ADVERSE CEREBRAL OUTCOMES AFTER CARDIAC SURGERY .

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Slide 1 : 12/98 1 ADVERSE CEREBRAL OUTCOMES AFTER CARDIAC SURGERY Anjan Gupta, M.D. Milwaukee Heart Institute Milwaukee, Wisconsin
Slide 2 : 12/98 2 Incidence of TIA or CVA after cardiac surgery Carotid disease No CVA/TIA PERCENT None 3894 74 1.9 Unilateral occlusion 29 4 13.8 Bilateral occlusion 3 1 33.0 Unilateral stenosis Endarterectomy 35 2 5.7 No endarterectomy 49 3 6.1 Bilateral stenosis Endarterectomy 15 0 - No endarterectomy 10 0 - Occlusion and stenosis Endarterectomy 7 3 42.9 No endarterectomy 5 1 20.0 Brener et al, J Vasc Surgery 1987 ; 5 : 269 - 79
Slide 3 : 12/98 3 Mean length of hospital and ICU stay according to cerebral outcomes Roach et al, NEJM 1996
Slide 4 : 12/98 4 Time of onset of postoperative stroke or TIA Reed et al, NEJM 1988 ; 319 : 1246 - 50
Slide 5 : 12/98 5 Annual incidence of stroke following CABG at John Hopkins Hospital Gardner et al, The Annals of Thor. Surgery 1985 ; 40 : 574 - 80
Slide 6 : 12/98 6 Mortality and postoperative resource use according to cerebral outcomes Roach et al, NEJM 1996
Slide 7 : 12/98 7 Incidence of stroke according to the age of the patient Gardner et al, The Annals of Thor. Surgery 1985 ; 40 : 574 - 80
Slide 8 : 12/98 8 Odds ratios for Type I and Type II Cerebral outcomes (Significant factors , p<0.05) FACTOR TYPE I CEREBRAL TYPE II CEREBRAL OUTCOME OUTCOME SIGNIFICANT FACTORS Prox Aortic Atherosclerosis 4.52 (2.52 - 8.09) Hx of neurologic disease 3.19 (1.65 - 6.15) Use of IABP 2.60 (1.21 - 5.58) DM 2.59 (1.46 - 4.60) HTN 2.31(1.20 - 4.47) Hx of Pulmonary disease 2.09 (1.14 - 3.85) 2.37 (1.34 - 4.18) Age 1.75 ( 1.27 - 2.43) 2.20 (1.60 - 3.02) Hx of UA 1.83 (1.03 - 3.27) Hx of ETOH 3.47 (1.41 - 8.55) Hx of CABG 2.18 (1.14 - 4.17) Dysrhytmia on day of surgery 1.97 (1.12 - 3.46) Roach et al, NEJM 1996
Slide 9 : 12/98 9 Incidence of Type I and Type II cerebral outcomes according to age Roach et al, NEJM 1996
Slide 10 : 12/98 10 Univariate predictors of stroke following CABG * * * * * + * p < 0.001 + p = 0.014 Rao et al, J Card Surg 1995 ; 10 : 468 - 474
Slide 11 : 12/98 11 Multivariable predictors of stroke in patients following CABG Rao et al, J Card Surg 1995 ; 10 : 468 - 474
Slide 12 : 12/98 12 Association of aging with postoperative cognitive dysfunction Newman et al, Circulation 1994 ; 90 : II - 243 - II - 249
Slide 13 : 12/98 13 Probability of major CNS events versus age and additonal risk factors from the stroke risk index Newman et al, Circulation 1996 ; 94 [suppl II] : II-74 - II-80
Slide 14 : 12/98 14 Effect of advanced age on predicted probability of neurologic and cardiac morbidity Tuman et al, J Thorac Cardiovasc Surg 1992 ; 104 : 1510-7
Slide 15 : 12/98 15 Significant risk factors for stroke after cardiac surgery Buffalo Cardiac-Cerebral Study Group Variables Odds Ratio p - value Carotid Stenosis > 50% 6.01 0.01 Previous stroke 3.9 0.05 Valve surgery 5.39 0.02 Redo 4.58 0.03 Ricotta et al, J Vasc Surg 1995 ; 21 : 359 -64
