Background Neurocognitive complications (NCCs) after cardiac surgery are one of the most devastating complications. Significant internal carotid artery stenosis is assumed to be a predictor of NCCs. Carotid duplex ultrasound (DUS) is a non-invasive imaging study that remains the modality of choice and is routinely used in many centers for screening adult cardiac surgery patients prior to surgery. This study aims to assess the utility of preoperative carotid DUS in the prediction of NCCs in adult patients undergoing cardiac surgery in our center. Methods We retrospectively reviewed the medical records of patients who underwent coronary artery bypass graft (CABG), valvular or combined surgery, at King Faisal Cardiac Center in Jeddah between January 2017 and December 2018 (n = 229). The preoperative carotid DUS findings were evaluated. Risk factors associated with NCC were analyzed. Results Over the study period, a total of 229 patients underwent 233 procedures. Median age was 60 years (interquartile range [IQR] = 51-67 years), of whom 71% were males. Out of the diabetic patients, 67% had an HbA1C level above 7% pre-operatively. Carotid DUS was performed on 63% of patients, but only 6.9% developed a post-operative NCC. Patients who were actively smoking were more likely to develop NCC compared to nonsmokers or ex-smokers (14.7% vs 4.6%; p = 0.02), with an odds ratio of 3.6 (95% CI = 1.2-10.5). Patients who developed NCC had a significantly higher median intensive care length of stay (7 vs. 5 days; p = 0.05). Conclusions Although international guidelines clearly define which patient should get preoperative carotid DUS screening, the level of evidence is low. Based on our findings, preoperative routine use of carotid DUS prior to cardiac surgery has low utility in predicting NCC. We recommend a more tailored approach based on signs, symptoms, and high-risk features to optimize the utilization of resources, avoid unwarranted delays, and personalize patient care.

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