- Email: [email protected]
Risk factors of stroke after cardic surgery: Reply
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important role in increasing the CVA rate even in OPCAB patients. In conclusion, we believe that the real advantages of beatingheart coronary operations in terms of CVA prevention should be analyzed by excluding the highly select population of MIDCAB candidates. Only by focusing on a strict comparison between OPCAB and traditional CABG on CPB can we elucidate the real advantages of this innovative procedure and understand its theoretical superiority in either the overall population or in select subgroups of high-risk patients. Giuseppe D’Ancona, MD Jose Saez de Ibarra, MD Richard Baillot, MD Francois Dagenais, MD Quebec Heart Institute Hoˆpital Laval 2725, Chemin Ste-Foy Ste-Foy, PQ G1V 4G5, Canada e-mail: [email protected]
References 1. Bucerius J, Gummert JF, Borger MA, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg 2003;75:472–8. 2. D’Ancona G, Saez de Ibarra JI, Baillot R, et al. Determinants of stroke after coronary artery bypass grafting. Eur J Cardiothorac Surg 2003;24:552–6. 3. Ascione R, Reeves BC, Chamberlain MH, Ghosh AK, Lim KHH, Angelini GD. Predictors of stroke in the modern era of coronary artery bypass grafting: a case control study. Ann Thorac Surg 2002;74:474 –80. 4. Patel NC, Deodhar AP, Grayson AD, et al. Neurological outcomes in coronary surgery: independent effect of avoiding cardiopulmonary bypass. Ann Thorac Surg 2002;74:400 –6.
Ann Thorac Surg 2004;78:752– 8
ing to perioperative stroke besides clamp-induced embolization from the ascending aorta. In the Comment section of our report, we suggested that avoidance of CPB per se may have a benefit in regard to the postoperative, especially the neurologic, outcome. In addition to these findings, the impact of prolonged CPB time and the lower, but nonsignificant, incidence of stroke in the OPCAB group compared with the conventional CABG group confirm this finding. When comparing the preoperative risk profile of all our patients undergoing OPCAB and MIDCAB, we found no significant differences in terms of preoperative history of cerebrovascular disease and left ventricular ejection fraction. However, patients undergoing OPCAB were significantly older than patients in the MIDCAB group. Some morbid and select patients with three-vessel disease even receive MIDCAB to avoid a sternotomy and accept incomplete revascularization. Preoperative history of cerebrovascular disease was found to be the strongest independent risk factor for perioperative stroke in our series. As we did not find a significantly different incidence preoperatively, we do not believe that the MIDCAB patients in our series were a “highly select population⬙. However, we agree with D’Ancona and associates that further analysis of patients undergoing CABG on the beating heart is mandatory to elucidate potential advantages of this promising technique in regard to outcome. Jan Bucerius, MD Thomas Walther, MD, PhD Jan F. Gummert, MD, PhD Friedrich W. Mohr, MD, PhD Department of Cardiac Surgery Heart Center, University of Leipzig Stru¨mpellstr 39 04289 Leipzig, Germany e-mail: [email protected]
MISCELLANEOUS
Reply
Reference
To the Editor
1. Bucerius J, Gummert JF, Borger MA, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg 2003;75:472–8.
We appreciate the comments of D’Ancona and colleagues. The Quebec data as well as our analysis [1] revealed that diabetes mellitus and a history of cerebrovascular disease are strong preoperative predictors of perioperative stroke. In contrast to their results, we found prolonged cardiopulmonary bypass time (CPB) of more than 120 minutes to be an independent intraoperative predictor of perioperative stroke. This is reasonable to believe, as patients requiring a longer time of CPB usually are seen with more severe cardiac disease and an increased additional risk profile. We agree with D’Ancona and associates that patients undergoing minimally invasive direct coronary artery bypass grafting (MIDCAB) should have a significantly lower incidence of perioperative neurologic complications compared with those having on-pump coronary artery bypass grafting (OPCAB). This can be explained by avoidance of manipulation of the ascending aorta, a potentially lower preoperative risk profile, and shorter operating times. However, as stated in our report, the incidence of perioperative stroke was lower in the MIDCAB group but failed to reach significance in comparison to the OPCAB group (MIDCAB, 1.6%, versus OPCAB, 2.5%.) Furthermore, it was surprising that in 17 patients undergoing MIDCAB, manifest neurologic complications occurred. Because of this finding, we have to suggest that there are other causative factors contribut© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Is Stenting an Option? To the Editor: We enjoyed the case report by Dr Sugimoto and colleagues [1] about rupture of the right coronary ostium as a result of blunt trauma. Was coronary arteriography considered shortly after repair of the acute injury? The anatomy suggests that stent placement might have been a possible intervention after the repair (with the requirement of an antiplatelet agent). Two case reports [2, 3] published in 2002 demonstrate that covered stents can be deployed successfully for atherosclerotic right and left giant coronary aneurysms. Stent placement might have eliminated the urgency of a second definitive surgical procedure or allowed elective repair. The age of the patient, the proximity of the initial tear to the right ostium, and the large, dominant right coronary artery might have made one lean toward surgical revascularization. Was placement of a polytetrafluoroethylene-covered stent considered in this patient? 0003-4975/04/$30.00
CORRESPONDENCE
important role in increasing the CVA rate even in OPCAB patients. In conclusion, we believe that the real advantages of beatingheart coronary operations in terms of CVA prevention should be analyzed by excluding the highly select population of MIDCAB candidates. Only by focusing on a strict comparison between OPCAB and traditional CABG on CPB can we elucidate the real advantages of this innovative procedure and understand its theoretical superiority in either the overall population or in select subgroups of high-risk patients. Giuseppe D’Ancona, MD Jose Saez de Ibarra, MD Richard Baillot, MD Francois Dagenais, MD Quebec Heart Institute Hoˆpital Laval 2725, Chemin Ste-Foy Ste-Foy, PQ G1V 4G5, Canada e-mail: [email protected]
References 1. Bucerius J, Gummert JF, Borger MA, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg 2003;75:472–8. 2. D’Ancona G, Saez de Ibarra JI, Baillot R, et al. Determinants of stroke after coronary artery bypass grafting. Eur J Cardiothorac Surg 2003;24:552–6. 3. Ascione R, Reeves BC, Chamberlain MH, Ghosh AK, Lim KHH, Angelini GD. Predictors of stroke in the modern era of coronary artery bypass grafting: a case control study. Ann Thorac Surg 2002;74:474 –80. 4. Patel NC, Deodhar AP, Grayson AD, et al. Neurological outcomes in coronary surgery: independent effect of avoiding cardiopulmonary bypass. Ann Thorac Surg 2002;74:400 –6.
