance of cerebral blood flow and blood pressure during cardiopulmonary bypass might be critical issues. Besides, there are conflicting two opinions regarding off-pump CABG; one supports an efficiency for the prevention of stroke while the other advocates no effect. This discrepancy might be explained by the difference of the risk of stroke in the population of the individual study and by the variation of the percentage of aortic clamping or aortic anastomosis in each study. Pharmaceutical therapies such as statin, preventive medication for atrial fibrillation, or antiplatelet are promising methods. Although it is hard to decrease the incidence of the stroke with any single countermeasure, sustained effort should be continued to overcome the stroke associated with CABG.
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Affiliation(s)
- Keiji Oi
- Department of Cardiovascular Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan,
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39
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Gefäßerkrankungen und -komplikationen im Rahmen von Herzoperationen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2015. [DOI: 10.1007/s00398-015-0006-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Antunes PE, Ferrão de Oliveira J, Prieto D, Coutinho GF, Correia P, Branco CF, Antunes MJ. Coronary artery bypass surgery without cardioplegia: hospital results in 8515 patients. Eur J Cardiothorac Surg 2015; 49:918-25. [DOI: 10.1093/ejcts/ezv177] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 04/13/2015] [Indexed: 12/17/2022] Open
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41
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Xu B, Qiao Q, Chen M, Rastogi R, Luo D, Bi Q. Relationship between neurological complications, cerebrovascular and cerebral perfusion following off-pump coronary artery bypass grafting. Neurol Res 2015; 37:421-6. [DOI: 10.1179/1743132815y.0000000030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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42
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Mack M. Can we make stroke during cardiac surgery a never event? J Thorac Cardiovasc Surg 2015; 149:965-7. [DOI: 10.1016/j.jtcvs.2014.12.072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 12/25/2014] [Accepted: 12/26/2014] [Indexed: 11/26/2022]
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43
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Bi Q, Li JY, Li XQ, Li Q, Luo D, Qiao QB. Impact of Intracranial Artery Disease and Prior Cerebral Infarction on Central Nervous System Complications After Off-Pump Coronary Artery Bypass Grafting. NEUROPHYSIOLOGY+ 2015. [DOI: 10.1007/s11062-015-9480-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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44
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Oakes DA, Eichenbaum KD. Perioperative management of combined carotid and coronary artery bypass grafting procedures. Anesthesiol Clin 2014; 32:699-721. [PMID: 25113728 DOI: 10.1016/j.anclin.2014.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objective of this review is to provide a high level overview on current thinking for treatment of patients with combined carotid and coronary artery disease given that these patients are at higher risk of adverse cardiac events, stroke, and death. This review discusses (1) the current literature addressing perioperative stroke risk in the setting of coronary artery bypass graft, (2) the literature regarding different surgical approaches when both carotid and coronary revascularization are being considered, and (3) the data available to guide optimal management of this complex patient population to minimize complications regardless of the surgical approach taken.
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Affiliation(s)
- Daryl A Oakes
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, 300 Pasteur Drive H3580, MC 5640, Stanford, CA 94305, USA.
| | - Kenneth D Eichenbaum
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, 300 Pasteur Drive H3580, MC 5640, Stanford, CA 94305, USA
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45
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Greve AM, Dalsgaard M, Bang CN, Egstrup K, Ray S, Boman K, Rossebø AB, Gohlke-Baerwolf C, Devereux RB, Køber L, Wachtell K. Stroke in Patients With Aortic Stenosis. Stroke 2014; 45:1939-46. [DOI: 10.1161/strokeaha.114.005296] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
There are limited data on risk stratification of stroke in aortic stenosis. This study examined predictors of stroke in aortic stenosis, the prognostic implications of stroke, and how aortic valve replacement (AVR) with or without concomitant coronary artery bypass grafting influenced the predicted outcomes.
Methods—
Patients with mild-to-moderate aortic stenosis enrolled in the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. Diabetes mellitus, known atherosclerotic disease, and oral anticoagulation were exclusion criteria. Ischemic stroke was the primary end point, and poststroke survival a secondary outcome. Cox models treating AVR as a time-varying covariate were adjusted for atrial fibrillation and congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65–74 years and female sex (CHA
2
DS
2
-VASc) scores.
