Magnetic resonance imaging findings and postoperative neurologic dysfunction in elderly patients undergoing coronary artery bypass grafting

Gotō, Tomoko; Baba, Tomoko; Honma, Keiko; Shibata, Yoshihiro; Arai, Yoshinori; Uozumi, Hideaki; Okuda, Tomoko

doi:10.1016/s0003-4975(01)02676-5

Cited by 116 publications

(67 citation statements)

References 19 publications

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“…1 However, this remains an area of controversy. The incidence of cognitive impairment varies depending on patient and surgical factors and is greater in those with preexisting ischemic white matter lesions and reduced cerebral reserve 8,10,13,34 and when more complex surgical procedures are performed. 3 The incidence of impairment is also affected by the tests used, the timing of testing, and the definitions of decline.…”

Section: Discussionmentioning

confidence: 99%

Cerebral Ischemic Lesions on Diffusion-Weighted Imaging Are Associated With Neurocognitive Decline After Cardiac Surgery

Barber

Hach

Tippett

et al. 2008

Stroke

185

103

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Background and Purpose-Improvements in cardiac surgery mortality and morbidity have focused interest on the neurological injury such as stroke and cognitive decline that may accompany an otherwise successful operation. We aimed to investigate (1) the rate of stroke, new ischemic change on MRI, and cognitive impairment after cardiac valve surgery; and (2) the controversial relationship between perioperative cerebral ischemia and cognitive decline. Methods-Forty patients (26 men; mean [SD] age 62.1 [13.7] years) undergoing intracardiac surgery (7 also with coronary artery bypass grafting) were studied. Neurological, neuropsychological, and MRI examinations were performed 24 hours before surgery and 5 days (MRI and neurology) and 6 weeks (neuropsychology and neurology) after surgery. Cognitive decline from baseline was determined using the Reliable Change Index. Results-Two of 40 (5%) patients had perioperative strokes and 22 of 35 (63%) tested had cognitive decline in at least one measure (range, 1 to 4). Sixteen of 37 participants (43%) with postoperative imaging had new ischemic lesions (range, 1 to 17 lesions) with appearances consistent with cerebral embolization. Cognitive decline was seen in all patients with, and 35% of those without, postoperative ischemic lesions (PϽ0.001), and there was an association between the number of abnormal cognitive tests and ischemic burden (PϽ0.001). Conclusion-We have provided a reliable estimate of the rate of stroke, postoperative ischemia, and cognitive impairment at 6 weeks after cardiac valve surgery. Cognitive impairment is associated with perioperative ischemia and is more severe with greater ischemic load.

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Section: Discussionmentioning

confidence: 99%

Cerebral Ischemic Lesions on Diffusion-Weighted Imaging Are Associated With Neurocognitive Decline After Cardiac Surgery

Barber

Hach

Tippett

et al. 2008

Stroke

185

103

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“…[48][49][50][51][52] In general, patients with coronary artery disease have a higher prevalence of cerebrovascular disease. 53 Van Dijk and coworkers 48 reported the results of neurocognitive outcomes over 5 years after OPCAB and on-pump CABG in a randomized, multicentered trial involving 281 patients. There was no difference in either cognitive outcomes or cardiovascular events between the groups.…”

Section: Neurological and Cognitive Changesmentioning

confidence: 99%

Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?

