(Stroke. 2001;32:1508.)
© 2001 American Heart Association, Inc.
Original Contributions |
Stroke After Coronary Artery Bypass
Incidence, Predictors, and Clinical Outcome
From the Section of Cardiac Surgery, Department of Surgery, Washington Hospital Center, Washington, DC.
Correspondence to Sotiris C. Stamou, MD, PhD, 2950 Van Ness St, NW, Apt 624, Washington, DC 20008. E-mail sxs3{at}mhg.edu
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Abstract |
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 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferencesIntroduction References |
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Background and Purpose—Early postoperative stroke is a serious adverse event after coronary artery bypass grafting (CABG). This study sought to investigate risk factors, prevalence, and prognostic implications of postoperative stroke in patients undergoing CABG.
Methods—We investigated the predictors of postoperative stroke (n=333, 2%) in 16 528 consecutive patients who underwent CABG between September 1989 and June 1999 in our institution. Predictors of postoperative stroke were identified by logistic regression analysis.
Results—Among the preoperative and postoperative factors, significant correlates of stroke included (1) chronic renal insufficiency (P<0.001), (2) recent myocardial infarction (P=0.01), (3) previous cerebrovascular accident (P<0.001), (4) carotid artery disease (P<0.001), (5) hypertension (P<0.001), (6) diabetes (P=0.001), (7) age >75 years (P=0.008), (8) moderate/severe left ventricular dysfunction (P=0.01), (9) low cardiac output syndrome (P<0.001), and (10) atrial fibrillation (P<0.001). Postoperative stroke was associated with longer postoperative stay (11±4 versus 7±3 days for patients without stroke, P<0.001) and with higher in-hospital mortality (14% versus 2.7% for patients without stroke; P<0.001).
Conclusions—Stroke after CABG is associated with high short-term morbidity and mortality. Increased stroke risk can be predicted by preoperative and postoperative clinical factors.
Key Words: coronary artery bypass • coronary artery disease • heart surgery • stroke
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferencesIntroduction References |
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Coronary artery bypass grafting (CABG) is associated with adverse neurological complications, of which stroke is the most debilitating. Previous studies have attempted to identify clinical predictors of stroke after CABG.1 2 3 However, the low frequency of the index event (<5%) limits the power of most published investigations. In addition to a wide variability in the sample sizes studied, previous studies have evaluated many different variables in a nonuniform manner.1 2 3 To systematically investigate the incidence, predictors, and early clinical outcome of stroke after CABG in a large, unselected, clinical setting, we conducted the present study, which includes our 10-year cumulative experience of CABG surgery.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferencesIntroduction References |
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The computerized database of the Division of Cardiac Surgery of the Washington Hospital Center was queried to identify all patients who had undergone CABG and received <4 grafts between September 1989 and July 1999 (n=19 512). Patients who had undergone CABG with concurrent valve replacement (n=1811), aneurysmectomy (n=22), or carotid endarterectomy (n=79) were excluded. Patients who had CABG without cardiopulmonary bypass (n=1072) were also excluded from the study. The remaining 16 528 consecutive patients who underwent CABG during the study period constituted the population of the present study. Baseline demographics, procedural data, and perioperative outcomes were prospectively collected by using standardized data-entry forms. Clinical events were source-documented.
Definitions
Preoperative Variables
Chronic renal insufficiency was defined as serum
creatinine 
2.0 mg/dL. Carotid artery disease was
considered a history of carotid artery disease verified by angiography
or duplex ultrasonography. Recent myocardial infarction was defined as
a myocardial infarction occurring within 24 hours before CABG.
Moderate/severe left ventricular dysfunction was defined as
an ejection fraction 
34%.
Operative Variables
Significant atherosclerosis of the
ascending aorta was defined by palpation and defined as diffuse
irregularities, large protruding atheromata, thrombi, or
circumferential involvement of most or all of the ascending
aorta.2
Postoperative Variables
Low cardiac output syndrome was defined as the use of
postoperative inotropic support for >24 hours. Prolonged ventilatory
support was defined as pulmonary insufficiency requiring
ventilatory support >24 hours. Postoperative stroke was defined as any
new major (type II) neurological deficit presenting in the hospital
and persisting >72 hours.4
Transient ischemic attacks were not included in this
analysis. Strokes were confirmed by an independent neurologist
and/or appropriate brain imaging.
