Neurocognitive outcome after retrograde cerebral perfusion

BACKGROUND: Neurocognitive outcome in patients undergoing thoracic aortic surgery using retrograde cerebral perfusion (RCP) remains uncertain. METHODS: Forty-two patients undergoing thoracic aortic surgery using RCP were enrolled in the study. The patients' neurocognitive state was assessed by the revised Wechsler Adult Intelligence Scale (WAIS-R) a few days before operation, at 2 to 3 weeks, and at 4 to 6 months after operation. RESULTS: There were no stroke, seizure, and hospital death. Significant performance deterioration was observed in digit span, arithmetic, and picture completion of the WAIS-R subtests. Bivariate comparison showed that older age (late vocabulary, late similarities, and late object assembly), longer RCP time (early picture arrangement, and early block design), later awake time (early and late picture arrangement, and early block design), longer respirator use (early and late digit span, late picture arrangement), longer ICU time (late picture completion, early and late picture arrangement, and early block design), and longer hospital stay (early picture arrangement) were significantly associated with the decline in neurocognitive performance. Stepwise logistic regression analysis disclosed that older age (late similarities and late object assembly), later awake time (late picture arrangement), and longer respirator use (early and late digit span, and late picture arrangement) were most predictive for the decline in neurocognitive performance. CONCLUSIONS: On average, digit span, arithmetic, and picture completion tests were most sensitive in detecting the decline in neurocognitive performance. The relationship between the duration of RCP and neurocognitive test results was not significant.     

No improvement in neurocognitive outcomes after off-pump versus on-pump coronary revascularisation: a meta-analysis

The popularity of off-pump (beating heart) coronary artery bypass grafting (CABG) was initially stimulated by numerous theoretical benefits including lower incidence of stroke and neurocognitive dysfunction. With a postoperative stroke rate of less than 1% for elective CABG, it has been very difficult to demonstrate any significant differences in this outcome between techniques. However, changes in neurocognitive function are more common in the postoperative setting and thus provide greater power for demonstrating improvement with changes in surgical technique. The aim of this meta-analysis was to assess whether there were significant differences in neurocognitive outcomes in patients after undergoing off-pump versus on-pump CABG. A database search for prospective randomised controlled trials of off-pump versus on-pump CABG in any language was conducted. Eight trials incorporating 892 patients fulfilled all the inclusion criteria for reporting of neurocognitive outcomes, and were able to be included in this meta-analysis. Sufficient data were available across the seven studies to combine results for five neurocognitive tests (Rey Auditory Verbal Learning, Grooved Pegboard, Trail A and B, and Digit Symbol). Overall there were no convincing differences in outcomes in neurocognitive testing between off-pump and on-pump CABG groups. The results of this meta-analysis show that there are no significant neurocognitive benefits when comparing off-pump versus on-pump CABG.     

胸主动脉瘤合并冠心病的外科治疗

目的探讨行胸主动脉瘤置换同期行冠状动脉旁路移植术的安全性及其对预后的影响。方法1982年5月至2004年10月我院收治67例胸主动脉瘤患者,其中同时行冠状动脉旁路移植术者24例：行降主动脉置换+冠状动脉旁路移植术9例,升主动脉置换+冠状动脉旁路移植术15例。将其术后结果与同期仅行胸主动脉置换者进行对比。结果同期行冠状动脉旁路移植术者总病死率为13%(3/24),同期行降主动脉置换+冠状动脉旁路移植术者虽因心肺转流和选择性脑灌注使手术时间显著延长[(278±54)与(188±59)min,t=5．397,P＜0．05],但术后并发症发生率、3年生存率和3年无心脏意外率与单纯行胸主动脉置换术者比较,差异无统计学意义(P＞0．05)。结论同期胸主动脉瘤置换+冠状动脉旁路移植术安全可靠,有助于防止因冠心病而致术后远期发生心脏意外。     

Retrograde cerebral perfusion during thoracic aortic surgery and late neuropsychological dysfunction.