Results—
One thousand five hundred nine patients were followed for 4.3±0.8 years (6529 patient-years). Rates of stroke were 5.6 versus 21.8 per 1000 patient-years pre- and post-AVR; 429 (28%) underwent AVR and 139 (9%) died. Atrial fibrillation (hazard ratio [HR], 2.7; 95% confidence interval [CI], 1.1–6.6), CHA
2
DS
2
-VASc score (HR 1.4 per unit; 95% CI, 1.1–1.8), diastolic blood pressure (HR, 1.4 per 10 mm Hg; 95% CI, 1.1–1.8), and AVR with concomitant coronary artery bypass grafting (HR, 3.2; 95% CI, 1.4–7.2, all
P
≤0.026) were independently associated with stroke. Incident stroke predicted death (HR, 8.1; 95% CI, 4.7–14.0;
P
<0.001).
Conclusions—
In patients with aortic stenosis not prescribed oral anticoagulation, atrial fibrillation, AVR with concomitant coronary artery bypass grafting, and CHA
2
DS
2
-VASc score were the major predictors of stroke. Incident stroke was strongly associated with mortality.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00092677.
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Affiliation(s)
- Anders M. Greve
- From the Department of Medicine B, The Heart Center, Rigshospitalet, Copenhagen, Denmark (A.M.G., M.D., C.N.B., L.K.); Department of Cardiology, OUH Svendborg Sygehus, Denmark (K.E.); Department of Cardiology, Manchester Academic Health Sciences Center, Manchester, United Kingdom (S.R.); Department of Medicine, Institution of Public Health and Clinical Medicine, Umeå University, Skelleftå, Sweden (K.B.); Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway (A.B.R.); Department
| | - Morten Dalsgaard
- From the Department of Medicine B, The Heart Center, Rigshospitalet, Copenhagen, Denmark (A.M.G., M.D., C.N.B., L.K.); Department of Cardiology, OUH Svendborg Sygehus, Denmark (K.E.); Department of Cardiology, Manchester Academic Health Sciences Center, Manchester, United Kingdom (S.R.); Department of Medicine, Institution of Public Health and Clinical Medicine, Umeå University, Skelleftå, Sweden (K.B.); Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway (A.B.R.); Department
| | - Casper N. Bang
- From the Department of Medicine B, The Heart Center, Rigshospitalet, Copenhagen, Denmark (A.M.G., M.D., C.N.B., L.K.); Department of Cardiology, OUH Svendborg Sygehus, Denmark (K.E.); Department of Cardiology, Manchester Academic Health Sciences Center, Manchester, United Kingdom (S.R.); Department of Medicine, Institution of Public Health and Clinical Medicine, Umeå University, Skelleftå, Sweden (K.B.); Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway (A.B.R.); Department
| | - Kenneth Egstrup
- From the Department of Medicine B, The Heart Center, Rigshospitalet, Copenhagen, Denmark (A.M.G., M.D., C.N.B., L.K.); Department of Cardiology, OUH Svendborg Sygehus, Denmark (K.E.); Department of Cardiology, Manchester Academic Health Sciences Center, Manchester, United Kingdom (S.R.); Department of Medicine, Institution of Public Health and Clinical Medicine, Umeå University, Skelleftå, Sweden (K.B.); Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway (A.B.R.); Department
| | - Simon Ray
- From the Department of Medicine B, The Heart Center, Rigshospitalet, Copenhagen, Denmark (A.M.G., M.D., C.N.B., L.K.); Department of Cardiology, OUH Svendborg Sygehus, Denmark (K.E.); Department of Cardiology, Manchester Academic Health Sciences Center, Manchester, United Kingdom (S.R.); Department of Medicine, Institution of Public Health and Clinical Medicine, Umeå University, Skelleftå, Sweden (K.B.); Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway (A.B.R.); Department
| | - Kurt Boman
- From the Department of Medicine B, The Heart Center, Rigshospitalet, Copenhagen, Denmark (A.M.G., M.D., C.N.B., L.K.); Department of Cardiology, OUH Svendborg Sygehus, Denmark (K.E.); Department of Cardiology, Manchester Academic Health Sciences Center, Manchester, United Kingdom (S.R.); Department of Medicine, Institution of Public Health and Clinical Medicine, Umeå University, Skelleftå, Sweden (K.B.); Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway (A.B.R.); Department
| | - Anne B. Rossebø
- From the Department of Medicine B, The Heart Center, Rigshospitalet, Copenhagen, Denmark (A.M.G., M.D., C.N.B., L.K.); Department of Cardiology, OUH Svendborg Sygehus, Denmark (K.E.); Department of Cardiology, Manchester Academic Health Sciences Center, Manchester, United Kingdom (S.R.); Department of Medicine, Institution of Public Health and Clinical Medicine, Umeå University, Skelleftå, Sweden (K.B.); Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway (A.B.R.); Department
