Postoperative cerebrovascular complications in high-risk patients with coronary artery disease in cardiac surgery
DOI:
https://doi.org/10.25305/unj.228425Keywords:
coronary artery disease, cardiac surgery, cerebral atherosclerosis, strokeAbstract
Aim: to analyze the frequency and specificity of cerebrovascular complications in patients with coronary artery disease (CAD) after cardiac surgery.
Materials and methods: a retrospective analysis of data of 354 randomly selected patients with CAD who were operated on and discharged from the Amosov National Institute of Cardiovascular Surgery, Ukraine from 2009 to 2019. The average age of the patients was 61.9±9.6 years old. In preoperative risk stratification according to the EuroSCORE II scale, patients were classified as high cardiac risk, the predictive risk of death was on average 8.8%. All patients underwent general clinical examinations, ECG, ECHO, coronary angiography and surgical treatment of CAD. Duplex scanningf the brachiocephalic arteries (BCA) was performed in 280 (79.09%) patients.
Results: 43 (12.1%) patients had a history of stroke. Among 280 patients who underwent ultrasound examination of BCA, stenosis more than 50% of the internal carotid arteries was diagnosed in 95 (33.9%) cases. For hemodynamically significant (> 70%) BCA stenoses, hemodynamic stability and coronary artery lesions that didn’t require emergency surgery, a neurosurgeon’s consultation is required. The predictive risk of postoperative stroke on the STS scale in average was 1.48±0.98% [range 0.2–6.8%]. In the postoperative period, in 10 (2.8%) patients non-fatal cerebrovascular accidents were developed, among which 5 (1.4%) had an ischemic stroke, and 5 (1.4%) had a transient ischemic attack. The risk of neurological complications in the perioperative period increases in patients with a history of stroke (р = 0,0002), preoperative atrial fibrillation (р = 0,013), aortic calcification (р = 0,003) and more significant decrease of blood pressure on the 1st postoperative day (systolic pressure p = 0.005, diastolic pressure p = 0.0008).
Conclusions: strict monitoring of blood pressure and prevention of hypotension are required at all stages of patients management. The cardiac surgeon, whenever possible, limits manipulations on the atheromatous aorta, using the no-touch aorta technique, by performing total arterial revascularization. The work of a multidisciplinary team helps to avoid life-threatening events.
References
1. Mao Z, Zhong X, Yin J, Zhao Z, Hu X, Hackett ML. Predictors associated with stroke after coronary artery bypass grafting: a systematic review. J Neurol Sci. 2015 Oct 15;357(1-2):1-7. [CrossRef] [PubMed]
2. Baker RA, Hallsworth LJ, Knight JL. Stroke after coronary artery bypass grafting. Ann Thorac Surg. 2005 Nov;80(5):1746-50. [CrossRef] [PubMed]
3. Floyd TF, Shah PN, Price CC, Harris F, Ratcliffe SJ, Acker MA, Bavaria JE, Rahmouni H, Kuersten B, Wiegers S, McGarvey ML, Woo JY, Pochettino AA, Melhem ER. Clinically silent cerebral ischemic events after cardiac surgery: their incidence, regional vascular occurrence, and procedural dependence. Ann Thorac Surg. 2006 Jun;81(6):2160-6. [CrossRef] [PubMed]
4. Gogayeva O, Rudenko A, Lazoryshynets V. [Neurological complications after coronary artery bypass grafting for high-risk patients: current state of the problem]. Ukrainian Journal of Cardiovascular Surgery. 2020 Mar 22;(2 (39)):15–7. Ukrainian. [CrossRef]
5. John R, Choudhri AF, Weinberg AD, Ting W, Rose EA, Smith CR, Oz MC. Multicenter review of preoperative risk factors for stroke after coronary artery bypass grafting. Ann Thorac Surg. 2000 Jan;69(1):30-5; discussion 35-6. [CrossRef] [PubMed]
6. Wagner BD, Grunwald GK, Hossein Almassi G, Li X, Grover FL, Shroyer ALW. Factors associated with long-term survival in patients with stroke after coronary artery bypass grafting. J Int Med Res. 2020 Jul;48(7):300060520920428. [CrossRef] [PubMed] [PubMed Central]
7. Jawitz OK, Gulack BC, Brennan JM, Thibault DP, Wang A, O'Brien SM, Schroder JN, Gaca JG, Smith PK. Association of postoperative complications and outcomes following coronary artery bypass grafting. Am Heart J. 2020 Apr;222:220-228. [CrossRef] [PubMed] [PubMed Central]
8. Gennari M, Polvani G, Generali T, Manganiello S, Ricciardi G, Agrifoglio M. Coronary artery bypass and stroke: incidence, etiology, pathogenesis, and surgical strategies to prevent neurological complications. Coronary Artery Bypass Graft Surgery. InTech; 2017. [CrossRef]
9. Gogayeva O, Rudenko A, Lazoryshynets V. [Comparison of on-pump and off-pump coronary artery bypass grafting. our experience of participation in the international study]. Ukrainian Journal of Cardiovascular Surgery. 2020 Dec 16(4 (41)):9-14. Ukrainian. [CrossRef]
10. Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Straka Z, Piegas LS, Avezum A, Akar AR, Lanas Zanetti F, Jain AR, Noiseux N, Padmanabhan C, Bahamondes JC, Novick RJ, Tao L, Olavegogeascoechea PA, Airan B, Sulling TA, Whitlock RP, Ou Y, Gao P, Pettit S, Yusuf S; CORONARY Investigators. Five-Year Outcomes after Off-Pump or On-Pump Coronary-Artery Bypass Grafting. N Engl J Med. 2016 Dec 15;375(24):2359-2368. [CrossRef] [PubMed]
11. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005 Apr;53(4):695-9. [CrossRef] Erratum in: J Am Geriatr Soc. 2019 Sep;67(9):1991. [PubMed]
12. Bowie CR, Harvey PD. Administration and interpretation of the Trail Making Test. Nat Protoc. 2006;1(5):2277-81. [CrossRef] [PubMed]
13. Jaeger J. Digit Symbol Substitution Test: The Case for Sensitivity Over Specificity in Neuropsychological Testing. J Clin Psychopharmacol. 2018 Oct;38(5):513-519. [CrossRef] [PubMed] [PubMed Central]
14. Rosano C, Perera S, Inzitari M, Newman AB, Longstreth WT, Studenski S. Digit Symbol Substitution test and future clinical and subclinical disorders of cognition, mobility and mood in older adults. Age Ageing. 2016 Sep;45(5):688-95. [CrossRef] [PubMed] [PubMed Central]
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