OBJECTIVE: Retrograde cerebral perfusion (RCP) is commonly used in thoracic aortic surgery, ostensibly to provide metabolic support, maintain cerebral hypothermia and/or wash out particulate emboli. We tested the hypothesis that RCP would affect neuropsychological outcome in a clinical cohort. METHODS: Ninety-four patients undergoing elective thoracic aortic repairs requiring deep hypothermic circulatory arrest consented to participate in this study. These patients underwent preoperative neuropsychological evaluation and comprise the reference group. Fifty-six of these patients also underwent neuropsychological evaluation several weeks postoperatively, 12 of whom (21%) had RCP. The neuropsychological domains tested were attention, processing speed, memory, executive function, and fine motor function. A global assessment of impairment, negative neuropsychological outcome (NNO), was defined as a postoperative decrease in function in two or more neuropsychological domains for patients with at least three domains tested both pre- and postoperatively (n=48). The relationship of three potential predictors (RCP, cerebral ischemia time and patient age) to negative outcomes was analyzed using Wilcoxon two-sample tests, chi(2) tests, Mantel-Haenszel tests and multiple logistic regression. P<0.05 was considered significant. RESULTS: Memory dysfunction and NNO had strong associations with RCP. This effect remained significant when controlling separately for age and cerebral ischemia time. CONCLUSIONS: The effects of RCP are difficult to distinguish from those of age and prolonged cerebral ischemia time, because complex thoracic aortic repairs are associated with advanced age, prolonged cerebral ischemia and use of RCP. Despite this limitation, these preliminary data indicated that RCP had no beneficial effect (and most likely a negative effect) upon cognitive outcome.     

Chronic exposure to nicotine does not prevent neurocognitive decline after cardiac surgery

OBJECTIVE: To establish the association between smoking and cognitive decline in patients undergoing coronary artery bypass graft (CABG) surgery. DESIGN: Retrospective review. SETTING: Referral center for cardiothoracic surgery at a university hospital. PARTICIPANTS: Four hundred seventeen patients undergoing CABG surgery. INTERVENTIONS: Based on preoperative data, patients were divided into 2 groups: smokers (n = 185) and nonsmokers (n = 232). Patients who smoked half a pack of cigarettes per day within the last 2 years were identified as smokers, and patients who did not smoke were included in the nonsmoker group. Patients with less than a seventh grade education; an inability to read; or a history of one of the following medical conditions: prior stroke with residual deficit, psychiatric illness, renal disease (creatinine > 2.0 mg/dL), or active liver disease; or patients who quit smoking prior to surgery were excluded from the study. Both groups received similar anesthetic and surgical management. All patients received a battery of neurocognitive tests both preoperatively and 6 weeks after CABG surgery. Neurocognitive test scores were separated into 4 cognitive domains, with a composite cognitive index (the mean of the four domain scores) determined for each patient at every testing period. MEASUREMENTS AND MAIN RESULTS: The overall rate of cognitive decline at 6 weeks after surgery in smokers was 36.2%, whereas nonsmokers showed a deficit rate of 36.6%. Nonsmokers were significantly older and presented for surgery on average 6 years later than the smokers. Female sex represented a considerably larger proportion of patients in the nonsmoker group. Smokers had a higher prevalence of myocardial infarction. The univariate analysis of cognitive change at 6 weeks adjusted for age, baseline cognitive index, and education years showed no difference between the 2 groups. Sex, history of myocardial infarction, hypertension, stroke, transient ischemic attack, and duration of cardiopulmonary bypass did not contribute to the multivariate logistic regression model and were dropped from the final analysis. Significant multivariate predictors of neurocognitive dysfunction included age, left ventricular ejection fraction, baseline education level, and baseline cognitive index. CONCLUSIONS: This study confirmed previous findings that age, baseline cognitive function, years of education, and impaired left ventricular function are independent predictors of neurocognitive decline at 6 weeks after CABG surgery. Smoking is neither preventive nor causative of cognitive decline after CABG surgery.     

