The North Pacific Surgical Association
A multimodal approach to the prevention of postoperative stroke in patients undergoing coronary artery bypass surgery

https://doi.org/10.1016/j.amjsurg.2008.12.008Get rights and content

Abstract

Background

Stroke is known to be multifactorial in origin. This study was designed to assess the effectiveness of a multimodal approach to preventing this complication in patients undergoing coronary artery bypass.

Methods

One thousand five hundred thirty consecutive coronary artery bypass patients operated on by a single surgeon from July 1994 to April 2008 were studied. Group 1 patients (n = 1,214) were operated on before 2004. Group 2 patients (n = 316) were operated on after 2004. In group 2 patients, epiaortic scanning, selective use of proximal anastomotic devices, and alternative cannulation were used. Off-pump coronary artery bypass (OPCAB) was used in 730 patients. On-pump coronary artery bypass (ONCAB) was used in 800 patients. Preoperative risk factors including age, cerebrovascular disease, peripheral vascular disease, hypertension, and diabetes were examined in all patients. The incidence of postoperative stroke was determined for group 1 and 2 patients and the individual cohorts of OPCAB and ONCAB patients.

Results

The overall incidence of stroke was 1.6% (25/1,530). The postoperative incidence of stroke was 1.7% (21/1,214) in group 1 patients as compared with 1.3% (4/316) in group 2 patients. The incidence of postoperative stroke was 2.4% (19/800) in ONCAB patients as compared with 0.8% (6/730) in OPCAB patients (P < .05).

Conclusions

OPCAB is an important tool for the prevention of postoperative stroke. Adjunctive techniques for the prevention of emboli from the ascending aorta may also reduce the risk of stroke in OPCAB and ONCAB patients.

Section snippets

Methods

One thousand five hundred thirty consecutive patients undergoing coronary bypass grafting by a single surgeon (JD) at Saint Joseph Hospital were reviewed. Group 1 patients (n = 1,214) were operated on between July 27, 1994, and December 31, 2003. Group 2 patients (n = 316) were operated on between January 1, 2004, and March 31, 2008.

In group 1 patients, off-pump bypass was performed whenever achievable, according to the surgeon's preference, after 1997. All other patients underwent conventional

Results

A total of 1,530 patients were retrospectively reviewed. These patients were compared as groups representing 2 eras of patient-management strategy by a single surgeon. Additionally, the patient population who underwent conventional coronary artery bypass grafting on pump was compared with those patients who underwent off-pump coronary artery bypass grafting. The primary endpoint was the postoperative incidence of stroke. The overall incidence of stroke was 1.6% (25/1,530).

On average, group2

Comments

A substantial volume of research over the years has examined the etiology and risk factors for postoperative stroke in patients undergoing coronary bypass surgery.1, 2, 3 Studies have consistently shown the strong association between both microemboli and macroemboli with the subsequent development of adverse neurologic events.3, 12 Transcranial Doppler ultrasound studies have confirmed peak incidences of embolization occurring during times of arterial cannulation, aortic cross-clamping and

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