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The impact of postoperative atrial fibrillation on neurocognitive outcome after coronary artery bypass grafting
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OUTCOMES 2000 SCIENTIFIC ABSTRACTS
Ann Thorac Surg 2000;70:1786 –97
NPMT Performance After Coronary Artery Bypass Grafting: Cardiopulmonary Bypass Versus Off-Pump Coronary Artery Bypass
Neurocognitive Outcomes After Standard Aortic Versus Femoral Cannulation in Coronary Artery Bypass Graft Surgery
H Manspeizer, MD,a EJ Heyer, MD, PhD,a K Lee, BS, L Mongero, B Esrig, MD,b and CR Smith, MD.b aDepartment of Anesthesiology, b Division Cardiothoracic Surgery, Columbia University, New York, New York
BW Shragge, FRCS(C), PL Prior, PhD, HC Bauman, MHSc, E Lonn, FRCP(C), F Merali, MD, and I Doris, FRCP(C). General Campus, HHSC, McMaster University, Hamilton, Ontario, Canada (ERB and informed consent obtained)
Introduction. New techniques to reduce cerebral dysfunction after coronary artery bypass grafting (CABG) are being developed, which include changes to the cardiopulmonary bypass (CPB) circuits and performing CABG off-pump (OPCAB). This prospective study was undertaken to determine the incidence of cerebral dysfunction in patients having CABG with nonheparin or heparin-bonded CPB circuits or OPCAB. Methods. Sixty-six patients scheduled for elective CABG surgery were randomly assigned to CPB either with non-heparin-bonded (group A) or heparin-bonded (Carmeda) (group B) CPB circuits. Some patients were chosen by their CT surgeon to have OPCAB (group C). Induction was with conventional agents and maintenance was by a continuous infusion of fentanyl, midazolam, and cisatracurium supplemented with isoflurane. All patients were examined before and after surgery (5 to 7 days and 1 to 2 months) with five NPMTs. These generated eight scores. A significant change was defined as a decrease in the postoperative performance by 25% or more. We calculated: 1) number of tests changed for each patient; and 2) number of patients with zero, only one, only two, only three, or more than three tests changed. The groups were than compared using the Mann-Whitney rank sum test. Results. The groups were different for OPCAB patients who had a significantly shorter duration of surgery, fewer grafts, and less transfusion. Cerebral dysfunction was statistically less in group C (OPCAB) compared with group A at 5 to 7 days, although group B showed a similar trend. There were no differences between the two types of CPB circuits although there was a trend to less cerebral dysfunction in group B (heparin-bonded) at 1 to 2 months. Conclusions. A number of new techniques associated with CPB surgery may decrease the incidence of cognitive changes. Our data demonstrate a better outcome in cognitive performance when surgery is performed OPCAB. 1) Is it possible to randomize patients into two distinctly different surgical treatment groups? 2) What confounders does one need to control for? For example, does one have to control for the amount of blood transfused, the number of grafts, etc. 3) What evidence does one require to argue that the groups are equal in terms of patient’s severity of illness? The Impact of Postoperative Atrial Fibrillation on Neurocognitive Outcome After Coronary Artery Bypass Grafting TO Stanley, GB Mackensen, HP Grocott, WD White, W Cohen, A Butler, and MF Newman. Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina Introduction. Neurocognitive (NC) decline is a continuing source of morbidity after coronary artery bypass grafting (CABG) surgery. The purpose of this study was to determine if postoperative atrial fibrillation (AF) was a factor in postoperative cognitive dysfunction. Methods. After Internal Review Board approval, 274 consenting patients received a battery of NC tests both preoperatively and 6 weeks after CABG surgery. Multivariable analysis compared the presence of postoperative AF with overall cognitive change, defined as the mean of four distinct cognitive domain z scores. Results. Sixty-four subjects had postoperative AF. As can be seen in the graph below, the No AF group increased its mean score by 0.105 while the AF group only increased by 0.028. This difference in improvement was significant ( p ⫽ 0.0355). Factors controlled for included age, years of education, diabetes, and left ventricular ejection fraction.