Evaluation of brain injury after coronary artery bypass grafting. A prospective study using neuropsychological assessment and diffusion-weighted magnetic resonance imaging.

OBJECTIVE: Neurocognitive dysfunction is a common complication after cardiac surgery with cardiopulmonary bypass (CPB). Studies using magnetic resonance imaging (MRI) have demonstrated that new focal brain lesions can occur after coronary artery bypass grafting (CABG), even in patients without apparent neurological deficits. Diffusion-weighted MRI is superior to conventional MRI and allows for sensitive and early detection of ischemic brain lesions. We prospectively investigated cerebral injury early and 3 months after CABG using diffusion-weighted MRI and related the findings to clinical data and neurocognitive functions. METHODS: Twenty-nine patients [67.6+/-8.6 (52-85) years, 5 females] undergoing elective CABG with CPB were examined before surgery, at discharge and 3 months after surgery. A battery of standardized neuropsychological tests and questionnaires on depression and mood were administered. Conventional and diffusion-weighted MRI of the brain was performed and new lesions were analyzed. Clinical characteristics, neuropsychological test performance and radiographic data were collected and compared. RESULTS: There was no major neurological complication after CABG. Thirteen patients (45%) exhibited 32 new ischemic lesions on postoperative diffusion-weighted MRI. The lesions were small, rounded and equally dispersed in both hemispheres. Eight patients had at least two lesions. At discharge, significant deterioration of neuropsychological performance was observed in 6 of the 13 tests compared to baseline assessment. By 3 months postoperatively, 5 of the 6 tests returned to preoperative levels. Verbal learning ability, however, remained impaired. The presence of new focal brain lesions was not associated with impaired neuropsychological performance. There was also no correlation between clinical variables, intraoperative parameters and postoperative complications and MRI findings. CONCLUSIONS: Although neurocognitive decline after CABG is mostly transient, memory impairment can persist for months. New ischemic brain lesions on postoperative diffusion-weighted MRI do not appear to account for the persistent neurocognitive decline.     

Propofol offers no advantage over isoflurane anesthesia for cerebral protection during cardiopulmonary bypass: a preliminary study of S-100ß protein levels

PURPOSE: Despite advances in anesthesia, cardiopulmonary bypass (CPB) and surgical techniques, cerebral injury remains a major source of morbidity after cardiac surgery. We compared the effects of two different anesthetic techniques, isoflurane vs propofol on neurological outcome by serum S-100beta protein and neuropsychological tests after coronary artery bypass grafting (CABG). METHODS: Twenty patients undergoing CABG, randomly allocated into two groups, were enrolled in this prospective, controlled, preliminary study. Isoflurane was used in group I and propofol in group P. Neurological examination and a neuropsychologic test battery consisting of the mini mental state examination (MMSET) and the visual aural digit span test (VADST) were obtained preoperatively and on the third and sixth postoperative days. Blood samples for analysis of S-100beta protein were collected before anesthesia (T1), after heparinization (T2), 15 min into CPB (T3), after CPB (T4) and at the 24(th) hr postoperatively (T5). RESULTS: Postoperative neurological examinations of the patients were normal. VADST performance declined significantly on the third day (P < 0.05) in both groups, and there were no significant differences on VADST and MMSET scores between the two groups. In group P, S-100beta protein levels increased significantly at T3 and T4 compared to preoperative and isoflurane levels (P < 0.05). CONCLUSIONS: Despite reports about the neuroprotective effects of propofol, S-100beta protein levels were significantly elevated in group P. Although there was no deterioration in neuropsychological outcome, propofol appeared to offer no advantage over isoflurane for cerebral protection during CPB in this preliminary study of 20 patients.     

Neuropsychological functioning 3–5 years after coronary artery bypass grafting: does the pump make a difference?

