Adverse Cerebral Outcomes after Coronary Artery Bypass Surgery—More Than a Decade of Experience in a Single Center

Abstract

Background Nonfatal strokes, transient ischemic attacks (TIAs), and reversible ischemic neurological deficits (RIND) after elective coronary artery bypass grafting (CABG) are devastating clinical problems. The anesthesiologist, surgical and intensive care teams in a community hospital adopted a strategy developed in an effort to minimize these adverse outcome events.

The purpose of this study is to determine the incidence of and predictors for perioperative adverse neurologic events.

Methods A historical cohort study of 1,108 consecutive CABG patients operated between 2002 and 2014. Outcomes were defined as (1) a new neurologic damage (a new stroke, TIA, or RIND) and (2) a new neurologic damage or 30 days mortality.

Results Adverse cerebral outcomes occurred in 16 patients (1.4 percent). Nine patients had postoperative stroke, six suffered TIAs, and one had postoperative RIND.

In multivariate analysis, older age (OR 1.07, 95% CI 1.01–1.14), congestive heart failure (OR 3.57, 95% CI 1.22–10.49) and prior stroke (OR 6.27, 95% CI 1.78–22.03) were significantly associated with increased risk of new neurologic damage. These parameters were also significantly associated with increased risk of the combined outcome (new neurologic damage/mortality).

Conclusions A low incidence rate of adverse cerebral outcomes after CABG in community hospital can be achieved with the use of the suggested surgical intensive care, and anesthetic strategy. Advanced age, congestive heart failure, and prior stroke are associated with adverse outcomes.

Keywords

coronary artery bypass grafting - CABG - neurology/neurologic deficits - disease - injury - neurocognitive deficits

• References

• 1 Roach GW, Kanchuger M, Mangano CM. , et al; Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. Adverse cerebral outcomes after coronary bypass surgery. N Engl J Med 1996; 335 (25) 1857-1863
• 2 Ikeoka DT, Fernandes VA, Gebara O. , et al. Evaluation of the Society of Thoracic Surgeons score system for isolated coronary bypass graft surgery in a Brazilian population. Rev Bras Cir Cardiovasc 2014; 29 (01) 51-58
• 3 Pepin E, Dulan S. Effect of mean arterial pressure on cerebral perfusion during cardiopulmonary bypass: a review. J Extra Corpor Technol 2003; 35 (04) 297-303
• 4 Dávila-Román VG, Barzilai B, Wareing TH, Murphy SF, Schechtman KB, Kouchoukos NT. Atherosclerosis of the ascending aorta. Prevalence and role as an independent predictor of cerebrovascular events in cardiac patients. Stroke 1994; 25 (10) 2010-2016
• 5 Aldea GS, Soltow LO, Chandler WL. , et al. Limitation of thrombin generation, platelet activation, and inflammation by elimination of cardiotomy suction in patients undergoing coronary artery bypass grafting treated with heparin-bonded circuits. J Thorac Cardiovasc Surg 2002; 123 (04) 742-755
• 6 Coull AJ, Lovett JK, Rothwell PM. ; Oxford Vascular Study. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. BMJ 2004; 328 (7435): 326
• 7 Lilly KJ, Balaguer JM, Pirundini PA. , et al. Early results of a comprehensive operative and perfusion strategy to attenuate the incidence of adverse neurological outcomes in on-pump coronary artery bypass grafting (CABG) patients. Perfusion 2006; 21 (06) 311-317
• 8 Mora CT, Henson MB, Weintraub WS. , et al. The effect of temperature management during cardiopulmonary bypass on neurologic and neuropsychologic outcomes in patients undergoing coronary revascularization. J Thorac Cardiovasc Surg 1996; 112 (02) 514-522
• 9 Engelman RM, Pleet AB, Rousou JA. , et al. Influence of cardiopulmonary bypass perfusion temperature on neurologic and hematologic function after coronary artery bypass grafting. Ann Thorac Surg 1999; 67 (06) 1547-1555 , discussion 1556
• 10 Zingone B, Rauber E, Gatti G. , et al. The impact of epiaortic ultrasonographic scanning on the risk of perioperative stroke. Eur J Cardiothorac Surg 2006; 29 (05) 720-728
• 11 Kouchoukos NT, Wareing TH, Daily BB, Murphy SF. Management of the severely atherosclerotic aorta during cardiac operations. J Card Surg 1994; 9 (05) 490-494
• 12 Aranki SF, Rizzo RJ, Adams DH. , et al. Single-clamp technique: an important adjunct to myocardial and cerebral protection in coronary operations. Ann Thorac Surg 1994; 58 (02) 296-302 , discussion 302–303
• 13 De Somer F, François K, van Oeveren W. , et al. Phosphorylcholine coating of extracorporeal circuits provides natural protection against blood activation by the material surface. Eur J Cardiothorac Surg 2000; 18 (05) 602-606
• 14 DioDato CP, Likosky DS, DeFoe GR. , et al; Nothern New England Cardiovascular Disease Study Group. Cardiopulmonary bypass recommendations in adults: the northern New England experience. J Extra Corpor Technol 2008; 40 (01) 16-20
• 15 De Somer F. Optimal versus suboptimal perfusion during cardiopulmonary bypass and the inflammatory response. Semin Cardiothorac Vasc Anesth 2009; 13 (02) 113-117
• 16 Lilly KJ, O'Gara PJ, Treanor PR. , et al. Heparin-bonded circuits without a cardiotomy: a description of a minimally invasive technique of cardiopulmonary bypass. Perfusion 2002; 17 (02) 95-97