Central nervous system injury associated with cardiac surgery

Department of Anesthesiology, Duke University, Durham, North Carolina, United States
The Lancet (Impact Factor: 45.22). 09/2006; 368(9536):694-703. DOI: 10.1016/S0140-6736(06)69254-4
Source: PubMed

ABSTRACT Millions of individuals with coronary artery or valvular heart disease have been given a new chance at life by heart surgery, but the potential for neurological injury is an Achilles heel. Technological advancements and innovations in surgical and anaesthetic technique have allowed us to offer surgical treatment to patients at the extremes of age and infirmity-the group at greatest risk for neurological injury. Neurocognitive dysfunction is a complication of cardiac surgery that can restrict the improved quality of life that patients usually experience after heart surgery. With a broader understanding of the frequency and effects of neurological injury from cardiac surgery and its implications for patients in both the short term and the long term, we should be able to give personalised treatments and thus preserve both their quantity and quality of life. We describe these issues and the controversies that merit continued investigation.

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Available from: Daniel Laskowitz, Jan 13, 2014
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    • "Postoperative cognitive dysfunction (POCD) affects approximately 50 – 70% of patients at hospital discharge (Newman et al. 2006). Cognitive domains that are mostly affected include memory, attention, concentration, psychomotor speed and dexterity (Newman et al. 2006; Deiner and Silverstein 2009). While most aspects of neurocognitive decline are transient, some (e.g., memory impairment) can persist for months (Knipp et al. 2004). "
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    ABSTRACT: Objectives. Postoperative cognitive dysfunction (POCD) is an important neuropsychiatric complication of coronary artery bypass grafting (CABG). It is most likely caused by microembolic brain damage and affects domains of attention, memory, executive functions and dexterity. In order to achieve better neuroprotection, surgeons introduced some advantageous operating procedures. Noteworthy among them is a state-of-the-art off-pump CABG aorta no-touch technique ("no touch" OPCABG). The aim of this study was to investigate the short-term effect of "no touch" OPCABG on patients' attention and executive functions. Methods. In this prospective, observational, single-surgeon trial, 74 patients scheduled for elective CABG were studied. Thirty-five patients underwent "no-touch" OPCABG and were compared to 39 patients who underwent "traditional" OPCABG. Subjects underwent neurological and neuropsychological evaluation at the time of admission (7 ± 2 days preoperatively) and discharge (7 days postoperatively). Results. Patients who underwent "traditional" OPCABG showed a significant decline in postoperative performance on 4 neuropsychological tests, while patients treated with "no touch" OPCABG showed a significant decline on 1 test. Twenty patients from "traditional" OPCABG group and ten patients from "no touch" OPCABG group were diagnosed with POCD. Conclusions. Use of "no touch" OPCABG was associated with better attention and executive functions 1 week after surgery compared with "traditional" OPCABG.
    The World Journal of Biological Psychiatry 08/2013; DOI:10.3109/15622975.2013.824611 · 4.23 Impact Factor
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    • "Most of the heart-valve interventions are carried out under cardiopulmonary bypass (CPB) [1]. However, CPB has a number of disadvantages such as induction of the systemic inflammatory response syndrome, which may cause postoperative complications , including neurological morbidity [2]. Nevertheless, off-pump coronary artery surgery without CPB may also be complicated by postoperative neurocognitive dysfunction [3]. "
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    ABSTRACT: OBJECTIVES In cardiac surgery, the choice of temperature regimen during cardiopulmonary bypass (CPB) remains a subject of debate. Hypothermia reduces tissue metabolic demands, but may impair the autoregulation of cerebral blood flow and contribute to neurological morbidity. The aim of this study was to evaluate the effect of two different temperature regimens during CPB on the systemic oxygen transport and the cerebral oxygenation during surgical correction of acquired heart diseases.METHODS In a prospective study, we randomized 40 adult patients with combined valvular disorders requiring surgical correction of two or more valves into two groups: (i) a normothermic (NMTH) group (n = 20), in which the body core temperature was maintained at 36.6°C during CPB and (ii) a hypothermic (HPTH) group (n = 20), in which the body was cooled to a core temperature of 32°C maintained throughout the period of CPB. The systemic oxygen transport and the cerebral oxygen saturation (SctO(2)) were assessed by means of a PiCCO(2) haemodynamic monitor and a cerebral oximeter, respectively. All the patients received standard perioperative monitoring. We assessed haemodynamic and oxygen transport parameters, the duration of mechanical ventilation and the length of the ICU and the hospital stays.RESULTSDuring CPB, central venous oxygen saturation was significantly higher in the HPTH group but SctO(2) was increased in the NMTH group (P < 0.05). Cardiac index, systemic oxygen delivery and consumption increased postoperatively in both groups. However, oxygen delivery and consumption were significantly higher in the NMTH group (P < 0.05). The duration of respiratory support and the length of ICU and hospital stays did not differ between the groups.CONCLUSIONS During combined valve surgery, normothermic CPB provides lower central venous oxygen saturation, but increases cerebral tissue oxygenation when compared with the hypothermic regimen.TRIAL REGISTRATION NUMBERNCT01685554.
    Interactive Cardiovascular and Thoracic Surgery 02/2013; 16(5). DOI:10.1093/icvts/ivt016 · 1.11 Impact Factor
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    • "Anaesthetic agents have a negative impact on cognitive function in the days immediately after surgery (Newman et al., 2006; Papaioannou, Fraidakis, Michaloudis, Balalis, & Askitopoulou, 2005; Rasmussen et al., 2003). Ritchie, Polge, de Roquefeuil, Djakovic, and Ledesert (1997) reviewed the effects of anaesthesia after various types of surgery and found that cognitive impairment is a common outcome of surgery and that the incidence of such impairment was highest following cardiac surgery. "
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    ABSTRACT: This brief review focuses on coronary artery bypass grafting (CABG) and valve surgery and their post-operative effects on cognitive domains. Despite the substantial technical advances in cardiac surgery over the past few decades, the incidence of permanent cognitive impairment remains alarmingly high: 20–70 per cent of patients exhibit cognitive impairment during the first week after surgery, with the incidence declining to 10–40 per cent after 6 weeks and remaining at this level thereafter. We find that language, concentration and motor control are most consistently reported to be affected, while memory, attention and executive function are more variably affected. Valve surgery is generally associated with a worse outcome than CABG surgery. It remains unclear whether the use of the cardio-pulmonary bypass machine adversely affects cognitive outcome. There is an urgent need to identify the risk factors and surgical techniques that influence post-operative cognitive impairment, yet it is difficult to reach meaningful conclusions from the present data due to a lack of concordance in experimental design and data analysis. To address this challenge, future research will need to control for confounds such as mood state, post-operative pain, learning effects, and anaesthesia and will need to compare a wide range of cognitive domains and surgical procedures within large multi-centre studies. Copyright © 2008 John Wiley & Sons, Ltd.
    Stress and Health 08/2008; 24(3):249 - 266. DOI:10.1002/smi.1204 · 1.34 Impact Factor
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