Statistical Analysis
Primary comparisons were performed between the
patients with and without stroke (stroke and no-stroke patients,
respectively). Data were expressed as percentages or as mean±SD.
Categorical variables were compared by using a 2-tailed Fisher
exact test. Continuous variables were compared by using 2-tailed
unpaired Student t tests for
variables with normal distributions and 2-tailed Mann-Whitney
U tests for variables with
nonnormal distributions. Univariate relative risks and 95%
CIs were calculated.
A multivariate, stepwise, forward logistic
regression analysis was conducted to determine independent
predictors of postoperative in-hospital stroke. The variables
included in the univariate risk analysis are
presented in
Table 1
. The criterion for a variable entry into
the logistic model was a univariate probability level of
P<0.2. A value of
P0.05 was considered
statistically significant. The quality of the fit of the logistic model
was tested with the Hosmer-Lemeshow goodness-of-fit test. The area
under the receiver operating characteristic curve was used to assess
how well the model could discriminate between patients with stroke
versus those without stroke. All statistical analyses were
performed by using the program SPSS 9.0 for
Windows 95 (Statistical Package for the Social Sciences,
Inc).
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferencesIntroduction References |
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A total of 16 528 consecutive patients undergoing CABG were included in the present study. Postoperative stroke occurred in 333 patients (2.0%). The baseline clinical characteristics of patients with and without stroke are summarized in Table 1
. Patients with postoperative stroke were
significantly older; they were more frequently female; and they were
more likely to have diabetes, hypertension, congestive heart failure,
recent myocardial infarction, previous cerebrovascular accident,
carotid artery disease, chronic renal insufficiency, ejection fraction
<34%, and unstable angina than were patients without stroke
(Table 1). Patients who had emergent CABG were also more
likely to develop postoperative stroke. Of patients who had carotid artery disease and developed stroke after surgery (n=21), 16 had stroke ipsilateral to the location of carotid artery disease, whereas 5 developed stroke in a contralateral location (n=3) or bilateral (n=2) relative to the site of carotid artery disease.
Operative and postoperative characteristics of patients are
presented in
Table 2 (univariate analysis).
Aortic atherosclerosis was more frequent in stroke
patients. Cross-clamp time was significantly higher in those who
developed postoperative stroke (46±19 minutes for stroke patients
versus 42±25 minutes for no-stroke patients,
P<0.001). Similarly,
cardiopulmonary bypass time was also significantly prolonged
for stroke patients (77±59 minutes for stroke patients versus 67±40
for no-stroke patients,
P<0.001). The number of
proximal anastomoses was higher in patients who had a stroke than in
those who did not (2.7±1 versus 2.4±1, respectively;
P<0.001).
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Postoperative cardiovascular,
pulmonary, and renal complications were significantly higher in
patients with stroke
(Table 2). Postoperative new-onset atrial fibrillation
occurred in 47% of the patients who developed postoperative stroke and
in 31% of the patients without stroke
(P<0.001).
Independent Predictors of Postoperative
Stroke
The results of the multivariate
logistic regression analysis model are summarized in
Table 3 (see also the
Figure). Variables that emerged as independent
predictors of stroke included chronic renal insufficiency, recent
myocardial infarction, previous cerebrovascular accident, carotid
artery disease, hypertension, diabetes, advanced age, moderate/severe
left ventricular dysfunction, low cardiac output syndrome,
and new-onset atrial fibrillation. The area under the receiver
operating characteristic curve was 0.92.
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Resource Utilization and In-Hospital
Mortality
Postoperative stroke was found to significantly prolong
the postoperative hospital stay (11±4 days for stroke patients versus
7±3 days for no-stroke patients,
P<0.001) as well as the
intensive care unit stay (2±2 days for stroke patients versus 1±1
days for no-stroke patients,
P<0.001). In-hospital
mortality was also significantly higher in patients with stroke (n=47,
14.4%) than in patients without stroke (n=436, 2.7%;
P<0.001).
