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Neurologic outcome in octogenarians after aortic arch repair with hypothermic circulatory arrest
Ann Thorac Surg 2002;73:S366 –77
Neurologic Outcome in Octogenarians After Aortic Arch Repair With Hypothermic Circulatory Arrest DJ DiBardino, MD, JK Bhama, MD, SA LeMaire, MD, and JS Coselli, MD. Baylor College of Medicine and The Methodist DeBakey Heart Center, Houston, Texas Introduction. Although increasing numbers of octogenarians are being referred for surgical treatment of transverse aortic arch aneurysms, data regarding this high-risk group of patients are limited. The purpose of this study was to evaluate the neurologic outcomes in octogenarians who underwent aortic arch repair with hypothermic circulatory arrest. Methods. Over a 12-year period, 703 consecutive patients underwent transverse aortic arch repair with hypothermic circulatory arrest; 13 of these patients (1.9%) were octogenarians. The mean age was 82.1 years (range 80 to 86 years). Three patients (23%) had suffered previous strokes; 1 of these patients presented with chronic embolic strokes. One patient (8%) presented with acute dissection. Aortic repairs consisted of ascending and hemi-arch repair in 9 patients (69%), ascending and elephant trunk arch repair in 3 (23%), and patch repair of the arch in 1 (8%). Retrograde cerebral perfusion was utilized in 6 patients (46%). Results. There was one operative death (8%). Postoperative neurologic complications occurred in 2 patients (15%). One patient (8%) had a stroke and 1 had seizures after developing sepsis. The median length of stay was 21 days (range 16 to 140 days). Conclusions. Aortic arch repair with circulatory arrest can be performed with acceptable neurologic outcome in octogenarians.
OUTCOMES 2001 ABSTRACTS
S367
Advanced Magnetic Resonance Imaging Techniques of Perfusion and Diffusion in Evaluation of Postsurgical Brain Injury: Preliminary Results in Coronary Artery Surgery On and Off Cardiopulmonary Bypass MD Baker,1 DM Moody,1 AS Field,1 Y-F Yen,1,2 JW Hammon,3 and DA Stump.4 Departments of 1Radiology, 2Medical Engineering, 3Cardiothoracic surgery and 4 Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina Magnetic resonance imaging (MRI) is a common clinical imaging tool for the evaluation of the wide spectrum of brain disorders and injuries, including postsurgical brain injury related to ischemia. Conventional and advanced MRI techniques offer the ability not only to image the sequellae of injury but also to identify some factors that may result in increased risk of brain injury from embolic and hypoperfusion events resulting from surgical cardiac intervention. Diffusion weighted imaging (DWI) is a powerful newer technique that allows for both the identification of acute ischemic injury and differentiation from chronic ischemic changes. DWI is abnormal within the first day of an infarct and should detect all but the smallest lesions. We present our current findings in an ongoing study comparing brain injury in patients undergoing cardiac surgery on and off cardiopulmonary bypass. So far, the data demonstrate a trend toward increased risk of brain infarcts for patients undergoing coronary artery surgery on conventional cardiopulmonary bypass compared with minimally invasive surgery on the beating heart (p ⫽ 0.26 Fisher’s exact test). Evaluation of the DWI sequences in patients undergoing coronary artery surgery, randomized to the two arms, demonstrates a significantly higher number of infarcts in patients on cardiopulmonary bypass. A total of 22 randomized patients have been imaged, of which 9 are on-pump and 13 off-pump. A total of four infarcts have been detected in the 22 patients, three in the on-pump and one in the off-pump group. A total of 33.33% of patients on-pump have had detectable infarcts on DWI and only 7.69% off-pump, and 75% of the infarcts detected on MRI have occurred in the patients on-pump. Additional advanced MRI techniques are available, including perfusion weighted imaging (PWI) techniques and MRI spectroscopy. A form of noninvasive MRI perfusion, flow-sensitive alternating inversion recovery (FAIR), has also been performed in our study patients. The FAIR MRI perfusion studies give a measure of cerebral blood flow in traditional units of mL/100 g/min without requiring exogenous administration of contrast or tracer as with other perfusion techniques. Thus far, MRP data demonstrate an increase in the degree of asymmetry in cerebral perfusion compared with normal volunteers. However, PWI has not shown any significant difference in perfusion asymmetry between the on and off-pump patients. A larger sample size may be required to demonstrate a statistical significance in PWI results. Supported by a grant from the National Institutes of Health (NS-38242), a grant from the Charles A. Dana Foundation, and Medtronic Inc, (Minneapolis, MN).
