(Stroke. 1999;30:514-522.)
© 1999 American Heart Association, Inc.
Original Contributions |
Cerebral Injury After Cardiac Surgery
Identification of a Group at Extraordinary Risk
From the Departments of Anesthesiology, Neurology, Surgery and Cardiology at the School of Medicine, Medical College of Virginia Campus, Richmond (R.L.W.); the Texas Heart Institute, Houston, Tex (N.A.N.); Veterans Administration Medical Center, Milwaukee, Wisc (A.A.); New York University, NY (M.S.K., K.E.M.); Kaiser Permanente Medical Center, San Francisco, Calif (G.W.R.); Duke Heart Center, Durham, NC (M.F.N.); Stanford University, Stanford, Calif (C.M.M.); the University of Pittsburgh, Pittsburgh, Pa (S.H.G.); Veterans Affairs Medical Center, San Francisco, Calif (G.M.O., D.T.M.); and the Ischemia Research and Education Foundation (C.L., D.M.B., A.H.), San Francisco, Calif.
Correspondence and reprint requests to Richard L. Wolman, MD, c/o The Editorial Office, The Ischemia Research and Education Foundation, Suite 3400, 250 Executive Park Blvd, San Francisco, CA 94134.
Background and Purpose—Cerebral injury after cardiac surgery is now recognized as a serious and costly healthcare problem mandating immediate attention. To effect solution, those subgroups of patients at greatest risk must be identified, thereby allowing efficient implementation of new clinical strategies. No such subgroup has been identified; however, patients undergoing intracardiac surgery are thought to be at high risk, but comprehensive data regarding specific risk, impact on cost, and discharge disposition are not available.
Methods—We prospectively studied 273 patients enrolled from 24 diverse US medical centers, who were undergoing intracardiac and coronary artery surgery. Patient data were collected using standardized methods and included clinical, historical, specialized testing, neurological outcome and autopsy data, and measures of resource utilization. Adverse outcomes were defined a priori and determined after database closure by a blinded independent panel. Stepwise logistic regression models were developed to estimate the relative risks associated with clinical history and intraoperative and postoperative events.
Results—Adverse cerebral outcomes occurred in 16% of patients (43/273), being nearly equally divided between type I outcomes (8.4%; 5 cerebral deaths, 16 nonfatal strokes, and 2 new TIAs) and type II outcomes (7.3%; 17 new intellectual deterioration persisting at hospital discharge and 3 newly diagnosed seizures). Associated resource utilization was significantly increased—prolonging median intensive care unit stay from 3 days (no adverse cerebral outcome) to 8 days (type I; P<0.001) and from 3 to 6 days (type II; P<0.001), and increasing hospitalization by 50% (type II, P=0.04) to 100% (type I, P<0.001). Furthermore, specialized care after hospital discharge was frequently necessary in those with type I outcomes, in that only 31% returned home compared with 85% of patients without cerebral complications (P<0.001). Significant risk factors for type I outcomes related primarily to embolic phenomena, including proximal aortic atherosclerosis, intracardiac thrombus, and intermittent clamping of the aorta during surgery. For type II outcomes, risk factors again included proximal aortic atherosclerosis, as well as a preoperative history of endocarditis, alcohol abuse, perioperative dysrhythmia or poorly controlled hypertension, and the development of a low-output state after cardiopulmonary bypass.
Conclusions—These prospective multicenter findings demonstrate that patients undergoing intracardiac surgery combined with coronary revascularization are at formidable risk, in that 1 in 6 will develop cerebral complications that are frequently costly and devastating. Thus, new strategies for perioperative management—including technical and pharmacological interventions—are now mandated for this subgroup of cardiac surgery patients.