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferencesIntroduction References |
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Stroke was a common complication after CABG in the 1960s (5% to 9%).5 Despite the improvement in surgical techniques and cardioplegic agents, along with the introduction of membrane oxygenators and in-line filtration, there is a persistent stroke rate associated with CABG ranging from 1% to 5%.6 It is estimated that 3000 to 15 000 patients each year suffer a stroke in the perioperative period after CABG.6 In the present study, the incidence of stroke was the same throughout the study period (1.8% from 1989 to 1994 versus 2.0% from 1995 to 1999) despite an increase in the high-risk patients who underwent surgery during the later study period (hypertension, 52% from 1989 to 1994 versus 60% from 1995 to 1999 [P<0.001]; diabetes, 27% versus 33% [P<0.001]; carotid artery disease, 1.1% versus 1.6% [P=0.006]; and age, 64±10 versus 64±11 years [P=0.06]). However, in the multivariate analysis, the period of study has not emerged as an independent predictor of higher risk of stroke.
Cerebral microemboli generated during CABG with cardiopulmonary bypass might be implicated in postoperative neurological impairment.7 8 Pathological examination by Moody et al9 of the brain after conventional CABG revealed the presence of multiple emboli lodged in small cerebral arterioles and capillaries. Additionally, BhaskerRao et al7 documented in a prospective study that cerebral dysfunction was significantly lower after CABG without cardiopulmonary bypass compared with on-pump CABG. Previous investigators have also found an association between prolonged cardiopulmonary bypass time (>120 minutes) and increased risk of postoperative stroke.3 5 Moreover, in patients who had on-pump CABG, proximal anastomoses were performed by use of complete cross-clamping of the aorta versus only a side clamp (used in off-pump CABG), a fact that may also contribute to an increased risk of stroke in on-pump CABG. These findings emphasize the unfavorable effects of cardiopulmonary bypass on the subsequent development of stroke.
Additionally, recent myocardial infarction (within 24 hours before CABG) was associated with a 3 times higher risk of stroke. Mooe et al10 reported a higher incidence of stroke after recent myocardial infarction that is probably related to the hemodynamic instability, increased blood thrombogenicity, and pronounced sympathetic activation in post–myocardial infarction patients. Comorbid conditions, such as chronic renal insufficiency,11 previous cerebrovascular accident,3 4 carotid artery disease,12 hypertension,13 diabetes mellitus,14 advanced age,15 and depressed ejection fraction,6 have been found in this and previous studies to predict postoperative stroke.
Among the postoperative variables, new-onset atrial fibrillation was associated with a higher risk of postoperative stroke. Atrial fibrillation has consistently been found to increase stroke rate in various clinical settings.3 16 Postoperative low cardiac output syndrome was associated with a 2-fold higher risk of stroke. Wide fluctuations in arterial blood pressure, as well as increased thrombogenicity and cerebral hypoperfusion, are implicated in the pathophysiology of stroke in this subset of patients.3 6 Atrial fibrillation most probably is related to the development of postoperative but not intraoperative stroke, as demonstrated by a previous study by Hogue et al.3 In their study, postoperative atrial fibrillation combined with low cardiac output was correlated only with late (postoperative) stroke because early (intraoperative) strokes precede the onset of postoperative atrial fibrillation.3
In the present study, stroke significantly increased the length of hospital and intensive care unit stay, as previously reported.2 Moreover, patients who developed stroke after CABG had a 5-fold higher rate of in-hospital mortality than did patients without stroke (14.4% versus 2.7%, respectively). This is in accordance with previous studies that have also reported a high mortality rate (13% to 41%) in patients with stroke after CABG.2
Clinical Implications
The typically poor postoperative course of patients who
develop stroke after CABG underlines the need for timely recognition
and prevention/modification of factors that predispose to stroke.
Carotid duplex ultrasonography may identify significant carotid disease
in high-risk patients. An alternative therapeutic approach in this
subset of patients may be concomitant CABG with carotid
endarterectomy or a staged approach with carotid
endarterectomy preceding
CABG.17
A modification of the surgical strategy, such as the "no-touch technique" described by Mills and Everson,18 might also be important in these patients. Furthermore, the increasing recognition of the role played by aortic atheroma, the innovative steps taken to minimize this risk (including epiaortic scanning), and the potential for intra-aortic filtration are all currently undergoing large-scale prospective evaluations.19 Royse et al20 have demonstrated that the use of epiaortic scanning and of a Y graft, which uses the radial artery joined to the pedicled left internal mammary artery in a Y-graft fashion, is associated with a significantly decreased incidence of cerebral embolization secondary to aortic instrumentation. CABG without cardiopulmonary bypass requires further investigation as an approach for decreasing the incidence of stroke and should potentially be considered in patients with carotid artery disease or other high-risk characteristics for stroke. However, the benefits of this technique have not been evaluated in a prospective randomized setting.