The Effect of Neuropsychological Deficits on Quality of Life 6 Months After Cardiac Surgery
Magnetic Resonance Imaging and Cognitive Changes Before and After Coronary Artery Bypass Graft
MJ Andrew, BA (Hons), RA Baker, PhD, and JL Knight, FRACS. Cardiac Surgery Research, Flinders Medical Centre, Adelaide, South Australia, Australia
MA Grega, MSN, A Hillis, MD, RJ Wityk, MD, BC Trinh, MD, LM Borowicz, MS, NJ Beauchamp, MD, and GM McKhann, MD. The Johns Hopkins Hospital, Baltimore, Maryland
Introduction. The impact of postoperative neuropsychological (NP) deficits on quality of life (QOL) after cardiac surgery is not well understood. The aim of this investigation was to determine the relationship between NP deficits and QOL 6 months after cardiac surgery. Methods. With informed consent and institutional approval, 77 patients undergoing cardiac surgery were administered a NP battery preoperatively, before discharge, and 6 months postoperatively. NP deficits were defined using reliable change criteria. QOL was assessed preoperatively and 6 months postoperatively using standardized instruments (SF-36, Depression Anxiety Stress Scale [DASS], and Beck Depression Inventory [BDI]). Results. Approximately 10% of patients exhibited deficits on at least two NP measures 6 months postoperatively. Significant improvement at 6-month follow-up was evident on all QOL measures. After controlling for preoperative QOL scores, 6-month NP deficits correlated significantly with 6-month SF-36 measures of general health, physical, physical role, and social functioning, DASS anxiety, and BDI depression. NP deficits were a significant multivariate predictor of 6-month physical functioning (p ⫽ 0.005), physical role functioning (p ⫽ 0.038), and DASS anxiety (p ⫽ 0.04). Other significant multivariate predictors of 6-month QOL included preoperative QOL scores, perioperative myocardial infarction, and length of stay. Conclusions. NP deficits detected 6 months after cardiac surgery have a negative impact on QOL. These results highlight the importance of presurgical assessments of QOL in this population.
Introduction. Conventional magnetic resonance imaging and angiography (MRI/MRA), MR perfusion (MRP), as well as the availability of new technology, diffusion weighted imaging (DWI), has allowed us to examine the role of baseline cerebrovascular disease and acute infarction on cognitive changes after surgery. Methods. The study had Internal Review Board approval and patients completed informed consent. Patients completed preoperative MRI/ MRA, DWI, and MRP, as well as the trail making test (TMT). Patients were to have the same protocol on postoperative days 3 to 5. Results. Thirteen patients completed all preoperative scans. MRI/MRA revealed the following: abnormalities in 9/13 (69%): old lesions in 4/13, periventricular white matter changes in 7/13, and intravascular stenosis in 4/13. Only 1 (8%) had an acute lesion identified on DWI preoperatively. Of the 7 patients who completed the postoperative scans, only 1 had an acute lesion not present preoperatively on DWI. MRP showed no perfusion changes in these 7 patients. Six patients who had a preoperative MRI/MRA abnormality completed the TMT both pre- and postoperative. All 6 patients declined on the TMT (mean decline ⫽ 49 seconds). Three patients had no preoperative MRI/MRA abnormalities, and all 3 improved on the TMT. (p ⬍ 0.003). Conclusions. Brain abnormalities are common before surgery in patients with diagnosed coronary disease. Few have acute lesions (on DWI) preoperatively. Patients with abnormal MRI/MRA preoperatively may be more likely to decline on the TMT, a test of psychomotor slowing.