Key Words: cardiopulmonary bypass • cerebral embolism and thrombosis • coronary heart disease • postoperative complications
This article has been cited by other articles:
 |
|
 |
|
  J. K. White, A. Jagannath, J. Titus, R. Yoneyama, J. Madsen, and A. K. Agnihotri Funnel-tipped aortic cannula for reduction of atheroemboli. Ann. Thorac. Surg., August 1, 2009; 88(2): 551 - 557. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Selim Angioplasty and Stenting of Asymptomatic Carotid Stenosis Before Cardiac Surgery: More Study Is Needed Arch Neurol, December 1, 2008; 65(12): 1672 - 1674. [Full Text] [PDF]
|
|
|
|
 |
|
 D. E. Singer, G. W. Albers, J. E. Dalen, M. C. Fang, A. S. Go, J. L. Halperin, G. Y. H. Lip, and W. J. Manning Antithrombotic Therapy in Atrial Fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, June 1, 2008; 133(6_suppl): 546S - 592S. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. E. Glas, M. Swaminathan, S. T. Reeves, J. S. Shanewise, D. Rubenson, P. K. Smith, J. P. Mathew, S. K. Shernan, and Council for Intraoperative Echocardiography of the Guidelines for the Performance of a Comprehensive Intraoperative Epiaortic Ultrasonographic Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists; Endorsed by the Society of Thoracic Surgeons Anesth. Analg., May 1, 2008; 106(5): 1376 - 1384. [Full Text] [PDF]
|
|
|
|
 |
|
 P. A. Barber, S. Hach, L. J. Tippett, L. Ross, A. F. Merry, and P. Milsom Cerebral Ischemic Lesions on Diffusion-Weighted Imaging Are Associated With Neurocognitive Decline After Cardiac Surgery Stroke, May 1, 2008; 39(5): 1427 - 1433. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. M. Mentzer Jr, C. Bartels, R. Bolli, S. Boyce, G. D. Buckberg, B. Chaitman, A. Haverich, J. Knight, P. Menasche, M. L. Myers, et al. Sodium-Hydrogen Exchange Inhibition by Cariporide to Reduce the Risk of Ischemic Cardiac Events in Patients Undergoing Coronary Artery Bypass Grafting: Results of the EXPEDITION Study Ann. Thorac. Surg., April 1, 2008; 85(4): 1261 - 1270. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. Zingone, E. Rauber, G. Gatti, A. Pappalardo, B. Benussi, G. Forti, U. Tognolli, and M. Gabrielli Diagnosis and management of severe atherosclerosis of the ascending aorta and aortic arch during cardiac surgery: focus on aortic replacement Eur. J. Cardiothorac. Surg., June 1, 2007; 31(6): 990 - 997. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J.-C. Tardif, M. Carrier, D. E. Kandzari, R. Emery, R. Cote, T. Heinonen, M. Zettler, V. Hasselblad, M.-C. Guertin, R. A. Harrington, et al. Effects of pyridoxal-5'-phosphate (MC-1) in patients undergoing high-risk coronary artery bypass surgery: Results of the MEND-CABG randomized study J. Thorac. Cardiovasc. Surg., June 1, 2007; 133(6): 1604 - 1611. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. Zingone, G. Gatti, E. Rauber, A. Pappalardo, B. Benussi, and L. Dreas Surgical Management of the Atherosclerotic Ascending Aorta: Is Endoaortic Balloon Occlusion Safe? Ann. Thorac. Surg., November 1, 2006; 82(5): 1709 - 1714. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Steinbrink, T. Fischer, H. Kuppe, R. Hetzer, K. Uludag, H. Obrig, and W. M. Kuebler Relevance of depth resolution for cerebral blood flow monitoring by near-infrared spectroscopic bolus tracking during cardiopulmonary bypass. J. Thorac. Cardiovasc. Surg., November 1, 2006; 132(5): 1172 - 1178. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. F. Floyd, P. N. Shah, C. C. Price, F. Harris, S. J. Ratcliffe, M. A. Acker, J. E. Bavaria, H. Rahmouni, B. Kuersten, S. Wiegers, et al. Clinically Silent Cerebral Ischemic Events After Cardiac Surgery: Their Incidence, Regional Vascular Occurrence, and Procedural Dependence Ann. Thorac. Surg., June 1, 2006; 81(6): 2160 - 2166. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. Zingone, E. Rauber, G. Gatti, A. Pappalardo, B. Benussi, L. Dreas, and L. Lattuada The impact of epiaortic ultrasonographic scanning on the risk of perioperative stroke. Eur. J. Cardiothorac. Surg., May 1, 2006; 29(5): 720 - 728. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M Paciaroni, V Caso, M Acciarresi, R W Baumgartner, and G Agnelli Management of asymptomatic carotid stenosis in patients undergoing general and vascular surgical procedures J. Neurol. Neurosurg. Psychiatry, October 1, 2005; 76(10): 1332 - 1336. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. Prasongsukarn and M. A. Borger Reducing Cerebral Emboli During Cardiopulmonary Bypass Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2005; 9(2): 153 - 158. [Abstract] [PDF]
|
|
|
|
 |
|
