Off-pump coronary bypass surgery: risk of ischemic brain lesions in patients with atheromatous thoracic aorta

Abstract

Purpose:The purpose of this study was to determine if there is an association between the proximal thoracic aortic (ascending aorta and aortic arch) atheroma and ischemic brain lesions on diffusion-weighted magnetic resonance imaging (DW-MRI) after on-pump (ONCAB) and off-pump (OPCAB) coronary artery bypass surgery. Methods:Patients who underwent ONCAB surgery (n = 13) and who had aortic atheroma > 2 mm were compared to a risk-adjusted prospective cohort of patients (n = 13) undergoing OPCAB surgery. Transesophageal echocardiography and epiaortic scanning were performed to assess the proximal thoracic aorta. Patients were evaluated for new ischemic brain lesions utilizing DW-MRI three to seven days after surgery. The NEECHAM confusion scale was used to evaluate patient consciousness. Results:The groups were comparable with respect to demographic data, and prevalence of preoperative risk factors. The extent and severity of aortic atheroma was similar in the two groups. The average maximum height of atheroma was 5.0 ± 2.0 mm in the OPCAB and 4.8 ± 1.9 in the ONCAB groups, respectively. The prevalence of new ischemic brain lesions on DW-MRI was 0% in the OPCAB group and 61% in the ONCAB group (P = 0.001). Patients in the OPCAB group were less confused during the first two postoperative days. Conclusion:Patients with aortic atheroma > 2 mm may have a lower risk of new ischemic brain lesions as identified by DW-MRI after OPCAB surgery. Patient stratification based upon aortic atheroma burden should be addressed in future trials designed to tailor treatment strategies to improve short-and long-term neurological outcomes in patients undergoing cardiac surgery. Objectif : Déterminer s'il y a une association entre l'athérome de l'aorte thoracique proximale (aorte ascendante et crosse de l'aorte) et les lésions cérébrales ischémiques à l'examen d'imagerie par résonance magnétique pondérée par diffusion (IRM-PD) à la suite du pontage aortocoronarien avec circulation extracorporelle (PACCE) et un PAC à coeur battant (PACCB). Méthode : Des patients subissant un PACCE (n = 13) et ayant de l'athérome aortique > 2 mm ont été comparés à une cohorte prospective de patients à risque ajusté (n = 13) subissant un PACCB. L'échocardiographie transoesophagienne et le balayage épiaortique ont permis d'évaluer l'aorte thoracique proximale. La présence de nouvelles lésions cérébrales ischémiques a été vérifiée avec l'IRM-PD trois à sept jours après l'opération. La conscience des patients a été évaluée par l'échelle de confusion NEECHAM. Résultats

Imagerie préopératoire par résonance magnétique du cerveau et délirium postopératoire après pontage coronarien à cœur battant: une étude prospective de cohorte

“…27 In a prior study of OPCAB, although the patient number was small (n = 13), no postoperative embolic ischemic events were observed. 28 Thus, in comparison to reports of onpump cardiac surgery, the incidence of injuries related to brain embolism following OPCAB was relatively low. The difference in the rates of DWI-defined ischemic lesions between the on-bypass and off-bypass cases might be explained by the numbers of cerebral emboli that occurred.…”

Clinical impact of computerised tomographic angiography performed for preoperative evaluation before coronary artery bypass grafting

“…In addition, atherosclerotic lesion of the thoracic aorta is relatively frequent in CABG patients and is one of the major risk factors of postoperative mortality and morbidity [14,15]. Consequently, preoperative identification of atherosclerotic disease of the aorta and non-coronary systemic arteries would affect perioperative management and outcome [16,17], long-term risk factor control and prediction of prognosis.…”

Brain Microstructural White and Gray Matter Alterations after Cardiopulmonary Bypass: Anatomical Distribution and Corresponding Neurocognitive Deficit

“…All preoperative MRI studies were examined by a roentgenologist and interpreted as normal. POD 1 MRI was performed at mean 22 ± 3 h (range, [19][20][21][22][23][24][25] after the operation and at mean 13 ± 2 h (range, 11-15) after tracheal extubation. All patients were extubated and hemodynamically stable during the transport and MRI examination.…”

“…Nevertheless, the anatomical location of the newly evident lesions could not necessarily explain concomitant findings of postoperative neurocognitive deterioration based on recognized neuroanatomical models [12,13]. Also, correlation was not established between patients who displayed new radiological brain lesion and those who demonstrated postoperative neurocognitive dysfunction [11][12][13][14][15][16][17][18][19][20].…”

“…Literature search has yielded 12 studies comprising of 446 patients that describe brain findings in the settings of cardiac surgery using standard MRI or DWI-MRI examinations [3,4,[11][12][13][14][15][16][17][18][19][20]. The incidence of detected radiological lesions was 29% of patients usually interpreted as cerebral microembolism [11][12][13][14][15][16][17][18][19][20].…”