Neurologic Outcome in Octogenarians After Aortic Arch Repair With Hypothermic Circulatory Arrest DJ DiBardino, MD, JK Bhama, MD, SA LeMaire, MD, and JS Coselli, MD. Baylor College of Medicine and The Methodist DeBakey Heart Center, Houston, Texas Introduction. Although increasing numbers of octogenarians are being referred for surgical treatment of transverse aortic arch aneurysms, data regarding this high-risk group of patients are limited. The purpose of this study was to evaluate the neurologic outcomes in octogenarians who underwent aortic arch repair with hypothermic circulatory arrest. Methods. Over a 12-year period, 703 consecutive patients underwent transverse aortic arch repair with hypothermic circulatory arrest; 13 of these patients (1.9%) were octogenarians. The mean age was 82.1 years (range 80 to 86 years). Three patients (23%) had suffered previous strokes; 1 of these patients presented with chronic embolic strokes. One patient (8%) presented with acute dissection. Aortic repairs consisted of ascending and hemi-arch repair in 9 patients (69%), ascending and elephant trunk arch repair in 3 (23%), and patch repair of the arch in 1 (8%). Retrograde cerebral perfusion was utilized in 6 patients (46%). Results. There was one operative death (8%). Postoperative neurologic complications occurred in 2 patients (15%). One patient (8%) had a stroke and 1 had seizures after developing sepsis. The median length of stay was 21 days (range 16 to 140 days). Conclusions. Aortic arch repair with circulatory arrest can be performed with acceptable neurologic outcome in octogenarians.
OUTCOMES 2001 ABSTRACTS
S367
Advanced Magnetic Resonance Imaging Techniques of Perfusion and Diffusion in Evaluation of Postsurgical Brain Injury: Preliminary Results in Coronary Artery Surgery On and Off Cardiopulmonary Bypass MD Baker,1 DM Moody,1 AS Field,1 Y-F Yen,1,2 JW Hammon,3 and DA Stump.4 Departments of 1Radiology, 2Medical Engineering, 3Cardiothoracic surgery and 4 Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina Magnetic resonance imaging (MRI) is a common clinical imaging tool for the evaluation of the wide spectrum of brain disorders and injuries, including postsurgical brain injury related to ischemia. Conventional and advanced MRI techniques offer the ability not only to image the sequellae of injury but also to identify some factors that may result in increased risk of brain injury from embolic and hypoperfusion events resulting from surgical cardiac intervention. Diffusion weighted imaging (DWI) is a powerful newer technique that allows for both the identification of acute ischemic injury and differentiation from chronic ischemic changes. DWI is abnormal within the first day of an infarct and should detect all but the smallest lesions. We present our current findings in an ongoing study comparing brain injury in patients undergoing cardiac surgery on and off cardiopulmonary bypass. So far, the data demonstrate a trend toward increased risk of brain infarcts for patients undergoing coronary artery surgery on conventional cardiopulmonary bypass compared with minimally invasive surgery on the beating heart (p ⫽ 0.26 Fisher’s exact test). Evaluation of the DWI sequences in patients undergoing coronary artery surgery, randomized to the two arms, demonstrates a significantly higher number of infarcts in patients on cardiopulmonary bypass. A total of 22 randomized patients have been imaged, of which 9 are on-pump and 13 off-pump. A total of four infarcts have been detected in the 22 patients, three in the on-pump and one in the off-pump group. A total of 33.33% of patients on-pump have had detectable infarcts on DWI and only 7.69% off-pump, and 75% of the infarcts detected on MRI have occurred in the patients on-pump. Additional advanced MRI techniques are available, including perfusion weighted imaging (PWI) techniques and MRI spectroscopy. A form of noninvasive MRI perfusion, flow-sensitive alternating inversion recovery (FAIR), has also been performed in our study patients. The FAIR MRI perfusion studies give a measure of cerebral blood flow in traditional units of mL/100 g/min without requiring exogenous administration of contrast or tracer as with other perfusion techniques. Thus far, MRP data demonstrate an increase in the degree of asymmetry in cerebral perfusion compared with normal volunteers. However, PWI has not shown any significant difference in perfusion asymmetry between the on and off-pump patients. A larger sample size may be required to demonstrate a statistical significance in PWI results. Supported by a grant from the National Institutes of Health (NS-38242), a grant from the Charles A. Dana Foundation, and Medtronic Inc, (Minneapolis, MN).
