Considerations for Reduction of Risk of Perioperative Stroke in Adult Patients Undergoing Cardiac and Thoracic Aortic Operations: A Scientific Statement From the American Heart Association

Gaudino, Mario; Benesch, Curtis; Bakaeen, Faisal G.; DeAnda, Abe; Fremes, Stephen E.; Glance, Laurent G.; Messé, Steven R.; Pandey, Aditya S.; Rong, Lisa Q.

doi:10.1161/cir.0000000000000885

Cited by 70 publications

(48 citation statements)

References 132 publications

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“…20 The latter includes stroke, with about a 1% perioperative rate, which is slightly higher than the risk associated with PCI. 21 Advanced age is an important risk factor for stroke and periprocedural mortality, but it should be considered in the context of other risk factors when choosing between therapies.…”

Section: ■ Treatment Considerationsmentioning

confidence: 99%

CABG: When, why, and how?

Dimeling

Bakaeen

Khatri

et al. 2021

CCJM

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Coronary revascularization has matured as a fi eld since coronary artery bypass grafting (CABG) was fi rst developed over 50 years ago, with diagnostic and treatment methods having advanced dramatically. CABG remains the standard of care for obstructive coronary artery disease, particularly for patients with multivessel disease or diabetes. It is now recognized that not all CABG is created equal-operative strategy, including conduit choice for bypass grafts and target coronary selection, affects survival. A multidisciplinary approach including surgeons with a special interest in CABG is recommended to optimize treatment selection and outcomes. KEY POINTSThe main criteria guiding the selection of revascularization therapy are disease stability, procedural risk, patient comorbidities, atherosclerotic burden, and lesion complexity.In general, CABG is preferred over percutaneous coronary intervention in patients with a heavy atherosclerotic burden and diabetes, and those without multiple signifi cant baseline comorbidities, frailty, or short life expectancy. CABG with arterial grafts can improve patient longevity, particularly with appropriate patient and coronary artery target selection.Multiple arterial grafts should be considered over single thoracic artery and multiple vein conduits.Less-invasive strategies are emerging.Guideline-directed medical therapy in coronary artery disease is essential for improved outcomes in primary and secondary prevention.

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Section: ■ Treatment Considerationsmentioning

confidence: 99%

CABG: When, why, and how?

Dimeling

Bakaeen

Khatri

et al. 2021

CCJM

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“…The authors acknowledge that the results of OPCAB in historical series, especially where the surgeons are inexperienced, have been worse than that of traditional on‐pump CABG 86 . However, there is now significant momentum within the cardiovascular community 3,4 and with groups such as the International Coronary Congress that are promoting the advancement of coronary surgery techniques and advocating for subspecialization and the concentration of expertise in high‐volume centers.…”

Section: Conquering Complexity and Surgical Inertia: The Role Of Specmentioning

confidence: 99%

“…Most perioperative strokes following CABG are ischemic in nature, with atheroembolic events due to aortic manipulation playing a major role. The importance of versatile surgical approaches, including thorough preoperative risk assessment and “aortic‐no‐touch,” techniques have also been strongly emphasized in the 2018 ESC/EACTS Guidelines on Myocardial Revascularization 3 and a recent Scientific Statement of the American Heart Association 4 (Table 1).…”

Section: Introductionmentioning

confidence: 99%

Toward stroke‐free coronary surgery: The role of the anaortic off‐pump bypass technique