Ann Thorac Surg 2004;78:752– 8
ing to perioperative stroke besides clamp-induced embolization from the ascending aorta. In the Comment section of our report, we suggested that avoidance of CPB per se may have a benefit in regard to the postoperative, especially the neurologic, outcome. In addition to these findings, the impact of prolonged CPB time and the lower, but nonsignificant, incidence of stroke in the OPCAB group compared with the conventional CABG group confirm this finding. When comparing the preoperative risk profile of all our patients undergoing OPCAB and MIDCAB, we found no significant differences in terms of preoperative history of cerebrovascular disease and left ventricular ejection fraction. However, patients undergoing OPCAB were significantly older than patients in the MIDCAB group. Some morbid and select patients with three-vessel disease even receive MIDCAB to avoid a sternotomy and accept incomplete revascularization. Preoperative history of cerebrovascular disease was found to be the strongest independent risk factor for perioperative stroke in our series. As we did not find a significantly different incidence preoperatively, we do not believe that the MIDCAB patients in our series were a “highly select population⬙. However, we agree with D’Ancona and associates that further analysis of patients undergoing CABG on the beating heart is mandatory to elucidate potential advantages of this promising technique in regard to outcome. Jan Bucerius, MD Thomas Walther, MD, PhD Jan F. Gummert, MD, PhD Friedrich W. Mohr, MD, PhD Department of Cardiac Surgery Heart Center, University of Leipzig Stru¨mpellstr 39 04289 Leipzig, Germany e-mail: [email protected]
MISCELLANEOUS
Reply
Reference
To the Editor
1. Bucerius J, Gummert JF, Borger MA, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. Ann Thorac Surg 2003;75:472–8.
We appreciate the comments of D’Ancona and colleagues. The Quebec data as well as our analysis [1] revealed that diabetes mellitus and a history of cerebrovascular disease are strong preoperative predictors of perioperative stroke. In contrast to their results, we found prolonged cardiopulmonary bypass time (CPB) of more than 120 minutes to be an independent intraoperative predictor of perioperative stroke. This is reasonable to believe, as patients requiring a longer time of CPB usually are seen with more severe cardiac disease and an increased additional risk profile. We agree with D’Ancona and associates that patients undergoing minimally invasive direct coronary artery bypass grafting (MIDCAB) should have a significantly lower incidence of perioperative neurologic complications compared with those having on-pump coronary artery bypass grafting (OPCAB). This can be explained by avoidance of manipulation of the ascending aorta, a potentially lower preoperative risk profile, and shorter operating times. However, as stated in our report, the incidence of perioperative stroke was lower in the MIDCAB group but failed to reach significance in comparison to the OPCAB group (MIDCAB, 1.6%, versus OPCAB, 2.5%.) Furthermore, it was surprising that in 17 patients undergoing MIDCAB, manifest neurologic complications occurred. Because of this finding, we have to suggest that there are other causative factors contribut© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Is Stenting an Option? To the Editor: We enjoyed the case report by Dr Sugimoto and colleagues [1] about rupture of the right coronary ostium as a result of blunt trauma. Was coronary arteriography considered shortly after repair of the acute injury? The anatomy suggests that stent placement might have been a possible intervention after the repair (with the requirement of an antiplatelet agent). Two case reports [2, 3] published in 2002 demonstrate that covered stents can be deployed successfully for atherosclerotic right and left giant coronary aneurysms. Stent placement might have eliminated the urgency of a second definitive surgical procedure or allowed elective repair. The age of the patient, the proximity of the initial tear to the right ostium, and the large, dominant right coronary artery might have made one lean toward surgical revascularization. Was placement of a polytetrafluoroethylene-covered stent considered in this patient? 0003-4975/04/$30.00