| | - Christa Gohlke-Baerwolf
- From the Department of Medicine B, The Heart Center, Rigshospitalet, Copenhagen, Denmark (A.M.G., M.D., C.N.B., L.K.); Department of Cardiology, OUH Svendborg Sygehus, Denmark (K.E.); Department of Cardiology, Manchester Academic Health Sciences Center, Manchester, United Kingdom (S.R.); Department of Medicine, Institution of Public Health and Clinical Medicine, Umeå University, Skelleftå, Sweden (K.B.); Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway (A.B.R.); Department
| | - Richard B. Devereux
- From the Department of Medicine B, The Heart Center, Rigshospitalet, Copenhagen, Denmark (A.M.G., M.D., C.N.B., L.K.); Department of Cardiology, OUH Svendborg Sygehus, Denmark (K.E.); Department of Cardiology, Manchester Academic Health Sciences Center, Manchester, United Kingdom (S.R.); Department of Medicine, Institution of Public Health and Clinical Medicine, Umeå University, Skelleftå, Sweden (K.B.); Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway (A.B.R.); Department
| | - Lars Køber
- From the Department of Medicine B, The Heart Center, Rigshospitalet, Copenhagen, Denmark (A.M.G., M.D., C.N.B., L.K.); Department of Cardiology, OUH Svendborg Sygehus, Denmark (K.E.); Department of Cardiology, Manchester Academic Health Sciences Center, Manchester, United Kingdom (S.R.); Department of Medicine, Institution of Public Health and Clinical Medicine, Umeå University, Skelleftå, Sweden (K.B.); Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway (A.B.R.); Department
| | - Kristian Wachtell
- From the Department of Medicine B, The Heart Center, Rigshospitalet, Copenhagen, Denmark (A.M.G., M.D., C.N.B., L.K.); Department of Cardiology, OUH Svendborg Sygehus, Denmark (K.E.); Department of Cardiology, Manchester Academic Health Sciences Center, Manchester, United Kingdom (S.R.); Department of Medicine, Institution of Public Health and Clinical Medicine, Umeå University, Skelleftå, Sweden (K.B.); Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway (A.B.R.); Department
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Messé SR, Acker MA, Kasner SE, Fanning M, Giovannetti T, Ratcliffe SJ, Bilello M, Szeto WY, Bavaria JE, Hargrove WC, Mohler ER, Floyd TF. Stroke after aortic valve surgery: results from a prospective cohort. Circulation 2014; 129:2253-61. [PMID: 24690611 DOI: 10.1161/circulationaha.113.005084] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The incidence and impact of clinical stroke and silent radiographic cerebral infarction complicating open surgical aortic valve replacement (AVR) are poorly characterized. METHODS AND RESULTS We performed a prospective cohort study of subjects ≥65 years of age who were undergoing AVR for calcific aortic stenosis. Subjects were evaluated by neurologists preoperatively and postoperatively and underwent postoperative magnetic resonance imaging. Over a 4-year period, 196 subjects were enrolled at 2 sites (mean age, 75.8±6.2 years; 36% women; 6% nonwhite). Clinical strokes were detected in 17%, transient ischemic attack in 2%, and in-hospital mortality was 5%. The frequency of stroke in the Society for Thoracic Surgery database in this cohort was 7%. Most strokes were mild; the median National Institutes of Health Stroke Scale was 3 (interquartile range, 1-9). Clinical stroke was associated with increased length of stay (median, 12 versus 10 days; P=0.02). Moderate or severe stroke (National Institutes of Health Stroke Scale ≥10) occurred in 8 (4%) and was strongly associated with in-hospital mortality (38% versus 4%; P=0.005). Of the 109 stroke-free subjects with postoperative magnetic resonance imaging, silent infarct was identified in 59 (54%). Silent infarct was not associated with in-hospital mortality or increased length of stay. CONCLUSIONS Clinical stroke after AVR was more common than reported previously, more than double for this same cohort in the Society for Thoracic Surgery database, and silent cerebral infarctions were detected in more than half of the patients undergoing AVR. Clinical stroke complicating AVR is associated with increased length of stay and mortality.