Background. Neurocognitive (NC) impairment or stroke, after coronary artery bypass grafting (CABG), may be associated with microembolization from ascending aortic and arch plaque. A pilot study of femoral (FemC) versus standard aortic cannulation (AoC) was undertaken to look for possible trends in NC outcome as a result of minimized plaque embolization with FemC. Methods. Inclusion criteria were age 60 years and isolated CABG. Exclusion criteria were presence of carotid bruit and carotid duplex 70% stenosis, femoral arterial disease classification 20% stenosis in both arteries, or previous history of stroke or transient ischemic attack. Transesophageal echocardiogram was done before surgery. NC and quality of life measurements were done a mean of 2 weeks before and repeated a mean of 6 weeks after surgery. Results. Five patients were initially randomized to FemC and 5 to AoC. One randomized to AoC died of multisystem failure and another, randomized to FemC, crossed over to AoC. Comparisons of the 5 patients in AoC versus the 4 in FemC show: age 68.6 versus 70.4 years ( p ⫽ 0.64), maximum ascending aortic and arch plaque thickness 3.9 versus 4.9 mm ( p ⫽ 0.48), pump time 65.8 versus 84.5 minutes ( p ⫽ 0.05), and cross-clamp time 40.2 versus 56.8 minutes ( p ⫽ 0.11). Overall, there was no consistent pattern of change in NC performance post- versus presurgery, nor between AoC and FemC. There were no complications with either technique. Increased age significantly predicted more decrement/ less improvement in memory and verbal function. There is suggestive correlational evidence that maximum ascending aortic and arch plaque thickness predicted more decrement/less improvement in memory and learning functions. Conclusions. There were trends toward associations between ascending aortic and arch plaque thickness and memory and learning functions that merit further investigation of cannulation techniques aimed at avoiding aortic plaque disruptions during surgery.
Neurocognitive Dysfunction and Quality of Life After Cardiac Surgery MF Newman, MD, HP Grocott, MD, TO Stanley, MD, GB Mackensen, MD, JL Kirchner, BS, DB Mark, MD, and JA Blumenthal, PhD. Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina Introduction. The importance of perioperative neurocognitive decline (NCD) has long been debated. The purpose of our investigation was to determine the association between NCD and long-term quality of life (QOL) after surgery. Methods. After Internal Review Board approval and informed consent, 261 patients had NCD measured using a previously described NC battery at baseline, discharge, 6 weeks, and 5 years postoperatively. QOL was assessed using a number of well-validated, standardized assessments. Results. Our results demonstrated significant univariate and multivariate correlations between NCD and multiple measures of QOL in patients 5 years after cardiac surgery. These correlations included significant associations between the severity of overall cognitive dysfunction and measures of executive function, (MMSE; p ⫽ 0.0001), anxiety (STAI; p ⫽ 0.02), depression (CES-D; p ⫽ 0.0012), activities of daily living (DASI; p ⫽ 0.002), perceived cognitive difficulty ( p ⫽ 0.0001), as well as multiple other areas of measured QOL. Age, gender, educational level, and diabetes were also found to be significantly associated with QOL. Table 1. Multivariable Adjusted Effects of Total 5-Year Cognitive Function Score on Quality of Life Measures Quality of Life Outcome Functional activity (DASI) Limitation on activity (from SF-36) Better mental awareness (MMSE) Less anxiety (STAIX)
p Value 0.0085 0.0004 0.0001 0.0071
Less depression (CESD) Better “general health” (self-rated) Cognitive difficulty (self-rated)
0.0006 0.0159 0.0046
Productive working status
0.0060
Significant Covariates Age, gender, diabetes Gender, diabetes Age, gender Age, gender, diabetes, education Age, gender, diabetes Age, gender Age, gender, diabetes, education Age, gender
Total R2 0.298 0.236 0.455 0.206 0.177 0.096 0.199 C ⫽ 0.786
Discussion. Cognitive dysfunction alters QOL after surgery. Perception of general health varies directly with cognitive functioning. Discussion. AF is associated with cognitive function 6 weeks after CABG surgery. The mechanis of this association is yet to be determined, but reduction in the incidence of AF may improve postoperative NC function.