In addition, pharmaceutical agents, such as gangliosides,21 glutamate receptor antagonists, and antioxidants, may potentially minimize neuronal damage and decrease the occurrence of stroke.21 It has also been suggested that prostacyclin infusion during cardiopulmonary bypass may lower the incidence of encephalopathy and stroke during CABG by preventing the adhesion of platelets to the extracorporeal tubing and the subsequent microembolization.22 Further studies are needed to prospectively investigate the potential benefits of pharmaceutical agents in reducing the incidence of stroke after CABG.
Study Limitations
We studied an unselected cohort of CABG patients that
enabled the documentation of 333 index events and allowed the creation
of a statistically powerful regression model to identify predictors of
postoperative stroke. Limitations of the present study include
limitations inherent in any retrospective analysis. However,
all data elements were prospectively recorded according to specific
definitions. Although evaluation by an independent neurologist and/or
brain imaging was routinely performed in patients with suspected
neurological events, there was no neuropsychological testing that would
have enabled the assessment of more subtle changes in mentation and
behavior.
The contribution of postoperative atrial fibrillation to stroke risk may have been underestimated in the present study because the timing of the neurological event was not taken into consideration. Indeed, because early strokes precede the onset of postoperative atrial fibrillation, this arrhythmia cannot be a predictor of these events.3
Another limitation was that we detected aortic atherosclerosis by surgical palpation and not by ultrasonography; however, surgical palpation, when positive, has a high degree of specificity,2 as reported by Wolman et al2 in a study involving 24 institutions. The reason we have not used ultrasonography was because it was not always available or considered to be the standard of care at the time the study was performed. Furthermore, long-term morbidity and mortality outcomes in patients who developed stroke after CABG were outside the scope of the present study.
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Received January 18, 2001; revision received March 7, 2001; accepted March 20, 2001.
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References |
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1. Newman MF, Wolman R, Kanchuger M, Marschall K, Mora-Mangano C, Roach G, Smith LR, Aggarwal A, Nussmeier N, Herskowitz A, et al. Multicenter preoperative stroke risk index for patients undergoing coronary artery bypass graft surgery: Multicenter Study of Perioperative Ischemia (McSPI) Research Group. Circulation. 1996;94(suppl II):II-74-II-80.
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Marschall KE, Ley C, Boisvert DM, et al. Cerebral injury after cardiac
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Hogue CW, Murphy
SF, Schechtman KB, Davila-Roman VG. Risk factors for early or delayed
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Roach GW, Kanchuger
M, Mangano CM, Newman M, Nussmeier N, Wolman R, Aggarwal A, Marschall
K, Graham SH, Ley C. Adverse cerebral outcomes after coronary
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5. Gilman S. Cerebral disorders after open heart operations. N Engl J Med. 1965;272:489–498.
6. Furlan AJ, Sila CA, Chimowitz MI, Jones SC. Neurologic complications related to cardiac surgery. Neurol Clin. 1992;10:145–166.[Medline] [Order article via Infotrieve]
7. BhaskerRao B, VanHimbergen D, Edmonds HL, Jaber S, Ali AT, Pagni S, Koenig S, Spence PA. Evidence for improved cerebral function after minimally invasive bypass surgery. J Card Surg. 1998;13:27–31.[Medline] [Order article via Infotrieve]
8. Selnes OA, Goldsborough MA, Borowicz LM, McKhann GM. Neurobehavioural sequelae of cardiopulmonary bypass. Lancet. 1999;353:1601–1606.[Medline] [Order article via Infotrieve]
9. Moody DM, Bell MA, Johnston WE, Prough DS. Brain microemboli during cardiac surgery or aortography. Ann Neurol. 1990;28:477–486.[Medline] [Order article via Infotrieve]
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BO, Stegmayr B, Eriksson P. Ischemic stroke: impact of a recent
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12. Reed GL, Singer DE, Picard EH, DeSanctis RW. Stroke following coronary artery bypass surgery: a case control estimate of the risk from carotid bruits. N Engl J Med. 1988;319:1246–1250.[Abstract]
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Breuer AC, Furlan
AJ, Hanson MR, Lederman RJ, Loop FD, Cosgrove DM, Greenstreet RL,
Estafanous FG. Central nervous system complications of coronary
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Bentsen N, Larsen
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15. Tuman Kj, McCarthy RJ, Najafi H, Ivankovich AD. Differential effects of advanced age on neurologic and cardiac risks of coronary artery operations. J Thorac Cardiovasc Surg. 1992;104:1510–1517.[Abstract]
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17. Hines GL, Scott WC, Schubach SL, Kofsky E, Wehbe U, Cabasino E. Prophylactic carotid endarterectomy in patients with high-grade carotid stenosis undergoing coronary bypass: does it decrease the incidence of perioperative stroke? Ann Vasc Surg. 1998;12:23–27.[Medline] [Order article via Infotrieve]
18. Mills NL, Everson CT. Atherosclerosis of the ascending aorta and coronary artery bypass. J Thorac Cardiovasc Surg. 1991;102:546–553.[Abstract]
19.