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Affiliation(s)
- Steven R Messé
- From the Departments of Neurology (S.R.M., S.E.K.), Surgery (M.A.A., M.F., W.Y.S., J.E.B., W.C.H.), and Radiology (M.B.), and Section of Vascular Medicine, Cardiovascular Division, Department of Medicine (E.R.M.), Hospital of the University of Pennsylvania, Philadelphia, PA; Department of Psychology, Temple University, Philadelphia, PA (T.G.); Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA (S.J.R.); Department of Anesthesia and Critical Care, State University of New York, Stony Brook, NY (T.F.F.)
| | - Michael A Acker
- From the Departments of Neurology (S.R.M., S.E.K.), Surgery (M.A.A., M.F., W.Y.S., J.E.B., W.C.H.), and Radiology (M.B.), and Section of Vascular Medicine, Cardiovascular Division, Department of Medicine (E.R.M.), Hospital of the University of Pennsylvania, Philadelphia, PA; Department of Psychology, Temple University, Philadelphia, PA (T.G.); Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA (S.J.R.); Department of Anesthesia and Critical Care, State University of New York, Stony Brook, NY (T.F.F.)
| | - Scott E Kasner
- From the Departments of Neurology (S.R.M., S.E.K.), Surgery (M.A.A., M.F., W.Y.S., J.E.B., W.C.H.), and Radiology (M.B.), and Section of Vascular Medicine, Cardiovascular Division, Department of Medicine (E.R.M.), Hospital of the University of Pennsylvania, Philadelphia, PA; Department of Psychology, Temple University, Philadelphia, PA (T.G.); Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA (S.J.R.); Department of Anesthesia and Critical Care, State University of New York, Stony Brook, NY (T.F.F.)
| | - Molly Fanning
- From the Departments of Neurology (S.R.M., S.E.K.), Surgery (M.A.A., M.F., W.Y.S., J.E.B., W.C.H.), and Radiology (M.B.), and Section of Vascular Medicine, Cardiovascular Division, Department of Medicine (E.R.M.), Hospital of the University of Pennsylvania, Philadelphia, PA; Department of Psychology, Temple University, Philadelphia, PA (T.G.); Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA (S.J.R.); Department of Anesthesia and Critical Care, State University of New York, Stony Brook, NY (T.F.F.)
| | - Tania Giovannetti
- From the Departments of Neurology (S.R.M., S.E.K.), Surgery (M.A.A., M.F., W.Y.S., J.E.B., W.C.H.), and Radiology (M.B.), and Section of Vascular Medicine, Cardiovascular Division, Department of Medicine (E.R.M.), Hospital of the University of Pennsylvania, Philadelphia, PA; Department of Psychology, Temple University, Philadelphia, PA (T.G.); Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA (S.J.R.); Department of Anesthesia and Critical Care, State University of New York, Stony Brook, NY (T.F.F.)
| | - Sarah J Ratcliffe
- From the Departments of Neurology (S.R.M., S.E.K.), Surgery (M.A.A., M.F., W.Y.S., J.E.B., W.C.H.), and Radiology (M.B.), and Section of Vascular Medicine, Cardiovascular Division, Department of Medicine (E.R.M.), Hospital of the University of Pennsylvania, Philadelphia, PA; Department of Psychology, Temple University, Philadelphia, PA (T.G.); Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA (S.J.R.); Department of Anesthesia and Critical Care, State University of New York, Stony Brook, NY (T.F.F.)
| | - Michel Bilello
- From the Departments of Neurology (S.R.M., S.E.K.), Surgery (M.A.A., M.F., W.Y.S., J.E.B., W.C.H.), and Radiology (M.B.), and Section of Vascular Medicine, Cardiovascular Division, Department of Medicine (E.R.M.), Hospital of the University of Pennsylvania, Philadelphia, PA; Department of Psychology, Temple University, Philadelphia, PA (T.G.); Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA (S.J.R.); Department of Anesthesia and Critical Care, State University of New York, Stony Brook, NY (T.F.F.)
| | - Wilson Y Szeto
- From the Departments of Neurology (S.R.M., S.E.K.), Surgery (M.A.A., M.F., W.Y.S., J.E.B., W.C.H.), and Radiology (M.B.), and Section of Vascular Medicine, Cardiovascular Division, Department of Medicine (E.R.M.), Hospital of the University of Pennsylvania, Philadelphia, PA; Department of Psychology, Temple University, Philadelphia, PA (T.G.); Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA (S.J.R.); Department of Anesthesia and Critical Care, State University of New York, Stony Brook, NY (T.F.F.)
| | - Joseph E Bavaria
- From the Departments of Neurology (S.R.M., S.E.K.), Surgery (M.A.A., M.F., W.Y.S., J.E.B., W.C.H.), and Radiology (M.B.), and Section of Vascular Medicine, Cardiovascular Division, Department of Medicine (E.R.M.), Hospital of the University of Pennsylvania, Philadelphia, PA; Department of Psychology, Temple University, Philadelphia, PA (T.G.); Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA (S.J.R.); Department of Anesthesia and Critical Care, State University of New York, Stony Brook, NY (T.F.F.)