Objective: Neurocognitive sequelae after coronary artery bypass grafting (CABG) are frequently reported. The present study investigated the possible difference between on- and off-pump CABG patients in a long-term perspective. Methods: We administered seven standardized neuropsychological tests 1 day before, 6 days after, 6 months after and 3–5 years after CABG. We measured intra-operative high intensity transient signals (HITS) as a reflection of embolic load by transcranial Doppler ultrasonography. Results: Of the 74 patients originally recruited, 54 of the patients (73%) (mean age 59 years ± 7.5 years) completed the neuropsychological battery. Cognitive decline was defined as 20% decline on two or more tests. Three to 5 years after the operation, 30% of the patients showed neurocognitive problems in domains of non-verbal immediate memory and attention, speed for visual search, visual attention and mental flexibility. Neither difference in frequency of cognitive dysfunction nor a difference in evolution over the 5 year time period between on- and off-pump patients was observed. No significant predictors for cognitive decline were found. Conclusions: Three to 5 years after the CABG surgery no difference in neurocognitive deficits is found between on- and off-pump CABG patients, indicating that the extracorporeal circulation (ECC) may not be the main cause of late neuropsychological decline.     

Thoracic epidural analgesia improves pulmonary function in patients undergoing cardiac surgery

PURPOSE: Pulmonary dysfunction commonly occurs following coronary artery bypass graft (CABG) surgery, increasing morbidity and mortality. We hypothesized that thoracic epidural anesthesia (TEA) would improve pulmonary function and would decrease complications in patients undergoing CABG surgery. METHODS: This prospective, randomized, controlled trial was conducted with Ethics Board approval. Fifty patients, undergoing CABG surgery, were randomized to the epidural group or to the patient-controlled analgesia morphine group. Patients in the epidural group received a high, thoracic epidural, preoperatively. Intraoperatively, 0.75% ropivacaine was infused, followed postoperatively, by 0.2% ropivacaine for 48 hr. Outcome measurements included: visual analogue pain scores; spirometry; atelectasis scores on chest radiographs; and the incidence of atrial fibrillation. RESULTS: Twenty-five patients were enrolled in each group. Patients in the epidural group had significantly less pain on the operative day, and for the subsequent two days. Compared to baseline, the forced expiratory volume in one second was significantly higher in the epidural group, on the first and second postoperative days (43.7 +/- 12.2% vs 36.4 +/- 12.0%, p < 0.002, and 43.3 +/- 12.5% vs 38.4 +/- 11.0%, p <0.05). There was significantly more atelectasis in the control group, four hours postoperatively (p < 0.04); however, on the third, postoperative day, the groups were similar with regards to this outcome. The incidence of atrial fibrillation was similar in both groups, and there were no complications related to the epidural. CONCLUSIONS: High TEA decreases postoperative pain and atelectasis and improves pulmonary function in patients undergoing CABG surgery. Our results support the use of TEA in this group of patients.     

Long-term comparison of aortic arch replacement with or without elephant trunk procedure via retrograde cerebral perfusion for aortic arch dissection.

OBJECTIVE: The aim of this study is to investigate the effects of the duration of retrograde cerebral perfusion (RCP) in patients with aortic arch dissection. METHODS: Between 1993 and December 2000, 56 patients were operated on for aortic arch dissection. Elephant trunk procedure was performed in 28 patients (Group A) and semiarcus replacement in 28 patients (Group B). Type I dissection (P=0.003), chronic ethiology (P=0.006), medial degeneration (P<0.001), and preoperative hemodynamic instability (P=0.004) were observed significantly more in Group A. In both groups RCP was used for cerebral protection. RESULTS: Hospital mortality was higher in Group A than Group B (32.1% versus 7.1%; P=0.015). Late mortality was observed only in Group A (10.5%; P=0.049). Actuarial survival was 55.1+/-11.55% in Group A and 91.67+/-5.64% in Group B at 5 yr (P=0.0113), while cumulative survival for all patients was 78.38+/-5.77% at 5 yr. RCP time was longer in Group A (62.7+/-16.8 versus 34.2+/-19.5 min; P<0.001). Forward stepwise logistic regression analysis showed that chronic obstructive pulmonary disease (P=0.014) and renal insufficiency (P=0.004) were significantly predictors for hospital mortality, whereas elephant trunk (P=0.052) and RCP (>60 min) (P=0.175) did not increase early mortality. Only hemodynamic instability was significantly (P=0.006) predictors for late mortality. CONCLUSIONS: Preoperative severity of dissection, hemodynamic instability or organ dysfunctions impair early or late outcome. Elephant trunk technique with increased RCP time do not increase early or late mortality. To shorten RCP time (<60-65 min) can improve surgical results.     

