Stroke and ON-Pump Coronary Artery Bypass Grafting. Should We Change to OFF-Pump? Our Experience from the North of Jordan.

摘要

PRINCIPLES: Stroke is a well known complication after coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB). We were interested in reviewing our experience with on-pump coronary artery bypass grafting, to evaluate its neurologic dysfunction and its impact on patient management. And to ask a question that recently applied. Should we change to OFF-Pump?MATERIAL AND METHODS: A retrospective review of 1.050 patients undergoing elective coronary artery bypass grafting (CABG) was performed from May 5, 2003, to December 31, 2007, in our institution. Stroke was defined as any new permanent global or focal neurological deficit, immediately after extubation (early) or within 5-6 day in the hospital (late). Medline literature was searched for all the studies published in the English language between 1999 and 2006 reporting neurological complications on patients undergoing CABG with emphasis on comparisons between off-pump coronary artery bypass surgery (OPCAB) and CPB techniques. The following terms were used: Stroke and on-pump coronary artery bypass grafting; on-pump versus off-pump; brain injury after coronary artery bypass grafting.RESULTS: Stroke occurred in 19 patients (1.81%). From this group thirteen were female (68.42%). Fifteen patients were diabetic (78.95%). History of previous transient ischemic attacks was found in 14 patients (73.68%). CONCLUSIONS: Female sex, diabetic patients and patients with previous transient ischemic attacks are associated with increased the risk of stroke and in-hospital mortality. Prospectively randomised trial is needed to give us a proper answer on our question. Introduction Coronary artery bypass grafting in the late 1960s was first performed without the use of cardiopulmonary bypass (CPB) [1]. But after the use of CPB and cardioplegic arrest this technique was largely abandoned [2]. With the use of cardiopulmonary bypass neurologic dysfunction is well documented as an associated complication of cardiac surgery [3]. Cerebral injury occurs in two distinct forms, and become an important cause of morbidity and mortality after open heart surgery [4]. Stroke, as devastating complication occurs in 3% of patients undergoing CABG [5]. Soon after open heart surgery using cardiopulmonary bypass (CPB), cognitive dysfunction, occurs in as many as 80% of patients and persists in one fourth of these patients six months after surgery and only by detailed neuropsychologic testing can be detected [4,6,7]. Many factors participate in the pathogenesis of cerebral injury and cognitive dysfunction after cardiac surgery, but there is increasing evidence that multiple microemboli arising from the ascending aorta, the heart chambers, or the bypass circuit are the primary pathophysiologic mechanisms producing diffuse ischemic cerebral injury [8]. Cardiopulmonary bypass requires cannulation and cross-clamping of the ascending aorta, which per se may dislodge atheromatous macroemboli, leading to stroke [9]. Cardiopulmonary bypass is a well known source that generates microemboli and increases the permeability of the blood-brain barrier which may adversely affect cognitive function [10,11]. Patients and Methods 1050 consecutive patients who were undergoing coronary artery bypass grafting (CABG) from May 5, 2003, to December 31, 2007, were enrolled in this retrospective study. Our cardiac center is a new one in the north since May 5, 2002. All patients had undergone conventional CABG using a left internal mammary artery (LIMA) graft with different surgeons. Stroke was defined as any new permanent global or focal neurological deficit. Stroke was first detected by cardiac surgeon immediately after extubation (early) or within 5-6 day in the hospital (late), then neurologist will be consulted, and in the majority of patients they were confirmed by CT head scan. Patients having cardiac valve surgery, ASD (atrial septal defect) repair, LVEF (left ventricular ejection fraction) <0.40, and undergoing repeat CAB