Slide 16 : 12/98 16 Significant risk factors for stroke Factor CVA Patients Controls Significance Age (yr) 63 ± 7.8 57 ± 8.8 p < 0.0001 Previous CV disease 20% 8% p < 0.03 Severe atherosclero- 14% 3% p < 0.05 -sis of ascending aorta Pump time (min) 122 ± 33 105 ± 35 p < 0.005 Severe perioperative 23% 4% p < 0.0001 hypotension Gardner et al, The Annals of Thor. Surgery 1985 ; 40 : 574 - 80
Slide 17 : 12/98 17 CNS Complications of CABG Prospective analysis of 421 patients Stroke Prolonged Encephalopathy Frequency 22/421 ( 5.2%) 49/421 (11.6%) Significant Risk Factors preop none none intraop none none postop none pressor agents IABP Clinical Outcome full recovery 6 80% mild residua 9 20% disabled 6 dead 1 Breuer et al, Stroke 1983 ; 14 : 682 - 687
Slide 18 : 12/98 18 Predictors of risk of stroke on the day of operation The CASS Experience Variables No of strokes Probability Rel. Risk 95% Confidence Interval Age <0.0001 <55 yr 0.2% 1.0 56 - 60 0.6% 2.62 1.22 - 5.60 61 - 65 0.9% 3.18 1.43 - 6.84 66 - 70 1.8% 6.63 3.07 - 14.3 71 - 75 0.9% 3.16 0.70 - 14.3 >75 5.0% 26.7 5.72 - 124.0 Support with a-adr- <0.0001 -energic agents No 0.4% 1.0 Yes 3.0% 4.56 2.33 - 8.9 Pump time <0.002 <100 min 0.2% 1.0 100 - 200 min 0.7% 2.62 1.38 - 4.98 >200 min 1.7% 4.24 1.67 - 10.8 Frye et al, Int Jnl of Card 1992 ; 36 : 213 - 221
Slide 19 : 12/98 19 Significant predictors of stroke at least one day after operation and during hospitalization The CASS Experience Variable No of strokes Probability Rel. Risk Confidence Interval AGE <0.0001 <55 yrs 0.6% 1.0 56 - 60 yrs 1.0% 1.49 0.87 - 2.54 61 - 65 yrs 1.6% 2.10 1.24 - 3.54 66 - 70 yrs 4.3% 6.46 3.94 - 10.6 71 - 75 yrs 2.8% 3.28 1.33 - 8.10 >75 yrs 7.8% 11.1 3.10 - 39.9 DURATION OF <0.0001 BYPASS <100 mins 0.6% 1.0 101 - 200 mins 1.5% 1.99 1.27 - 3.12 >200 mins 4.8% 4.41 2.34 - 8.31 Frye et al, Int Jnl of Card 1992 ; 36 : 213 - 221
Slide 20 : 12/98 20 Predictors of stroke within 1 yr after discharge from the hospital The CASS Experience Variable No of strokes Probability Rel. Risk 95% CI Med Hx of cerbro - <0.0001 vascular disease No 1.1% 1.0 Yes 19.3% 19.16 12.43 - 29.53 HTN <0.0001 No 0.9% 1.0 Yes 2.9% 2.79 1.89 - 4.11 Frye et al, Int Jnl of Card 1992 ; 36 : 213 - 221
Slide 21 : 12/98 21 Risk factors for postoperative stroke or TIA Risk Factors Controls Cases OR 95% CI SIGNIFICANT Carotid bruits 7.4% 24% 3.9 1.2 - 12.8 Hx of stroke or TIA 5.5% 25% 6.0 1.6 - 22.1 Hx of Heart Failure 7.4% 29.6% 5.3 1.6 - 17.0 Mitral regurgitation 9.2% 29.6% 4.3 1.4 - 12.9 Post op Afib 27.7% 53% 3.0 1.4 - 6.7 Pump time >120min 16.6% 35.1% 2.7 1.1 - 6.7 Previous MI 48.1% 68.5% 2.3 1.1 - 5.1 NOT SIG Age >60 yrs 40.7% 57.4% 2.3 0.9 - 4.3 Yr of Surgery Reed et al, NEJM 1988 ; 319 : 1246 - 50