Cognitive changes with coronary artery disease: a prospective study of coronary artery bypass graft patients and nonsurgical controls

BACKGROUND: Cognitive impairment after coronary artery bypass grafting (CABG) is well recognized, but previous investigations have been limited by lack of an appropriate control group. We compared changes in cognitive performance at 3 and 12 months after CABG with those in a control group of patients with comparable risk factors for coronary artery disease (CAD) who had not undergone surgery. METHODS: Patients undergoing CABG (n = 140) and demographically similar nonsurgical control subjects with CAD (n = 92) completed baseline neuropsychological assessment and were followed prospectively at 3 and 12 months. Cognitive function was evaluated with a battery of neuropsychological tests assessing the cognitive domains of attention, language, verbal and visual memory, visuoconstruction, executive function, and psychomotor and motor speed. RESULTS: The CABG patients who were tested in their hospital rooms before surgery had lower scores for timed tests; however, after adjustment for demographic variables and testing location there were no statistically significant differences between the CABG and nonsurgical control subjects in baseline neuropsychological test performance. Both groups improved from baseline to 3 months; the only statistically significant group difference was a greater improvement in the CABG group with regard to verbal memory. At 12 months there were no statistically significant differences between the two groups. CONCLUSIONS: The prospective longitudinal neuropsychological performance of patients with CABG did not differ from that of comparable nonsurgical control subjects with CAD at 3 months or 1 year after base line examination. This suggests that the previously reported cognitive decline during the early postoperative period after CABG is transient and reversible. Continued follow-up will determine whether a specific "late decline" occurs in CABG patients but not in nonsurgical control subjects with similar risk factors for cardiovascular and cerebrovascular disease.     

An analysis of perfusion technology preadmission factors effects on academic success, perfusion certification achievement, and career placement

This retrospective study was designed to evaluate the contribution of grade point average (GPA) and the Wechsler Adult Intelligence Scale-Revised (WAIS-R) practical scores toward predicting perfusion academic success, career placement as a clinical perfusionist, and certification success or failure. The files of 95 students enrolled in the perfusion technology program at Carlow University-University of Pittsburgh Medical Center School of Cardiovascular Perfusion (CARLOW-UPMC) from 1995 through 2005 were reviewed to obtain admission and academic data. The independent variables used were WAIS-R practical results of the picture completion (PC), picture arrangement (PA), block design (BD), object assembly (OA) and digit symbol (DS) tests, undergraduate grade point average (UGPA), science grade point average (SGPA), and anatomy and physiology grade point average (APGPA). The dependent variables used were perfusion grade point average (PGPA), career placement status as a clinical perfusionist (CAREER), and success or failure on the American Board of Cardiovascular Perfusion (ABCP) certification examination. The research plan consisted of logistic and multiple linear regression analyses to determine which of the WAIS-R and GPA independent variables were significantly associated with the dependent variables. UGPA, SGPA, and APGPA all correlate at the 5% level with success achieving high PGPA. WAIS-R measures were not significant indicators of academic success. PGPA, UGPA, SGPA, and APGPA did not significantly correlate with any of the tested WAIS-R scores. PC, BD, and OA scores correlate well with CAREER. OA and DS scores correlate at the p = 0.05 level with ABCP certification success.     

Thoracic aortic operations in patients aged 70 years or older.