Murkin JM, Stump
DA. Res ipsa loquitur: protecting the brain in the new millennium,
"outcomes 2000." Ann Thorac
Surg. 2000;69:1317–1318.
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21. Redmond JM, Gillinov AM, Blue ME, Zehr KJ, Troncoso JC, Cameron DE, Johnston MV, Baumgartner WA. The monosialoganglioside, GM1, reduces neurologic injury associated with hypothermic circulatory arrest. Surgery. 1993;114:332–333.
22. Fish KJ, Sarnquist FH, van Steennis C, Mitchell RS, Hilberman M, Jamieson SW, Linet OI, Miller DC. A prospective randomized study of the effects of prostacyclin on platelets and blood loss during coronary bypass operations. J Thorac Cardiovasc Surg. 1986;91:436–442. Stroke[Abstract]
Editorial Comment
Incidence, Predictors, and Clinical Outcome
Department of Neurology, Henry Ford Hospital, Detroit, Michigan
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferencesIntroduction References |
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An estimated 650 000 coronary artery bypass graft operations are performed in the United States each year.R1 The procedure has significantly reduced morbidity related to unstable angina and mortality in certain patients with chronic stable angina.R2 However, the incidence of clinically obvious stroke is reported to be between 0.8% and 5.2%.R1 Those figures suggest that between 5 000 and 35 000 new strokes are the result of this procedure, which possibly makes cardiac bypass surgery the single largest cause of iatrogenic stroke in the United States.
The study by Stamou et al focused solely on patients who had cardiopulmonary bypass (so-called on-pump patients) as part of the surgical procedure. Some authors suggest that patients who have coronary bypass surgery without cardiopulmonary bypass (so-called off-pump patients) are at lower risk for stroke.R3 To date, there is no randomized trial evidence to suggest that the hypothesis of reduced strokes in off-pump patients is true. And, even if true, there are other factors to consider between the 2 methods of surgery. For example, graft durability may be better in on-pump surgery, because off-pump surgery can be technically more challenging.
By virtue of the size of the database available to them, Stamou et al were able to identify, with sufficient power, risk factors that are more likely to be associated with this outcome in on-pump patients. A similar analysis of the >1000 off-pump patients in their database would be interesting, to see whether similar factors are related to clinically obvious stroke. Their findings are, all at once, new, confirmatory, and in some instances, surprising. Chronic renal insufficiency (serum creatinine >2.0 mg/dL) emerged as the most potent risk factor while aortic atherosclerosis (as detected by palpation) failed to emerge as an independent risk factor. Other factors such as advanced age, hypertension, diabetes, and postoperative atrial fibrillation seem more obvious. Their research raises important questions. What is the mechanism by which these factors put patients at greater risk? Since the strokes that occur around the time of cardiopulmonary bypass are presumed to be embolic, what is it about chronic renal failure, for example, that might increase the risk of embolism? Or, are these conditions merely markers of other disease states?