The Effect of Neuropsychological Deficits on Quality of Life 6 Months After Cardiac Surgery
Magnetic Resonance Imaging and Cognitive Changes Before and After Coronary Artery Bypass Graft
MJ Andrew, BA (Hons), RA Baker, PhD, and JL Knight, FRACS. Cardiac Surgery Research, Flinders Medical Centre, Adelaide, South Australia, Australia
MA Grega, MSN, A Hillis, MD, RJ Wityk, MD, BC Trinh, MD, LM Borowicz, MS, NJ Beauchamp, MD, and GM McKhann, MD. The Johns Hopkins Hospital, Baltimore, Maryland
Introduction. The impact of postoperative neuropsychological (NP) deficits on quality of life (QOL) after cardiac surgery is not well understood. The aim of this investigation was to determine the relationship between NP deficits and QOL 6 months after cardiac surgery. Methods. With informed consent and institutional approval, 77 patients undergoing cardiac surgery were administered a NP battery preoperatively, before discharge, and 6 months postoperatively. NP deficits were defined using reliable change criteria. QOL was assessed preoperatively and 6 months postoperatively using standardized instruments (SF-36, Depression Anxiety Stress Scale [DASS], and Beck Depression Inventory [BDI]). Results. Approximately 10% of patients exhibited deficits on at least two NP measures 6 months postoperatively. Significant improvement at 6-month follow-up was evident on all QOL measures. After controlling for preoperative QOL scores, 6-month NP deficits correlated significantly with 6-month SF-36 measures of general health, physical, physical role, and social functioning, DASS anxiety, and BDI depression. NP deficits were a significant multivariate predictor of 6-month physical functioning (p ⫽ 0.005), physical role functioning (p ⫽ 0.038), and DASS anxiety (p ⫽ 0.04). Other significant multivariate predictors of 6-month QOL included preoperative QOL scores, perioperative myocardial infarction, and length of stay. Conclusions. NP deficits detected 6 months after cardiac surgery have a negative impact on QOL. These results highlight the importance of presurgical assessments of QOL in this population.
Introduction. Conventional magnetic resonance imaging and angiography (MRI/MRA), MR perfusion (MRP), as well as the availability of new technology, diffusion weighted imaging (DWI), has allowed us to examine the role of baseline cerebrovascular disease and acute infarction on cognitive changes after surgery. Methods. The study had Internal Review Board approval and patients completed informed consent. Patients completed preoperative MRI/ MRA, DWI, and MRP, as well as the trail making test (TMT). Patients were to have the same protocol on postoperative days 3 to 5. Results. Thirteen patients completed all preoperative scans. MRI/MRA revealed the following: abnormalities in 9/13 (69%): old lesions in 4/13, periventricular white matter changes in 7/13, and intravascular stenosis in 4/13. Only 1 (8%) had an acute lesion identified on DWI preoperatively. Of the 7 patients who completed the postoperative scans, only 1 had an acute lesion not present preoperatively on DWI. MRP showed no perfusion changes in these 7 patients. Six patients who had a preoperative MRI/MRA abnormality completed the TMT both pre- and postoperative. All 6 patients declined on the TMT (mean decline ⫽ 49 seconds). Three patients had no preoperative MRI/MRA abnormalities, and all 3 improved on the TMT. (p ⬍ 0.003). Conclusions. Brain abnormalities are common before surgery in patients with diagnosed coronary disease. Few have acute lesions (on DWI) preoperatively. Patients with abnormal MRI/MRA preoperatively may be more likely to decline on the TMT, a test of psychomotor slowing.