Thirty-one patients over the age of 70 years (group A) and 72 patients less than 69 years (group B) underwent a variety of thoracic aortic surgical procedures. Early and long-term results and cerebral function were compared between the two groups. Preoperative and postoperative cerebral function was evaluated using mini mental state-Himeji and Wechsler adult intelligence scale tests. The operative mortality of groups A and B was 12.9% and 11.1%, respectively (not significant). There were no significant differences in postoperative complications between the two groups. The late mortality rates of groups A and B were 11.1% and 9.3%, respectively (not significant). There were no significant differences between the two groups in the mini mental state-Himeji test, digit symbol, vocabulary, and total Wechsler adult intelligence scale scores before and after operation. We conclude that thoracic aortic surgical procedures in patients over 70 years of age can be performed with acceptable mortality and morbidity risks. Most patients showed symptomatic improvement.     

Best evidence in anesthetic practice Prognosis: cognitive function at hospital discharge predicts long-term cognitive function after coronary artery bypass surgery

Question  

In patients undergoing elective coronary artery bypass grafting (CABG) with cardiopulmonary bypass, what is the effect of perioperative neurocognitive decline on long-term neurocognitive function?     

Impact of estimated glomerular filtration rate on the 15-year outcome after coronary artery bypass surgery.

OBJECTIVE: The aim of the present study was to evaluate the impact of estimated glomerular filtration rate (eGFR) on the 15-year outcome after coronary artery bypass surgery (CABG) in a community-wide population study. METHODS: Eight hundred and eighty-two patients who underwent CABG were included in this study. eGFR was estimated by the modified Modification of Diet in Renal Disease study equation. RESULTS: Among 30-day operative survivors, patients with eGFR<60 ml/min/1.73 m(2) had significantly poorer overall survival (at 5, 10 and 15 year, 84.7%, 63.5% and 43.8% vs 92.8%, 77.6% and 58.3%, respectively, p<0.0001). eGFR (HR 0.989, 95% CI 0.981-0.997, as well as eGFR<60 ml/min/1.73 m(2): HR 1.470, 95% CI 1.092-1.979) was an independent predictor of late all-cause mortality only when patients' age was excluded from the regression model. This was probably due to strong impact of age on eGFR. eGFR (HR 0.987, 95% CI 0.975-0.998, as well as eGFR<60 ml/min/1.73 m(2); HR 1.612, 95% CI 1.086-2.395) was an independent predictor of cardiovascular mortality secondary to ischemic heart disease or ischemic stroke. eGFR (HR 0.991, 95% CI 0.983-0.999, as well as eGFR<60 ml/min/1.73 m(2): HR 1.396 95% CI 1.031-1.891) was an independent predictor of cardiovascular mortality and morbidity (myocardial infarction, stroke, need for redo CABG or PCI). When both preoperative serum creatinine and eGFR were included in the regression model, only eGFR was predictive of all-cause mortality, cardiovascular mortality and combined cardiovascular mortality and morbidity. CONCLUSIONS: This study showed that an eGFR<60 ml/min/1.73 m(2) is an important determinant of long-term outcome after isolated CABG. Since its predictive value seems to be superior to serum creatinine, eGFR may be useful to identify those patients undergoing CABG with subclinical chronic kidney disease.     