The occurrence of clinically obvious stroke, the outcome
measure in this study, likely represents only the tip of the
iceberg. Postoperative cognitive impairment or delirium, conditions
that may not necessarily fall under the rubric of "stroke," quite
possibly represent multiple territory cerebral microinfarcts
occurring as a result of an embolic shower. Consider the example of a
73-year-old woman 2 days after on-pump bypass surgery referred for
consultation because of "confusion and left arm weakness." Though
the clinical picture suggested only a right hemispheric event,
diffusion-weighted imaging suggested a more diffuse pattern of insult
(Figure). Similarly, a physician who undergoes bypass
surgery and is no longer able to practice 3 months after surgery
because of "difficulty concentrating" has possibly also sustained
multiterritory cerebral embolism. The 2.0% complication rate of
"stroke" quoted in the current article likely represents an
underestimate, because not all patients were independently assessed and
patients with strokes might have been classified in other categories,
such as delirium, depression, or dementia. Unfortunately, diagnosing
these patients radiologically has traditionally been difficult in the
past. Newer modalities may show promise in that regard.
Finally, the coronary artery bypass surgery operating room may represent an excellent venue in which to test the efficacy of putative neuroprotectants. In contrast to traditional trials, which are conducted in relatively uncontrolled settings (eg, emergency rooms), trials in bypass patients may more closely mirror those of the preclinical studies (eg, controlled blood pressure, temperature, and blood sugar). Studies such as those of Stamou et al help to identify those at highest risk and may help focus future studies of alleged neuroprotectants so that smaller sample sizes are required.
Received January 18, 2001; revision received March 7, 2001; accepted March 20, 2001.
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References |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferencesIntroduction References |
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1. Selnes OA, Goldsborough MA, Borowicz LM, McKhann GM. Neurobehavioural sequelae of cardiopulmonary bypass. Lancet. 1999;353:1601–1606.
2. Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW, Davis K, Killip T, Passamani E, Norris R, et al. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomized trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration [published correction appears in Lancet. 1994;344:1446]. Lancet. 1994;344:563–570.[Medline] [Order article via Infotrieve]
3. BhaskerRao B, VanHimbergen D, Edmonds HL Jr, Jaber S, Ali AT, Pagni S, Koenig S, Spence PA. Evidence for improved cerebral function after minimally invasive bypass surgery. J Card Surg. 1998;13:27–31.
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D. Bainbridge, D. Cheng, J. Martin, R. Novick, and The Evidence-based Peri-operative Clinical Outcome Does off-pump or minimally invasive coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with percutaneous coronary intervention? A meta-analysis of randomized trials J. Thorac. Cardiovasc. Surg., March 1, 2007; 133(3): 623 - 631. [Abstract] [Full Text] [PDF]
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J. Dunning, T. Treasure, M. Versteegh, S. A.M. Nashef, and on behalf of the EACTS Audit and Guidelines Commit Guidelines on the prevention and management of de novo atrial fibrillation after cardiac and thoracic surgery Eur. J. Cardiothorac. Surg., December 1, 2006; 30(6): 852 - 872. [Full Text] [PDF]
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V. Aboyans, L. Labrousse, P. Lacroix, J. Guilloux, S. Sekkal, A. Le Guyader, E. Cornu, and M. Laskar Predictive factors of stroke in patients undergoing coronary bypass grafting: statins are protective. Eur. J. Cardiothorac. Surg., August 1, 2006; 30(2): 300 - 304. [Abstract] [Full Text] [PDF]
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R. A. Baker, L. J. Hallsworth, and J. L. Knight Stroke After Coronary Artery Bypass Grafting Ann. Thorac. Surg., November 1, 2005; 80(5): 1746 - 1750. [Abstract] [Full Text] [PDF]
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K.-J. Wang, H.-H. Wu, S.-Y. Fang, Y.-R. Yang, and A. C.-C. Tseng Serum S-100 {beta} Protein During Coronary Artery Bypass Graft Surgery With or Without Cardiopulmonary Bypass Ann. Thorac. Surg., October 1, 2005; 80(4): 1371 - 1374. [Abstract] [Full Text] [PDF]