Slide 22 : 12/98 22 Studies of risk of postoperative stroke in patients with carotid bruits STUDY Type of Surgery No of Pts Strokes Carotid bruits Odds Ratio 95% CI Breuer et al CABG 416 21 6.3% 0.7 0.1 - 5.7 Turnipseed et al CABG 170 9 16.5% 1.5 0.3 - 7.5 Ropper et al CABG + 735 5 14.1% 1.5 0.2 - 13.8 Reed et al CABG 108 54 7.5% 3.9 1.2 - 12.8 Taylor et al CABG 453 10 4.4% 17.8 4.6 - 69.3 Coffey et al CABG 1669 13 6.0% 9.8 3.2 - 30.6 Reed et al, NEJM 1988 ; 319 : 1246 - 50
Slide 23 : 12/98 23 Association between risk factors and postoperative mortality and stroke rates Variables No of Patients Percent Odds Ratio Mortality Stroke Gender, female 163 30.2 0.50 0.81 Hypercholesterolemia 358 66.4 0.43 0.24 Hypertension 252 46.8 0.72 0.87 Diabetes Mellitus 106 19.7 1.34 0.36 Smoking 316 58.6 0.90 0.86 CS >75% 47 8.7 0.68 9.87* Peripheral Vasc. Surgery 13 2.4 23.57** Redo CABG 40 7.4 3.8*** 5.26¶ * p <0.005, ** p <0.001, *** p <0.07, ¶ p <0.05 Faggioli et al, J Vasc Surg 1990 ; 12 : 724 - 31
Slide 24 : 12/98 24 Frequency of postoperative neurologic deficit and mortality rate by groups according to status of carotid disease and treatment received Group Number TIA Stroke Mortality rate Minimal or mild stenosis 432 (80.1%) 4 (0.9%) 5 (1.2%) 8 (1.8%) ( < 50%) Moderate stenosis 60 (11.2%) 1 (1.7%) 0 2 (3.3%) ( 50 - 75%) Asymtomatic severe 19 (3.5%) 0 0 0 stenosis ( >75%) undergoing PCE Asymptomatic severe 28 (5.2%) 6 (1.1%) 4 (14.3%)* 2 (7.1%) stenosis ( >75%) not undergoing PCE * p = 0.0019 c/w other groups Faggioli et al, J Vasc Surg 1990 ; 12 : 724 - 31
Slide 25 : 12/98 25 Neuropsychological impact of microemboli in cardiac surgery Neuropsychological deteriorations 8 days after cardiac surgery in filtered and nonfiltered patients Pugsley et al, Stroke 1994 ; 25 : 1393 - 1399
Slide 26 : 12/98 26 Distribution of number of microemboli for each of the major CNS event categories Clark et al, J Thoracic Cardiovasc Surgery, 1995 ; 109: 249 -58
Slide 27 : 12/98 27 Neuropsychologic outcomes after Open-Heart surgery Sotniemi et al, Arch Neurology 1981 ; 38 : 2 - 8 Follow-up of neuropsychologic indices of postoperative patients
Slide 28 : 12/98 28 Complications of surgery in patients with atherosclerosis of ascending aorta in whom adequate precautions were taken Complications A (463) B (132) C (16) D (14) E (7) Infarct 2 0 0 0 0 Intraaortic 5 0 0 0 0 balloons Operative CVA 2 0 2 0 0 Postoperative 0 1 2 0 0 TIA Postoperative 1 0 0 0 0 CVA Death 4 0 1 0 0 A - soft aorta with no palpable disease B - aorta with palpable atheromas needing surgical modifications C - unclampable aorta D - untouchable aorta Yaron Bar-El et al, J Thorac Cardiovasc Surg 1992 ; 104 : 469 -74
Slide 29 : 12/98 29 CONCLUSIONS Adverse cerebral outcomes after coronary bypass surgery are relatively common and serious Adverse cerebral outcomes are associated with increases in mortality, length of hospitalization and use of intermediate or long-term care facilities New diagnostic and therapeutic strategies must be developed to lessen such injury
Slide 30 : 12/98 30

 


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