The Impact of Coronary Artery Bypass Grafting Surgical Technique on Stroke in Young and Elderly Patients
DOI:
https://doi.org/10.1532/HSF98.20081132Abstract
Background: Today, the elderly represent a large and rapidly growing segment of society and are being referred in increasing numbers for coronary artery bypass grafting (CABG) surgery. Stroke is a major complication of CABG surgery. The risk of stroke after CABG can be managed successfully, especially in high-risk patients, by choosing an adequate and appropriate surgical technique.
Methods: We evaluated 890 consecutive patients who underwent isolated CABG surgery by the same team between June 2006 and July 2008. The patients were divided by age into 2 groups. Group I consisted of 480 patients <65 years of age, and group II comprised 410 patients >65 years of age. Each group was then divided into 4 subgroups according to the surgical technique used: double-clamp technique (DCT), single-clamp technique (SCT), off-pump, and on-pump cross-clamp off. Preoperative risk factors for stroke and all clinical data were collected for the patients.
Results: In group I, 192 (40%) of the patients were female, and 288 (60%) were male. In group II, 170 (41.5%) were female, and 240 (58.5%) were male. Five patients in each group experienced stroke, with an incidence of 1.04% in group I (4 men and 1 woman) and 1.21% in group II (3 men and 2 women). The stroke rates of the 2 age groups were not significantly different (P = .802). Three of the 480 patients in group I died, with only 1 (33.3%) of the deaths related to stroke. In group II, however, 2 (50%) of the 4 deaths were related to stroke. The incidences of stroke-associated mortality in the 2 age groups were not significantly different (P = 1.0).
Conclusion: Although off-pump and on-pump cross-clamp off techniques were performed for some of the patients, DCT and SCT were used for the majority of the patients. We detected no statistically significant difference between these 2 groups of patients in the impact of applying DCT and SCT on the stroke rate. We conclude that this result was due to the different surgical techniques performed on a minority of the patients (82 patients).
References
Almassi GH, Sommers T, Moritz TE, et al. 1999. Stroke in cardiac surgical patients: determinants and outcome. Ann Thorac Surg 68:391-7, discussion 397-8.nAranki SF, Rizzo RJ, Adams DH, et al. 1994. Single-clamp technique: an important adjunct to myocardial and cerebral protection in coronary operations. Ann Thorac Surg 58:296-303.nBarbut D, Hinton RB, Szatrowski TP, et al. 1994. Cerebral emboli detected during bypass surgery are associated with clamp removal. Stroke 25:2398-402.nBar-Yosef S, Anders M, Mackensen GB, et al. 2004. Aortic atheroma burden and cognitive dysfunction after coronary artery bypass graft surgery. Ann Thorac Surg 78:1556-62.nBraekken SK, Reinvang I, Russell D, Brucher R, Svennevig JL. 1998. Association between intaoperative cerebral microembolic signals and postoperative neuropsychological deficit: comparison between patients with cardiac valve replacement and patients with coronary artery bypass grafting. J Neurol Neurosurg Psychiatry 65:573-6.nBrener BJ, Brief DK, Alpert J, Goldenkranz RJ, Parsonnet V. 1987. The risk of stroke in patients with asymptomatic carotid stenosis undergoing cardiac surgery: a follow-up study. J Vasc Surg 5:269-79.nClark RE, Brillman J, Davis DA, Lovell MR, Price TR, Magovern GJ. 1995. Microemboli during coronary artery bypass grafting: genesis and effect on outcome. J Thorac Cardiovasc Surg 109:249-58.nCosgrove DM. 1983. Management of the calcified aorta: an alternative method of occlusion. Ann Thorac Surg 36:718-9.nCosgrove DM, Loop FD, Lytle BW, et al. 1984. Primary myocardial revascularization: trends in surgical mortality. J Thorac Cardiovasc Surg 88(pt 1):673-84.nDemopoulos LA, Tunick PA, Bernstein NE, Perez JL, Kronzon I. 1995. Protruding atheromas of the aortic arch in symptomatic patients with carotid artery disease. Am Heart J 129:40-4.nDiegeler A, Hirsch R, Schneider F, et al. 2000. Neuromonitoring and neurocognitive outcome in off-pump versus conventional coronary bypass operation. Ann Thorac Surg 69:1162-6.nFaggioli GL, Curl GR, Ricotta JJ. 1990. The role of carotid screening before coronary artery bypass. J Vasc Surg 12:724-31.nFilsoufi F, Rahmanian PB, Castillo JG, Bronster D, Adams DH. 2008. Incidence, topography, predictors and long-term survival after stroke in patients undergoing coronary artery bypass grafting. Ann Thorac Surg 85:862-70.nGardner TJ, Horneffer PJ, Manolio TA, et al. 1985. Stroke following coronary artery bypass grafting: a ten-year study. Ann Thorac Surg 40:574-81.nGoto T, Baba T, Matsuyama K, Honma K, Ura M, Koshiji T. 2003. Aortic atherosclerosis and postoperative neurological dysfunction in elderly coronary surgical patients. Ann Thorac Surg 75:1912-8.nGrega MA, Borowicz LM, Baumgartner WA. 2003. Impact of single clamp versus double clamp technique on neurologic outcome. Ann Thorac Surg 75:1387-91.nGrigore AM, Grocott HP, Mathew JP, et al., the Neurologic Outcome Research Group of the Duke Heart Center. 