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T. Schachner, A. Zimmer, G. Nagele, G. Laufer, and J. Bonatti Risk factors for late stroke after coronary artery bypass grafting J. Thorac. Cardiovasc. Surg., August 1, 2005; 130(2): 485 - 490. [Abstract] [Full Text] [PDF]
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A. Budaj, K. Flasinska, J. M. Gore, F. A. Anderson Jr, O. H. Dabbous, F. A. Spencer, R. J. Goldberg, K. A.A. Fox, and for the GRACE Investigators Magnitude of and Risk Factors for In-Hospital and Postdischarge Stroke in Patients With Acute Coronary Syndromes: Findings From a Global Registry of Acute Coronary Events Circulation, June 21, 2005; 111(24): 3242 - 3247. [Abstract] [Full Text] [PDF]
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D. Bainbridge, J. Martin, and D. Cheng Off Pump Coronary Artery Bypass Graft Surgery Versus Conventional Coronary Artery Bypass Graft Surgery: A Systematic Review of the Literature Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2005; 9(1): 105 - 111. [Abstract] [PDF]
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L. J. Dacey, D. S. Likosky, B. J. Leavitt, S. J. Lahey, R. D. Quinn, F. Hernandez Jr, H. B. Quinton, J. P. Desimone, C. S. Ross, G. T. O'Connor, et al. Perioperative Stroke and Long-Term Survival After Coronary Bypass Graft Surgery Ann. Thorac. Surg., February 1, 2005; 79(2): 532 - 536. [Abstract] [Full Text] [PDF]
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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]
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J. Dunning, D. V. Nagarajan, M. Amanullah, and S. M. Nouraei What is the optimal anticoagulation management of patients post-cardiac surgery who go into atrial fibrillation? Interactive CardioVascular and Thoracic Surgery, September 1, 2004; 3(3): 503 - 509. [Abstract] [Full Text] [PDF]
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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]
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S. Dukkipati, W. W. O'Neill, K. J. Harjai, W. P. Sanders, D. Deo, J. A. Boura, B. A. Bartholomew, M. W. Yerkey, H. M. Sadeghi, and J. K. Kahn Characteristics of cerebrovascular accidents after percutaneous coronary interventions J. Am. Coll. Cardiol., April 7, 2004; 43(7): 1161 - 1167. [Abstract] [Full Text] [PDF]
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J. Lahtinen, F. Biancari, E. Salmela, M. Mosorin, J. Satta, P. Rainio, J. Rimpilainen, M. Lepojarvi, and T. Juvonen Postoperative atrial fibrillation is a major cause of stroke after on-pump coronary artery bypass surgery Ann. Thorac. Surg., April 1, 2004; 77(4): 1241 - 1244. [Abstract] [Full Text] [PDF]
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W. Mistiaen, Ph. Van Cauwelaert, Ph. Muylaert, S. U. Sys, F. Harrisson, and H. Bortier Thromboembolic events after aortic valve replacement in elderly patients with a Carpentier-Edwards Perimount pericardial bioprosthesis J. Thorac. Cardiovasc. Surg., April 1, 2004; 127(4): 1166 - 1170. [Abstract] [Full Text] [PDF]
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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]
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T. Athanasiou, S. Al-Ruzzeh, P. Kumar, M.-C. Crossman, M. Amrani, J. R. Pepper, R. Del Stanbridge, R. Casula, and B. Glenville Off-pump myocardial revascularization is associated with less incidence of stroke in elderly patients Ann. Thorac. Surg., February 1, 2004; 77(2): 745 - 753. [Abstract] [Full Text] [PDF]
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D. C. Charlesworth, D. S. Likosky, C. A. S. Marrin, C. T. Maloney, H. B. Quinton, J. R. Morton, B. J. Leavitt, R. A. Clough, and G. T. O'Connor Development and validation of a prediction model for strokes after coronary artery bypass grafting Ann. Thorac. Surg., August 1, 2003; 76(2): 436 - 443. [Abstract] [Full Text] [PDF]
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P. E. Antunes, J. Ferrao de Oliveira, and M. J. Antunes Predictors of cerebrovascular events in patients subjected to isolated coronary surgery. The importance of aortic cross-clamping Eur. J. Cardiothorac. Surg., March 1, 2003; 23(3): 328 - 333. [Abstract] [Full Text] [PDF]
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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]
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S. Fuchs, E. Stabile, T. D. Kinnaird, G. S. Mintz, L. Gruberg, D. A. Canos, E. E. Pinnow, R. Kornowski, W. O. Suddath, L. F. Satler, et al. Stroke Complicating Percutaneous Coronary Interventions: Incidence, Predictors, and Prognostic Implications Circulation, July 2, 2002; 106(1): 86 - 91. [Abstract] [Full Text] [PDF]
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