OUTCOMES 2000 SCIENTIFIC ABSTRACTS
Ann Thorac Surg 2000;70:1786 –97
NPMT Performance After Coronary Artery Bypass Grafting: Cardiopulmonary Bypass Versus Off-Pump Coronary Artery Bypass
Neurocognitive Outcomes After Standard Aortic Versus Femoral Cannulation in Coronary Artery Bypass Graft Surgery
H Manspeizer, MD,a EJ Heyer, MD, PhD,a K Lee, BS, L Mongero, B Esrig, MD,b and CR Smith, MD.b aDepartment of Anesthesiology, b Division Cardiothoracic Surgery, Columbia University, New York, New York
BW Shragge, FRCS(C), PL Prior, PhD, HC Bauman, MHSc, E Lonn, FRCP(C), F Merali, MD, and I Doris, FRCP(C). General Campus, HHSC, McMaster University, Hamilton, Ontario, Canada (ERB and informed consent obtained)
Introduction. New techniques to reduce cerebral dysfunction after coronary artery bypass grafting (CABG) are being developed, which include changes to the cardiopulmonary bypass (CPB) circuits and performing CABG off-pump (OPCAB). This prospective study was undertaken to determine the incidence of cerebral dysfunction in patients having CABG with nonheparin or heparin-bonded CPB circuits or OPCAB. Methods. Sixty-six patients scheduled for elective CABG surgery were randomly assigned to CPB either with non-heparin-bonded (group A) or heparin-bonded (Carmeda) (group B) CPB circuits. Some patients were chosen by their CT surgeon to have OPCAB (group C). Induction was with conventional agents and maintenance was by a continuous infusion of fentanyl, midazolam, and cisatracurium supplemented with isoflurane. All patients were examined before and after surgery (5 to 7 days and 1 to 2 months) with five NPMTs. These generated eight scores. A significant change was defined as a decrease in the postoperative performance by 25% or more. We calculated: 1) number of tests changed for each patient; and 2) number of patients with zero, only one, only two, only three, or more than three tests changed. The groups were than compared using the Mann-Whitney rank sum test. Results. The groups were different for OPCAB patients who had a significantly shorter duration of surgery, fewer grafts, and less transfusion. Cerebral dysfunction was statistically less in group C (OPCAB) compared with group A at 5 to 7 days, although group B showed a similar trend. There were no differences between the two types of CPB circuits although there was a trend to less cerebral dysfunction in group B (heparin-bonded) at 1 to 2 months. Conclusions. A number of new techniques associated with CPB surgery may decrease the incidence of cognitive changes. Our data demonstrate a better outcome in cognitive performance when surgery is performed OPCAB. 1) Is it possible to randomize patients into two distinctly different surgical treatment groups? 2) What confounders does one need to control for? For example, does one have to control for the amount of blood transfused, the number of grafts, etc. 3) What evidence does one require to argue that the groups are equal in terms of patient’s severity of illness? The Impact of Postoperative Atrial Fibrillation on Neurocognitive Outcome After Coronary Artery Bypass Grafting TO Stanley, GB Mackensen, HP Grocott, WD White, W Cohen, A Butler, and MF Newman. Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina Introduction. Neurocognitive (NC) decline is a continuing source of morbidity after coronary artery bypass grafting (CABG) surgery. The purpose of this study was to determine if postoperative atrial fibrillation (AF) was a factor in postoperative cognitive dysfunction. Methods. After Internal Review Board approval, 274 consenting patients received a battery of NC tests both preoperatively and 6 weeks after CABG surgery. Multivariable analysis compared the presence of postoperative AF with overall cognitive change, defined as the mean of four distinct cognitive domain z scores. Results. Sixty-four subjects had postoperative AF. As can be seen in the graph below, the No AF group increased its mean score by 0.105 while the AF group only increased by 0.028. This difference in improvement was significant ( p ⫽ 0.0355). Factors controlled for included age, years of education, diabetes, and left ventricular ejection fraction.