2002. The rewarming rate and increased peak temperature alter neurocognitive outcome after cardiac surgery. Anesth Analg 94:4-10.nGrocott HP, Mackensen GB, Grigore AM, et al., the Neurologic Outcome Research Group (NORG) Cardiothoracic Anesthesiology Research Endeavors (CARE) Investigators of the Duke Heart Center. 2002. Postoperative hyperthermia is associated with cognitive dysfunction after coronary artery bypass graft surgery. Stroke 33:537-41.nHammon JW Jr, Stump DA, Kon ND, et al. 1997. Risk factors and solutions for the development of neurobehavioral changes after coronary artery bypass grafting. Ann Thorac Surg 63:1613-8.nHarrison MJ. 1995. Neurologic complications of coronary artery bypass grafting: diffuse or focal ischemia? Ann Thorac Surg 59:1356-8.nHertzer NR, Loop FD, Beven EG, O'Hara. 1989. Surgical staging for simultaneous coronary and carotid disease: a study including prospective randomization. J Vasc Surg 9:455-63.nJohn R, Choudhri AF, Weinberg AD, et al. 2000. Multicenter review of preoperative risk factors for stroke after coronary artery bypass grafting. Ann Thorac Surg 69:30-6.nJones EL, Craver JM, Guyton RA, Bone DK, Hatcher CR Jr. 1983. Trends in the treatment of coronary disease today. Selective use of PTCA and bypass surgery. Ann Surg 197:728-37.nKim RW, Mariconda DC, Tellides G, et al. 2001. Single-clamp technique does not protect against cerebrovascular accident in coronary artery bypass grafting. Eur J Cardiothorac Surg 20:127-32.nLoop FD, Lytle BW, Cosgrove DM, et al. 1988. Coronary artery bypass graft surgery in the elderly. Indications and outcome. Cleve Clin J Med 55:23-34.nMcKhann GM, Grega MA, Borowicz LM Jr, Baumgartner WA, Selnes OA. 2006. Stroke and encephalopathy after cardiac surgery: an update. Stroke 37:562-71.nMusumeci F, Feccia M, MacCarthy PA, et al. 1998. Prospective randomized trial of single clamp technique versus intermittent ischaemic arrest: myocardial and neurological outcome. Eur J Cardiothorac Surg 13:702-9.nNewman MF, Kirchner JL, Phillips-Bute B, et al., for the Neurological Outcome Research Group and the Cardiothoracic Anesthesiology Research Endeavors Investigators. 2001. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J Med 344:395-402.nRicotta JJ, Faggioli GL, Castilone A, Hasset JM., for the Buffalo Cardiac-Cerebral Study Group. 1995. Risk factors for stroke after cardiac surgery. J Vasc Surg 21:359-64.nSalazar JD, Witky RJ, Grega MA, et al. 2001. Stroke after cardiac surgery: short- and long-term outcomes. Ann Thorac Surg 72:1195-201, discussion 1201-2.nSalerno TA. 1982. Single aortic cross-clamping for distal and proximal anastomoses in coronary surgery: an alternative to conventional techniques. Ann Thorac Surg 33:518-20.nStamou SC, Hill PC, Dangas G, et al. 2001. Stroke after coronary artery bypass: incidence, predictors, and clinical outcome. Stroke 32:1508-13.nSternby NH. 1968. Atherosclerosis in a defined population. An autopsy survey in Malmo, Sweden. Acta Pathol Microbiol Scand 194(suppl):1-216.nStump DA, Kon NA, Rogers AT, Hammon JW. 1996. Emboli and neuropsychological outcome following cardiopulmonary bypass. Echocardiography 13:555-8.nTardiff BE, Newman MF, Saunders AM, et al., the Neurologic Outcome Research Group of the Duke Heart Center. 1997. Preliminary report of a genetic basis for cognitive decline after cardiac operations. Ann Thorac Surg 64:715-20.nTrehan N, Mishra M, Kasliwal RR, Mishra A. 2000. Surgical strategies in patients at high risk for stroke undergoing coronary artery bypass grafting. Ann Thorac Surg 70:1037-45.nWeintraub WS, Craver JM, Cohen CL, Jones EL, Guyton RA. 1991. Influence of age on results of coronary artery surgery. Circulation. 84(suppl):III226-35.nZingone B, Rauber E, Gatti G, et al. 2006. The impact of epiaortic ultrasonographic scanning on the risk of perioperative stroke. Eur J Cardiothorac Surg 29:720-8.n