Cognitive deficit after aortic valve replacement

BACKGROUND: Impairment of cognitive brain function after coronary artery bypass grafting (CABG) is well known. In contrast the potential neurocognitive damage related to aortic valve replacement (AVR) is uncertain. METHODS: In this contemporary case-matched control study we followed 30 patients (mean age 70 years) receiving isolated AVR with a biological prosthesis. A cohort of sex-and age-matched patients (n = 30, mean age 70 years) receiving CABG with cardiopulmonary bypass served as controls. Cognitive brain function was measured by means of auditory evoked P300 potentials (peak latencies, ms) before the operation and 7 days and 4 months after the operation. Additionally, two standard psychometric tests (Mini-Mental State Examination and the Trailmaking Test A) were performed. RESULTS: In preoperative measures there was no difference between patients undergoing AVR and patients undergoing CABG (AVR 378 +/- 37 ms, CABG 374 +/- 32 ms, p = 0.629). One week after surgery P300 peak latencies were prolonged (impaired) in both groups compared with preoperative values (AVR 405 +/- 43 ms, p = 0.001; CABG 398 +/- 44 ms, p = 0.004). At this point of follow-up there was no difference between the groups (p = 0.607). Finally, 4 months after surgery P300 auditory evoked potentials returned to normal in the CABG group (380 +/- 24 ms, p = 0.940) while in contrast in the valve group they continued to become prolonged (worsened) compared with preoperative values (410 +/- 47 ms, p = 0.005). At this time of follow-up P300 peak latencies were prolonged in AVR patients as compared with CABG patients (p = 0.032). The Trailmaking Test A and Mini-Mental State Examination failed to discriminate any difference. CONCLUSIONS: Four-month impairment of cognitive brain function is more pronounced in patients undergoing biological AVR as compared with age-matched control patients undergoing CABG. Further studies are needed to clarify the potential pathologic mechanisms causing an ongoing cognitive impairment in patients with biological aortic valve prostheses.     

Off-pump versus on-pump coronary artery bypass surgery and postoperative pulmonary dysfunction

OBJECTIVE: To investigate how off-pump coronary artery bypass grafting (CABG) affects postoperative pulmonary function when compared with on-pump CABG. DESIGN: Prospective clinical study. SETTING: University-affiliated teaching hospital. PARTICIPANTS: Adult patients (n = 39) undergoing elective coronary artery bypass surgery with or without cardiopulmonary bypass. INTERVENTIONS: Two groups of patients were compared: 19 consecutive patients undergoing off-pump CABG surgery and 20 consecutive patients undergoing conventional CABG surgery. MEASUREMENTS AND MAIN RESULTS: Pulmonary function tests (flow volume loops and lung volumes with plethysmography) were done preoperatively and 72 hours postoperatively. Arterial blood gases and PaO2/FIO2 were measured at various stages. Sequential chest x-rays were obtained and evaluated for pleural changes, pulmonary edema, and atelectasis. In both groups, PaO2/FIO2 ratios decreased progressively throughout the perioperative period, with no significant differences between the groups at any stage during the study. There was a significant decline in postoperative pulmonary function tests in both groups, but there was no difference between groups at 72 hours postoperatively. No differences were found in the time to extubation, atelectasis scores, or postoperative complications. CONCLUSIONS: Off-pump CABG does not confer major protection from postoperative pulmonary dysfunction compared with CABG surgery with CPB. Strategies for minimizing pulmonary impairment after CABG surgery should be directed to factors other than the use of CPB.     

Effects of Aprotinin During Cardiopulmonary Bypass in Patients Treated with Acetylsalicylic Acid

Abstract

Objectives. To assess preoperative depression in middle-aged men undergoing coronary artery bypass graft surgery (CABG) and to determine if depression is related to perioperative outcomes. Design. One hundred and nine middle-aged male patients were randomly selected and assessed for depression one day before CABG using the Symptom Checklist-90 Revised (SCL-90R). Perioperative outcomes were: (1) postoperative length of hospital stay, (2) the presence of any early complications (at intensive care unit), and (3) the presence of any late complications (at cardiac surgery unit). Results. Twenty-five (23%) patients had a high level of depression. Preoperative depression scores significantly predicted postoperative length of hospital stay (p<0.001) and the incidence of late perioperative complications (p<0.05) independently from biomedical and sociodemographic factors. Each increase in depression T score increased the odds of occurrence of late complications by 10% (p=0.018, CI 95% 1.02–1.19). Conclusions. Depression is common in middle-aged men undergoing CABG and is an independent predictor of postoperative length of hospital stay and late perioperative complications.     