| | - W Clark Hargrove
- From the Departments of Neurology (S.R.M., S.E.K.), Surgery (M.A.A., M.F., W.Y.S., J.E.B., W.C.H.), and Radiology (M.B.), and Section of Vascular Medicine, Cardiovascular Division, Department of Medicine (E.R.M.), Hospital of the University of Pennsylvania, Philadelphia, PA; Department of Psychology, Temple University, Philadelphia, PA (T.G.); Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA (S.J.R.); Department of Anesthesia and Critical Care, State University of New York, Stony Brook, NY (T.F.F.)
| | - Emile R Mohler
- From the Departments of Neurology (S.R.M., S.E.K.), Surgery (M.A.A., M.F., W.Y.S., J.E.B., W.C.H.), and Radiology (M.B.), and Section of Vascular Medicine, Cardiovascular Division, Department of Medicine (E.R.M.), Hospital of the University of Pennsylvania, Philadelphia, PA; Department of Psychology, Temple University, Philadelphia, PA (T.G.); Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA (S.J.R.); Department of Anesthesia and Critical Care, State University of New York, Stony Brook, NY (T.F.F.)
| | - Thomas F Floyd
- From the Departments of Neurology (S.R.M., S.E.K.), Surgery (M.A.A., M.F., W.Y.S., J.E.B., W.C.H.), and Radiology (M.B.), and Section of Vascular Medicine, Cardiovascular Division, Department of Medicine (E.R.M.), Hospital of the University of Pennsylvania, Philadelphia, PA; Department of Psychology, Temple University, Philadelphia, PA (T.G.); Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA (S.J.R.); Department of Anesthesia and Critical Care, State University of New York, Stony Brook, NY (T.F.F.).
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Uva MS, Naylor AR. Re: Simultaneous hybrid carotid stenting and coronary bypass surgery versus concomitant open carotid and coronary bypass surgery: a pilot, feasibility study. Eur J Cardiothorac Surg 2014; 46:863-4. [PMID: 24648425 DOI: 10.1093/ejcts/ezu106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Miguel Sousa Uva
- Department of Cardiac Surgery, Hospital da Cruz Vermelha, Lisbon, Portugal
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Abstract
OPINION STATEMENT Numerous risk factors for perioperative stroke have been identified and many are modifiable. Surgical patients with a history of cerebrovascular disease should be evaluated by a neurologist. Cardiac and cerebrovascular testing is critical in identifying patients at high risk for perioperative stroke. The identification and treatment of carotid disease in the context of upcoming surgery has been a source of controversy. Routine carotid revascularization performed with coronary artery bypass graft (CABG) surgery for incidentally discovered carotid stenosis is not recommended. Prior to aortic manipulation during CABG, epiaortic ultrasound should be performed to identify aortic atheromatous plaques. If possible, preoperative aspirin, beta blocker, statin, and angiotensin converting-enzyme (ACE) inhibitor therapy should be continued in the perioperative period. Patients who are prescribed anticoagulation at high risk of thromboembolism should receive bridging anticoagulation during the perioperative period. The identification and prevention of postoperative atrial fibrillation (AF) is central to stroke prevention. CABG patients should be initiated on beta blockade +/- amiodarone to prevent postoperative AF. Many practitioners have been traditionally nihilistic towards acute perioperative stroke treatment. Given the narrow therapeutic window of treatment options, candidacy is dependent on timely recognition. Intravenous and endovascular thrombolysis/therapies are viable options in selected patients under the guidance and expertise of a neurologist. This article will present the epidemiology of perioperative stroke, the pathophysiology, risk assessment and stratification for common surgeries. The article will additionally focus on treatment options including modifiable risk factor reduction and the perioperative management of medications.
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Anaortic Off-Pump Coronary Artery Bypass Grafting in the Elderly and Very Elderly. Heart Lung Circ 2013; 22:989-95. [DOI: 10.1016/j.hlc.2013.05.650] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 05/13/2013] [Accepted: 05/30/2013] [Indexed: 11/19/2022]
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50
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Cerebral dysfunction after coronary artery bypass surgery. J Anesth 2013; 28:242-8. [DOI: 10.1007/s00540-013-1699-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Accepted: 08/08/2013] [Indexed: 01/01/2023]
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