 J. Pepper Controversies in Off-pump Coronary Artery Surgery Clin. Med. Res., February 1, 2005; 3(1): 27 - 33. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. I. Kapetanakis, S. C. Stamou, M. K.C. Dullum, P. C. Hill, E. Haile, S. W. Boyce, A. S. Bafi, K. R. Petro, and P. J. Corso The Impact of Aortic Manipulation on Neurologic Outcomes After Coronary Artery Bypass Surgery: A Risk-Adjusted Study Ann. Thorac. Surg., November 1, 2004; 78(5): 1564 - 1571. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. M. Homi, H. Yang, R. D. Pearlstein, and H. P. Grocott Hemodilution During Cardiopulmonary Bypass Increases Cerebral Infarct Volume After Middle Cerebral Artery Occlusion in Rats Anesth. Analg., October 1, 2004; 99(4): 974 - 981. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Kaukuntla, A. Walker, D. Harrington, T. Jones, and R. S. Bonser Differential brain and body temperature during cardiopulmonary bypass--a randomised clinical study Eur. J. Cardiothorac. Surg., September 1, 2004; 26(3): 571 - 579. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. E. Singer, G. W. Albers, J. E. Dalen, A. S. Go, J. L. Halperin, and W. J. Manning Antithrombotic Therapy in Atrial Fibrillation: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest, September 1, 2004; 126(3_suppl): 429S - 456S. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. K. Peel, S. C. Stamou, M. K. C. Dullum, P. C. Hill, K. A. Jablonski, A. S. Bafi, S. W. Boyce, K. R. Petro, and P. J. Corso Chronologic distribution of stroke after minimally invasive versus conventional coronary artery bypass J. Am. Coll. Cardiol., March 3, 2004; 43(5): 752 - 756. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Taggart Off-pump surgery and cerebral injury J. Thorac. Cardiovasc. Surg., January 1, 2004; 127(1): 7 - 9. [Full Text] [PDF]
|
|
|
|
|
|
C. Schmitz, S. Weinreich, J. White, I. Oengoeren, R. Schneider, D. Schneider, I. Speth, C. Pohl, and A. Welz Can particulate extraction from the ascending aorta reduce neurologic injury in cardiac surgery? J. Thorac. Cardiovasc. Surg., December 1, 2003; 126(6): 1829 - 1836. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Schoenburg, B. Kraus, A. Muehling, U. Taborski, H. Hofmann, G. Erhardt, S. Hein, M. Roth, P. R. Vogt, G. F. Karliczek, et al. The dynamic air bubble trap reduces cerebral microembolism during cardiopulmonary bypass J. Thorac. Cardiovasc. Surg., November 1, 2003; 126(5): 1455 - 1460. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. D'Ancona, J. I. S. de Ibarra, R. Baillot, P. Mathieu, D. Doyle, J. Metras, D. Desaulniers, and F. Dagenais Determinants of stroke after coronary artery bypass grafting Eur. J. Cardiothorac. Surg., October 1, 2003; 24(4): 552 - 556. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D P Taggart, S M Browne, D T Wade, and P W Halligan Neuroprotection during cardiac surgery: a randomised trial of a platelet activating factor antagonist Heart, August 1, 2003; 89(8): 897 - 900. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. A. Grega, L. M. Borowicz, and W. A. Baumgartner Impact of single clamp versus double clamp technique on neurologic outcome Ann. Thorac. Surg., May 1, 2003; 75(5): 1387 - 1391. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Bucerius, J. F. Gummert, M. A. Borger, T. Walther, N. Doll, J. F. Onnasch, S. Metz, V. Falk, and F. W. Mohr Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients Ann. Thorac. Surg., February 1, 2003; 75(2): 472 - 478. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. J. Frumento, C. M.N. O'Malley, and E. Bennett-Guerrero Stroke after cardiac surgery: a retrospective analysis of the effect of aprotinin dosing regimens Ann. Thorac. Surg., February 1, 2003; 75(2): 479 - 483. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Wimmer-Greinecker Reduction of neurologic complications by intra-aortic filtration in patients undergoing combined intracardiac and CABG procedures Eur. J. Cardiothorac. Surg., February 1, 2003; 23(2): 159 - 164. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. J. Cook, T. A. Orszulak, K. J. Zehr, N. A. Nussmeier, J. J. Livesay, J. W. Hammon, and X. Chen Effectiveness of the Cobra aortic catheter for dual-temperature management during adult cardiac surgery J. Thorac. Cardiovasc. Surg., February 1, 2003; 125(2): 378 - 384. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. B. Dobkowski Myocardial Protection During Minimally Invasive Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, December 1, 2002; 6(4): 319 - 324. [Abstract] [PDF]
|
|
|
|
|
|