Recovery of older patients undergoing ambulatory anaesthesia with isoflurane or sevoflurane

BACKGROUND: Delayed recovery of cognitive function is a well-recognized phenomenon in older patients. The potential for the volatile anaesthetic used to contribute to alterations in postoperative cognitive function in older patients following minor surgical procedures has not been determined. We compared emergence from isoflurane and sevoflurane anaesthesia in older surgical patients undergoing urological procedures of short duration. METHODS: Seventy-one patients, 60 yr of age or older, undergoing anaesthesia expected to last less than 60 min for ambulatory surgery, were randomly assigned to receive isoflurane or sevoflurane. A standardized anaesthetic protocol was used, with intravenous fentanyl 1 microg kg(-1) and propofol 1.5-2.0 mg kg(-1) administered to induce anaesthesia. Anaesthesia was maintained with either sevoflurane or isoflurane in 65% nitrous oxide and oxygen. Early and intermediate recovery times were recorded. The Mini Mental State Examination and digit repetition forwards and backwards were administered at baseline, and at 1, 3 and 6 h postoperatively, to assess cognitive function. RESULTS: There were no between-group differences in (sevoflurane vs. isoflurane, mean +/- standard error of the mean) times to removal of the laryngeal mask airway (7.7 +/- 0.6 vs. 7.1 +/- 0.4 min), verbal response time (10.1 +/- 0.7 vs. 9.9 +/- 0.7 min) and orientation (12.1 +/- 0.7 vs. 12.1 +/- 0.7 min). Intermediate recovery, as measured by time to readiness for discharge from the post anaesthesia care unit (44.9 +/- 1.5 vs. 44.3 +/- 1.5 min), was similar in the two groups. Postoperative indices of cognitive function and attention were comparably reduced at 1 h, but returned to baseline in both groups at 6 h. CONCLUSIONS: Isoflurane and sevoflurane anaesthesia resulted in similar clinical and neurocognitive recovery profiles in older patients undergoing ambulatory surgical procedures of short duration.     

Angiographic coronary diffuseness and outcomes in dialysis patients undergoing coronary artery bypass grafting surgery.

OBJECTIVE: Pre-operative dialysis-dependent renal failure (DDRF) is a predictor of morbidity and mortality following coronary artery bypass grafting surgery (CABG). Whether this is due in part to a more diffuse coronary atherosclerotic burden in these patients is unknown. The purpose of this study was to compare coronary atherosclerotic disease burden in patients with and without pre-existing DDRF undergoing CABG. METHODS: From a retrospective analysis of a single-centre cardiac surgical database, consecutive DDRF patients undergoing isolated CABG (n=35) were matched to 70 non-dialysis-dependent (NDD) patients without renal failure by procedure, age, sex, functional status, ejection fraction, number of diseased vessels, and diabetes. Pre-operative angiograms were analyzed by a single, blinded adjudicator using a modification of a previously published coronary diffuseness score (range: 0-45). Angiographic scores and baseline and outcome characteristics were compared using chi(2) tests, Fisher's Exact tests, and t-tests as appropriate. RESULTS: No statistical differences were found among pre-operative characteristics between the two groups. The mean angiographic coronary diffuseness scores for the dialysis and non-dialysis groups were 18.2 and 20.6, respectively (p=0.13). Transfusion was more frequent (77 vs. 23%, p<0.0001) and median length of stay longer (9 vs. 7 days, p=0.02) in the DDRF group. There were no differences in the number of distal anastomoses performed in the two groups. Low rates of peri-operative myocardial infarction, stroke, re-operation, and in-hospital mortality were observed in both groups. CONCLUSIONS: Objective quantification revealed that patients with DDRF undergoing CABG did not have a greater coronary artery atherosclerosis disease burden than matched controls who did not have pre-operative DDRF. This may be due to pre-operative patient selection bias. The increased morbidity and mortality of CABG in patients with DDRF is more likely to be due to the multiple adverse systemic effects of renal failure and dialysis on the cardiovascular system as opposed to diffuseness of distal coronary disease.