ADVERSE CEREBRAL OUTCOMES AFTER CARDIAC SURGERY Anjan Gupta, M'D' Milwaukee Heart Institute Milwauke

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ADVERSE CEREBRAL OUTCOMES AFTER CARDIAC
SURGERYAnjan Gupta, M.D.Milwaukee Heart
InstituteMilwaukee, Wisconsin
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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
3
Mean length of hospital and ICU stay according to
cerebral outcomes
Roach et al, NEJM 1996
4
Time of onset of postoperative stroke or TIA
Reed et al, NEJM 1988 319 1246 - 50
5
Annual incidence of stroke following CABG at John
Hopkins Hospital
Gardner et al, The Annals of Thor. Surgery 1985
40 574 - 80
6
Mortality and postoperative resource use
according to cerebral outcomes
Roach et al, NEJM 1996
7
Incidence of stroke according to the age of the
patient
Gardner et al, The Annals of Thor. Surgery 1985
40 574 - 80
8
Odds ratios for Type I and Type II Cerebral
outcomes (Significant factors , plt0.05)

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
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Incidence of Type I and Type II cerebral outcomes
according to age
Roach et al, NEJM 1996
10
Univariate predictors of stroke following CABG
p lt 0.001 p 0.014






Rao et al, J Card Surg 1995 10 468 - 474
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Multivariable predictors of stroke in patients
following CABG
Rao et al, J Card Surg 1995 10 468 - 474
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Association of aging with postoperative cognitive
dysfunction
Newman et al, Circulation 1994 90 II - 243 -
II - 249
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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
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Effect of advanced age on predicted probability
of neurologic and cardiac morbidity
Tuman et al, J Thorac Cardiovasc Surg 1992 104
1510-7
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Significant risk factors for stroke after cardiac
surgeryBuffalo Cardiac-Cerebral Study Group
Variables Odds
Ratio p - value
Carotid Stenosis gt 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
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Significant risk factors for stroke
Factor CVA Patients
Controls Significance

Age (yr) 63 7.8
57 8.8 p lt
0.0001 Previous CV disease 20
8 p lt
0.03 Severe atherosclero- 14
3 p lt 0.05 -sis
of ascending aorta Pump time (min)
122 33 105 35
p lt 0.005 Severe perioperative 23
4 p lt
0.0001 hypotension
Gardner et al, The Annals of Thor. Surgery 1985
40 574 - 80
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CNS Complications of CABGProspective 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
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Predictors of risk of stroke on the day of
operation The CASS Experience
Variables No of strokes
Probability Rel. Risk 95
Confidence Interval
Age
lt0.0001 lt55 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 gt75
5.0
26.7 5.72 -
124.0 Support with a-adr-
lt0.0001
-energic agents



No 0.4
1.0 Yes
3.0
4.56 2.33
- 8.9 Pump time
lt0.002 lt100 min
0.2
1.0 100 - 200 min 0.7
2.62
1.38 - 4.98 gt200 min
1.7 4.24
1.67 - 10.8


Frye et al, Int Jnl of Card 1992 36 213 - 221
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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
lt0.0001 lt55 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 gt75
yrs 7.8
11.1
3.10 - 39.9 DURATION OF
lt0.0001 BYPASS lt100 mins
0.6
1.0 101 - 200 mins
1.5
1.99 1.27 - 3.12 gt200 mins
4.8
4.41 2.34 -
8.31





Frye et al, Int Jnl of Card 1992 36 213 - 221
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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 -
lt0.0001 vascular disease No
1.1
1.0 Yes 19.3
19.16 12.43
- 29.53 HTN
lt0.0001 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
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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 gt120min
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 gt60 yrs 40.7
57.4 2.3 0.9 - 4.3 Yr of
Surgery
Reed et al, NEJM 1988 319 1246 - 50
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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
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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 gt75
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 lt0.005, p lt0.001, p lt0.07, p lt0.05
Faggioli et al, J Vasc Surg 1990 12 724 - 31
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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) ( lt 50) Moderate stenosis
60 (11.2) 1 (1.7) 0
2 (3.3) ( 50 -
75) Asymtomatic severe 19 (3.5)
0 0
0 stenosis ( gt75) undergoing
PCE Asymptomatic severe 28 (5.2)
6 (1.1) 4 (14.3)
2 (7.1) stenosis ( gt75) not undergoing PCE
p 0.0019 c/w other groups
Faggioli et al, J Vasc Surg 1990 12 724 - 31
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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
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Distribution of number of microemboli for each of
the major CNS event categories
Clark et al, J Thoracic Cardiovasc Surgery, 1995
109 249 -58
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Neuropsychologic outcomes after Open-Heart surgery
Follow-up of neuropsychologic indices of
postoperative patients
Sotniemi et al, Arch Neurology 1981 38 2 - 8
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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
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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

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