Background. Neurocognitive (NC) impairment or stroke, after coronary artery bypass grafting (CABG), may be associated with microembolization from ascending aortic and arch plaque. A pilot study of femoral (FemC) versus standard aortic cannulation (AoC) was undertaken to look for possible trends in NC outcome as a result of minimized plaque embolization with FemC. Methods. Inclusion criteria were age 60 years and isolated CABG. Exclusion criteria were presence of carotid bruit and carotid duplex 70% stenosis, femoral arterial disease classification 20% stenosis in both arteries, or previous history of stroke or transient ischemic attack. Transesophageal echocardiogram was done before surgery. NC and quality of life measurements were done a mean of 2 weeks before and repeated a mean of 6 weeks after surgery. Results. Five patients were initially randomized to FemC and 5 to AoC. One randomized to AoC died of multisystem failure and another, randomized to FemC, crossed over to AoC. Comparisons of the 5 patients in AoC versus the 4 in FemC show: age 68.6 versus 70.4 years ( p ⫽ 0.64), maximum ascending aortic and arch plaque thickness 3.9 versus 4.9 mm ( p ⫽ 0.48), pump time 65.8 versus 84.5 minutes ( p ⫽ 0.05), and cross-clamp time 40.2 versus 56.8 minutes ( p ⫽ 0.11). Overall, there was no consistent pattern of change in NC performance post- versus presurgery, nor between AoC and FemC. There were no complications with either technique. Increased age significantly predicted more decrement/ less improvement in memory and verbal function. There is suggestive correlational evidence that maximum ascending aortic and arch plaque thickness predicted more decrement/less improvement in memory and learning functions. Conclusions. There were trends toward associations between ascending aortic and arch plaque thickness and memory and learning functions that merit further investigation of cannulation techniques aimed at avoiding aortic plaque disruptions during surgery.
Neurocognitive Dysfunction and Quality of Life After Cardiac Surgery MF Newman, MD, HP Grocott, MD, TO Stanley, MD, GB Mackensen, MD, JL Kirchner, BS, DB Mark, MD, and JA Blumenthal, PhD. Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina Introduction. The importance of perioperative neurocognitive decline (NCD) has long been debated. The purpose of our investigation was to determine the association between NCD and long-term quality of life (QOL) after surgery. Methods. After Internal Review Board approval and informed consent, 261 patients had NCD measured using a previously described NC battery at baseline, discharge, 6 weeks, and 5 years postoperatively. QOL was assessed using a number of well-validated, standardized assessments. Results. Our results demonstrated significant univariate and multivariate correlations between NCD and multiple measures of QOL in patients 5 years after cardiac surgery. These correlations included significant associations between the severity of overall cognitive dysfunction and measures of executive function, (MMSE; p ⫽ 0.0001), anxiety (STAI; p ⫽ 0.02), depression (CES-D; p ⫽ 0.0012), activities of daily living (DASI; p ⫽ 0.002), perceived cognitive difficulty ( p ⫽ 0.0001), as well as multiple other areas of measured QOL. Age, gender, educational level, and diabetes were also found to be significantly associated with QOL. Table 1. Multivariable Adjusted Effects of Total 5-Year Cognitive Function Score on Quality of Life Measures Quality of Life Outcome Functional activity (DASI) Limitation on activity (from SF-36) Better mental awareness (MMSE) Less anxiety (STAIX)
p Value 0.0085 0.0004 0.0001 0.0071
Less depression (CESD) Better “general health” (self-rated) Cognitive difficulty (self-rated)
0.0006 0.0159 0.0046
Productive working status
0.0060
Significant Covariates Age, gender, diabetes Gender, diabetes Age, gender Age, gender, diabetes, education Age, gender, diabetes Age, gender Age, gender, diabetes, education Age, gender
Total R2 0.298 0.236 0.455 0.206 0.177 0.096 0.199 C ⫽ 0.786
Discussion. Cognitive dysfunction alters QOL after surgery. Perception of general health varies directly with cognitive functioning. Discussion. AF is associated with cognitive function 6 weeks after CABG surgery. The mechanis of this association is yet to be determined, but reduction in the incidence of AF may improve postoperative NC function.