et al. 2021

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Surgical coronary revascularization remains the preferred strategy in a significant portion of patients with coronary artery disease due to superior long‐term outcomes. However, there is a significant risk of perioperative neurologic injury that has influenced guideline recommendations. These complications occur in 1%–5% of patients, ranging from overt neurologic deficits with permanent disability, to subtle cerebral defects noted on neuroimaging that may result in slow cognitive and functional decline. The primary mechanism by which these events occur is thromboembolism from manipulation of the ascending aorta. This occurs during cardiopulmonary bypass, aortic cross‐clamping, and partial occlusion clamping (side clamp). Elderly patients and patients with aortic atheroma are, therefore, at significantly increased risk. Initial surgical techniques addressed this by aggressively debriding or replacing the ascending aorta during coronary artery bypass grafting (CABG). Strategies then moved toward minimizing aortic manipulation through pump‐assisted beating heart surgery and off‐pump surgery with partial occlusion clamping or proximal anastomosis devices. Finally, anaortic off‐pump CABG aims to avoid all manipulation of the ascending aorta through advanced off‐pump grafting techniques combined with in situ and composite grafts. This has been demonstrated to result in the greatest reduction in risk. Establishing successful anaortic off‐pump CABG programs requires subspecialization and focused interest groups dedicated to advancing CABG outcomes.

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“…The incidence of neurologic events after isolated coronary artery bypass grafting (CABG) varies from 1% to 5% (1-2), with older age and increased atherosclerotic burden representing important risk factors. Most perioperative strokes after coronary surgery are ischemic in nature with atheroembolic events due to aortic cannulation and cross-clamping playing a major role (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16). The importance of a versatile approach employing "aortic-no-touch" strategies has been strongly emphasized in a recent Scientific Statement of the American Heart Association (16).…”

Section: Introductionmentioning

confidence: 99%

“…Most perioperative strokes after coronary surgery are ischemic in nature with atheroembolic events due to aortic cannulation and cross-clamping playing a major role (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16). The importance of a versatile approach employing "aortic-no-touch" strategies has been strongly emphasized in a recent Scientific Statement of the American Heart Association (16). Avoiding aortic manipulation with "anaortic" techniques (anaortic off-pump coronary bypass grafting, anOPCAB) significantly reduces the risk of cerebrovascular events (17)(18)(19)(20)(21)(22)(23)(24)(25)(26).…”

Section: Introductionmentioning

confidence: 99%

Towards stroke-free coronary surgery: the role of the anaortic off-pump bypass technique

Ramponi¹,

Seco²,

Brereton³

et al. 2020

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Coronary artery and cerebrovascular disease represent a major cause of cardiovascular morbidity and mortality worldwide. Despite technological advancements in percutaneous interventions, surgical revascularization remains the preferred strategy in patients with left main or multivessel disease and in those with complex lesions with high SYNTAX score. As a result, an increasing number of older patients with diffuse atherosclerotic extracoronary disease are referred for coronary artery bypass grafting (CABG). Cerebrovascular complications after isolated coronary surgery occurs in 1-5% of patients; the magnitude of injury ranges from overt neurologic lesions with varying degree of permanent disability to “asymptomatic” cerebral events detected by dedicated neuro-imaging, nevertheless associated with significant long term cognitive and functional decline. Thromboembolic events due to manipulation of an atherosclerotic aorta are universally recognized as the leading etiology of early postoperative stroke following CABG. Coronary bypass surgery performed on an arrested heart relies on considerable aortic instrumentation associated with significant atheroembolic risk especially in older patients presenting with diffuse aortic calcifications. Surgical techniques to deal with a calcified ascending aorta during isolated coronary surgery have evolved over the last forty years. Moving away from aggressive aortic debridement or replacement, surgeons have developed strategies aimed to minimize aortic manipulation: from pump-assisted beating heart surgery with the use of composite grafts to complete avoidance of aortic manipulation with “anaortic” off-pump coronary artery bypass grafting, a safe and effective approach in significantly reducing the risk of intraoperative stroke.

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Considerations for Reduction of Risk of Perioperative Stroke in Adult Patients Undergoing Cardiac and Thoracic Aortic Operations: A Scientific Statement From the American Heart Association

Cited by 70 publications

References 132 publications

CABG: When, why, and how?

CABG: When, why, and how?

Toward stroke‐free coronary surgery: The role of the anaortic off‐pump bypass technique

Towards stroke-free coronary surgery: the role of the anaortic off-pump bypass technique

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