Comparison of cerebral embolization during off-pump and on-pump coronary artery bypass surgery

Oslo University Hospital, Kristiania (historical), Oslo, Norway
The Annals of Thoracic Surgery (Impact Factor: 3.85). 10/2003; 76(3):765-70; discussion 770. DOI: 10.1016/S0003-4975(03)00679-9
Source: PubMed


Coronary artery bypass surgery with cardiopulmonary bypass carries a significant risk of perioperative brain injury. At least 1% to 5% will suffer a stroke, and at 3-months postoperatively approximately 30% are reported to have cognitive impairment assessed by neuropsychologic testing. In off-pump surgery cardiopulmonary bypass is not used and instrumentation on the ascending aorta is reduced. The main aim of this study was to assess if off-pump surgery reduces intraoperative cerebral embolization.
This was a prospective and randomized study of two comparable groups with regard to age, sex, years of education, preoperative cognitive functioning, and surgical characteristics. Fifty-two patients (29 off-pump) were monitored by the use of transcranial Doppler ultrasound for cerebral microembolization during surgery. Preoperative and postoperative clinical, cerebral magnetic resonance imaging, and neuropsychologic examinations were also carried out.
There was a significant reduction in the number of cerebral microemboli during off-pump compared with on-pump surgery (16.3 [range 0 to 131] versus 90.0 [range 15 to 274], p < 0.0001). No significant difference with regard to the incidence of neuropsychologic performance (decline in 29% off-pump, 35% on-pump) or neuroradiologic findings at 3 months was found, and there was no association between the number of cerebral microemboli and cognitive outcome.
This study clearly demonstrates that off-pump surgery leads to a reduction in intraoperative cerebral microembolization. A significant reduction in the number of off-pump patients with cognitive decline or ischemic brain lesions on cerebral magnetic resonance imaging could not be demonstrated in this relatively small patient population.

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    • "Yes 40 Transcranial Doppler to assess HITS, S-100b levels and neuro-psychological testing Standard neurocognitive tests not used 3 2000 Lloyd et al. [11] Yes 60 Neuropsychological testing and S-100b levels Insufficient reporting of neurocognitive measures 4 2003 Lund et al. [12] Yes 52 Transcranial Doppler to assess HITS, cerebral MRI and neuro-psychological testing Data contained in later publication 5 2003 Schmitz et al. [13] No 251 Neurocognitive testing Non randomised 6 2003 Keizer et al. [14] Yes 81 Neurocognitive testing Neurocognitive testing did not follow consensus statement 7 2004 Van Dijk et al. [15] Yes 281 Neurocognitive testing Contained data on previous published results 8 2005 Ascione et al. [16] "
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    ABSTRACT: 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.
    European Journal of Cardio-Thoracic Surgery 07/2008; 33(6):961-70. DOI:10.1016/j.ejcts.2008.03.022 · 3.30 Impact Factor
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    • "Transcranial Doppler evaluation revealed an average of 90.0 (range, 15- 274) microemboli in the middle cerebral artery during surgery in the on-pump group and 16.3 (range, 0-131) microemboli in the off-pump group (P < .0001). However, the groups did not differ significantly in results of psychomotoric tests performed 3 months postoperatively [Lund 2003]. "
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    ABSTRACT: Abstract Background: Off-pump coronary artery bypass surgery has emerged as an alternative technique to traditional onpump surgery. The aim of this randomized study was to compare perioperative morbidity and mortality and intraoperative and short-term graft patency in off-pump and on-pump coronary artery bypass grafting. Methods: One hundred twenty patients were randomized for coronary revascularization with or without cardiopulmonary bypass. In all patients grafts and anastomoses were monitored with transit time Doppler ultrasonography and angiography. Angiography was repeated 3 months after the procedure in 115 of the patients. Results: Angiography 3 months postoperatively revealed that internal mammary artery patency was 98% in both groups. Vein graft patency was 83% in the off-pump group and 91% in the on-pump group, a difference that was not statistically significant. One perioperative death was recorded in each group. Two strokes were recorded in the on-pump group, none in the off-pump group. Conclusion: In this prospective, controlled study, perioperative and short-term outcome of off-pump coronary surgery equaled that of on-pump surgery.
    Heart Surgery Forum 02/2004; 7(1):37-41. · 0.39 Impact Factor
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    • "15 Discharge, 3 mo 2 Test z-scores or composite 46.7% with decline at discharge, 6.7% with decline at 3 mo z-score above 1.96 [Reents 2002] 47 6 d ≥1 SD decline on at least 2 tests 34% with decline [Restrepo 2002a] 39 7 d ≥0.5 SD decline on at least 1 test 77% with decline [Reynolds 2002] 33 5-6 d ≥1 SD decline on at least % Not reported 1 domain [Stroobant 2002] 49 6-7 d, 6 mo 20% decline on 2 or more tests 61% with decline at 6-7 d, 11% with decline at 6 mo [Van Dijk 2002] 128 OPCAB, 3 mo, 1 year 20% decline on 20% of tests 29.2% CABG with decline at 3 mo, 21.1% OPCAB with 120 CABG decline at 3 mo, 33.6% CABG with decline at 3 mo, 30.8% OPCAB with decline at 3 mo [Ahlgren 2003] 23 CABG, 4-6 weeks ≥1 SD decline on at least two 48% of CABG with decline, 10% of PCI with decline 19 PCI test variables [Lee 2003] 30 CABG, 2 weeks, 1 year 20% decline on 20% of tests, 15.4% of CABG with decline at 2 weeks, 16.1% of OPCAB 30 OPCAB ANOVA with decline at 2 weeks, 14.8% of CABG with decline at 1 year, 18.5% of OPCAB with decline at 1 year [Lund 2003] "
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    ABSTRACT: Neurologic injuries, whether subtle or overt, are a major source of morbidity secondary to coronary artery bypass graft (CABG) surgery. A comprehensive review of research in the area of neurologic injury is provided. We conclude this article by providing insight regarding areas requiring further investigation in order to reduce sustainably the risk of these iatrogenic events among patient undergoing CABG surgery.
    Heart Surgery Forum 02/2004; 7(6):E650-62. DOI:10.1532/HSF98.20041103 · 0.39 Impact Factor
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