S. C. Stamou, K. A. Jablonski, A. J. Pfister, P. C. Hill, M. K.C. Dullum, A. S. Bafi, S. W. Boyce, K. R. Petro, and P. J. Corso Stroke after conventional versus minimally invasive coronary artery bypass Ann. Thorac. Surg., August 1, 2002; 74(2): 394 - 399. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Bendszus, W. Reents, D. Franke, W. Mullges, J. Babin-Ebell, M. Koltzenburg, M. Warmuth-Metz, and L. Solymosi Brain Damage After Coronary Artery Bypass Grafting Arch Neurol, July 1, 2002; 59(7): 1090 - 1095. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y. Sato, D. T. Laskowitz, E. R. Bennett, M. F. Newman, D. S. Warner, and H. P. Grocott Differential Cerebral Gene Expression During Cardiopulmonary Bypass in the Rat: Evidence for Apoptosis? Anesth. Analg., June 1, 2002; 94(6): 1389 - 1394. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. P. Grocott, G. B. Mackensen, A. M. Grigore, J. Mathew, J.G. Reves, B. Phillips-Bute, P. K. Smith, and M. F. Newman Postoperative Hyperthermia Is Associated With Cognitive Dysfunction After Coronary Artery Bypass Graft Surgery Stroke, February 1, 2002; 33(2): 537 - 541. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. A. Macoviak, J. Hwang, K. L. Boerjan, and D. D. Deal Comparing dual-stream and standard cardiopulmonary bypass in pigs Ann. Thorac. Surg., January 1, 2002; 73(1): 203 - 208. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. G. Leyh, S. Fischer, W. Harringer, and A. Haverich Intraoperative acute type A dissection caused by an intra-aortic filter (EMBOL-X(R)) in a patient undergoing mitral valve re-replacement for acute endocarditis Eur. J. Cardiothorac. Surg., January 1, 2002; 21(1): 100 - 101. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Schmitz and E. H. Blackstone International Council of Emboli Management (ICEM) Study Group results: risk adjusted outcomes in intraaortic filtration Eur. J. Cardiothorac. Surg., November 1, 2001; 20(5): 986 - 991. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. C. Stamou, P. C. Hill, G. Dangas, A. J. Pfister, S. W. Boyce, M. K.C. Dullum, A. S. Bafi, P. J. Corso, and B. Silver Stroke After Coronary Artery Bypass : Incidence, Predictors, and Clinical Outcome Editorial Comment: Incidence, Predictors, and Clinical Outcome Stroke, July 1, 2001; 32(7): 1508 - 1513. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Svedjeholm, E. Hakanson, Z. Szabo, and F. Vanky Neurological injury after surgery for ischemic heart disease: risk factors, outcome and role of metabolic interventions Eur. J. Cardiothorac. Surg., May 1, 2001; 19(5): 611 - 618. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. J. Wityk, M. A. Goldsborough, A. Hillis, N. Beauchamp, P. B. Barker, L. M. Borowicz Jr, and G. M. McKhann Diffusion- and Perfusion-Weighted Brain Magnetic Resonance Imaging in Patients With Neurologic Complications After Cardiac Surgery Arch Neurol, April 1, 2001; 58(4): 571 - 576. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. Pretre and M. I. Turina Choice of Revascularization Strategy for Patients With Coronary Artery Disease JAMA, February 28, 2001; 285(8): 992 - 994. [Full Text] [PDF]
|
|
|
|
|
|
S. Wan and A. P. C. Yim Is Off-Pump Cardiac Surgery Better for the Brain? Chest, January 1, 2001; 119(1): 1 - 1. [Full Text] [PDF]
|
|
|
|
|
|
W. Harringer Capture of particulate emboli during cardiac procedures in which aortic cross-clamp is used Ann. Thorac. Surg., September 1, 2000; 70(3): 1119 - 1123. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. Fan, K. L. Lee, C. S.W. Chiu, J. W.T. Lee, G.-W. He, D. Cheung, M. P. Sun, and C.-P. Lau Effects of Biatrial Pacing in Prevention of Postoperative Atrial Fibrillation After Coronary Artery Bypass Surgery Circulation, August 15, 2000; 102(7): 755 - 760. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. S. Ali, M. Harmer, and R. Vaughan Serum S100 protein as a marker of cerebral damage during cardiac surgery Br. J. Anaesth., August 1, 2000; 85(2): 287 - 298. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. G. Royse, C. F. Royse, A. E. Ajani, E. Symes, P. Maruff, S. Karagiannis, R. P. Gerraty, L. E. Grigg, and S. M. Davis Reduced neuropsychological dysfunction using epiaortic echocardiography and the exclusive Y graft Ann. Thorac. Surg., May 1, 2000; 69(5): 1431 - 1438. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Reichenspurner, J. A. Navia, G. Berry, R. C. Robbins, D. Barbut, J. P. Gold, and B. Reichart PARTICULATE EMBOLI CAPTURE BY AN INTRA-AORTIC FILTER DEVICE DURING CARDIAC SURGERY J. Thorac. Cardiovasc. Surg., February 1, 2000; 119(2): 233 - 241. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Z. G. Nadareishvili, Z. Choudary, C. Joyner, D. Brodie, and J. W. Norris Cerebral Microembolism in Acute Myocardial Infarction Stroke, December 1, 1999; 30(12): 2679 - 2682. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Neurologic Complications from Intracardiac Surgery Journal Watch Neurology, May 1, 1999; 1999(501): 1 - 1. [Full Text]
|
|