Lazar

2013

Circulation

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406O ne of the most controversial areas of cardiac surgery has been whether off-pump coronary artery bypass graft (OPCAB) surgery is superior to traditional on-pump coronary artery bypass graft (CABG) surgery. On-pump CABG surgery has been an effective, safe, and time-proven technique and is the gold standard with which all other surgical revascularization methods have been compared. However, performing coronary revascularization on cardiopulmonary bypass (CPB) can result in myocardial ischemic injury, neurocognitive deficits, and strokes and activate inflammatory pathways that contribute to pulmonary, renal, and hematologic complications. OPCAB offered a promising alternative strategy that had the potential to decrease perioperative morbidity, mortality, and cost by eliminating CPB. In fact, throughout Asia and particularly in India, 95% of CABG surgery is performed offpump. In North America, OPCAB procedures peaked at 25% in 2004 and have declined steadily since that time.1 It is a more technically demanding procedure and results in less complete revascularization. There is growing concern that OPCAB is associated with reduced long-term graft patency and increased need for revascularization procedures and results in inferior long-term survival compared with traditional on-pump CABG surgery.In view of these concerns, should OPCAB be abandoned? The purpose of this review is to examine clinical data that most accurately compare the advantages and disadvantages of OPCAB to determine what, if any, role it should have in the practice of surgical coronary artery revascularization. To reach these conclusions, retrospective nonrandomized, prospective randomized, and meta-analyses trials will be reviewed. The effect of incomplete revascularization and conversion to conventional CABG will be examined. The relationship between OPCAB and the inflammatory response, neurological and cognitive changes, and quality of life will be studied, and the impact of OPCAB on sex, renal transplant recipients, and elderly patients will be determined. Retrospective StudiesRetrospective studies were largely single center and lacked randomization. Surgeons who were more skilled in OPCAB were more likely to perform these procedures. Hence, there was a significant selection bias. In most studies, the intentionto-treat principle was not honored. Therefore, if a patient was converted to an on-pump CABG, an adverse outcome associated with this patient would be attributed to the on-pump CABG and not the originally planned OPCAB. Earlier studies may have lacked proper stabilizing equipment and intracoronary perfusion devices. Many trials reported only short-term outcomes. The retrospective studies discussed in this section generally involve >1 surgeon, had larger sample sizes to detect statistically significant differences in clinical outcomes, and contained long-term data.One of the largest databases used to compare outcomes between OPCAB and on-pump CABG techniques involved the New York State Registry for CABG Surgery. Racz and coworkers 2 first...

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“…Cerebrovascular disease predisposing to cognitive impairment is increasingly recognized in patients scheduled for cardiac surgery, likely due to hypertension, diabetes, and widespread atherosclerosis. 30,[42][43][44] A recognized limitation of psychometric testing is the low likelihood of identifying further decrements in cognition in individuals with low levels of baseline function (the "basement effect"). Studies evaluating neuroprotective strategies in patients with cerebrovascular disease might be more authoritative if brain imaging end points are included with clinical and neurocognitive outcomes.…”

Section: Discussionmentioning

confidence: 99%

Neurocognitive Outcomes Are Not Improved by 17β-Estradiol in Postmenopausal Women Undergoing Cardiac Surgery

Hogue

Freedland

Hershey

et al. 2007

Stroke

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Background and Purpose-Neurocognitive dysfunction is an important source of patient morbidity and mortality after cardiac surgery that may disproportionately affect postmenopausal women. 17␤-Estradiol limits the extent of ischemic neuronal injury in a variety of experimental models. The purpose of this study was to evaluate whether perioperative administration of 17␤-estradiol to postmenopausal women reduces the frequency of neurocognitive dysfunction after cardiac surgery. Methods-One hundred seventy-four postmenopausal women not on estrogen replacement therapy who were undergoing primary coronary artery bypass graft surgery and/or valve surgery with cardiopulmonary bypass were prospectively randomized to receive in a double-blinded manner either 17␤-estradiol or placebo beginning the day before surgery and continuing for 5 days postoperatively. The patients were evaluated before and after surgery with the National Institutes of Health Stroke Scale and a psychometric test battery. Results-There were no differences in the frequency of neurocognitive dysfunction (primary outcome) between patients randomized to perioperative 17␤-estradiol (nϭ86) and those randomized to placebo (nϭ88) 4 to 6 weeks after surgery 22.4% versus placebo, 21.4%, Pϭ0.45). The mean scores on tests of psychomotor speed were worse in women in the 17␤-estradiol group than in the placebo group at the 4-to 6-week (Pϭ0.005) postoperative testing sessions. Conclusions-Perioperative treatment with 17␤-estradiol did not result in improved neurocognitive outcomes in postmenopausal women undergoing cardiac surgery.

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Magnetic resonance imaging findings and postoperative neurologic dysfunction in elderly patients undergoing coronary artery bypass grafting

Cited by 116 publications

References 19 publications

Cerebral Ischemic Lesions on Diffusion-Weighted Imaging Are Associated With Neurocognitive Decline After Cardiac Surgery

Cerebral Ischemic Lesions on Diffusion-Weighted Imaging Are Associated With Neurocognitive Decline After Cardiac Surgery

Should Off-Pump Coronary Artery Bypass Grafting Be Abandoned?

Neurocognitive Outcomes Are Not Improved by 17β-Estradiol in Postmenopausal Women Undergoing Cardiac Surgery

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