CLINICAL STUDY
Postoperative stroke in cardiac surgery is related to the location and extent of atherosclerotic disease in the ascending aorta
Jan van der Linden, MD*,
Leonidas Hadjinikolaou, MD ,
Per Bergman, MD* and
Dan Lindblom, MD*
* Department of Cardiothoracic Surgery and Anesthesiology, Karolinska Institutet, Huddinge University Hospital, Stockholm, Sweden
Department of Cardiothoracic Surgery, University of Thessaly, Larissa, Greece
Manuscript received October 11, 2000;
revised manuscript received March 15, 2001,
accepted March 29, 2001.
Reprint requests and correspondence: Dr. Jan van der Linden, Department of Cardiothoracic Surgery and Anesthesiology, Karolinska Institutet, Huddinge University Hospital, SE-14186 Stockholm, Sweden
jan.vanderlinden{at}thsurg.hs.sll.se
OBJECTIVES
The aim of the study was to evaluate the risk from calcified atheromas in the ascending aorta, and the extent and topography of the disease in the development of stroke after cardiac surgery.
BACKGROUND
Postoperative stroke constitutes a serious problem in cardiac surgery, and atherosclerosis of the ascending aorta is an important risk factor.
METHODS
Before surgical manipulation epiaortic echocardiographic ultrasound was performed to evaluate the ascending aorta in 921 consecutive patients undergoing cardiac surgery. The presence of calcification, location of atheroma, extent of the disease and clinical variables including postoperative stroke were recorded prospectively.
RESULTS
A total of 26.2% of the patients had atherosclerosis of the ascending aorta, and in 44.4% of them more than one of 12 possible segments was involved. Logistic regression showed that atherosclerotic disease in the ascending aorta was the most important predictive factor for postoperative stroke. The incidence of stroke was 1.8% in patients without atherosclerotic disease of the ascending aorta, and 8.7% in patients with the disease (p < 0.0001). Diabetes mellitus was also a predictive factor (p = 0.04). A new and unique finding of this study was that the middle-lateral segment is an independent predictive factor for postoperative stroke, with a relative risk of 26% (p = 0.04).
CONCLUSIONS
Patients with atheromatosis in the ascending aorta had an 8.7% incidence of postoperative stroke, in spite of minor surgical modifications. The risk depended on the presence, location and extent of the disease. Randomized trials evaluating alternative surgical strategies in coronary surgery are urgently needed in high risk patients.
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Abbreviations and Acronyms
| | CABG | = coronary artery bypass grafting | | CPB | = cardiopulmonary bypass | | TEE | = transesophageal echocardiography |
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|
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|
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|
|
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|
J. S. Savino and A. T. Cheung
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3(2008):
281 - 314.
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|
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84(4):
1195 - 1200.
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|
|
|
|
|
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July 1, 2007;
84(1):
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|
|
|
|
|
|
|
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June 6, 2007;
(2007)
ehm180v1.
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|
|
|
|
|
|
|
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Diagnosis and management of severe atherosclerosis of the ascending aorta and aortic arch during cardiac surgery: focus on aortic replacement
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|
|
|
|
|
|
|
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2087 - 2092.
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|
|
|
|
|
|
|
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|
|
|
|
|
|
|
G. N. Djaiani
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June 1, 2006;
10(2):
143 - 157.
[Abstract]
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|
|
|
|
|
|
|
B. Zingone, E. Rauber, G. Gatti, A. Pappalardo, B. Benussi, L. Dreas, and L. Lattuada
The impact of epiaortic ultrasonographic scanning on the risk of perioperative stroke.
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May 1, 2006;
29(5):
720 - 728.
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|
|
|
|
|
|
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131(2):
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|
|
|
|
|
|
|
M. Skjelland, J. Bergsland, R. Lundblad, P. S. Lingaas, K. A. Rein, S. Halvorsen, J. L. Svennevig, E. Fosse, R. Brucher, and D. Russell
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130(6):
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|
|
|
|
|
|
S. F. Aranki, M. Nathan, P. Shekar, G. Couper, R. Rizzo, and L. H. Cohn
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80(5):
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|
|
|
|
|
|
|
K. Karkouti, G. Djaiani, M. A. Borger, W. S. Beattie, L. Fedorko, D. Wijeysundera, J. Ivanov, and J. Karski
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80(4):
1381 - 1387.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. E. Hill, H. P. Grocott, B. J. Leone, W. D. White, M. F. Newman, and Neurologic Outcome Research Group of the Duke Hear
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Ann. Thorac. Surg.,
October 1, 2005;
80(4):
1401 - 1407.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Khosravi, C. A Skrabal, B. Westphal, G. Kundt, B. Greim, E. Kunesch, A. Liebold, and G. Steinhoff
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September 1, 2005;
20(5):
249 - 254.
[Abstract]
[PDF]
|
|
|
|
|
|
|
Y. Carrascal, E. Casquero, J. Gualis, S. Di Stefano, S. Florez, E. Fulquet, J. R. Echevarria, and L. Fiz
Cognitive decline after cardiac surgery: proposal for easy measurement with a new test
Interactive CardioVascular and Thoracic Surgery,
June 1, 2005;
4(3):
216 - 221.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Aviram, R. Sharony, A. Kramer, N. Nesher, D. Loberman, Y. Ben-Gal, M. Graif, G. Uretzky, and R. Mohr
Modification of Surgical Planning Based on Cardiac Multidetector Computed Tomography in Reoperative Heart Surgery
Ann. Thorac. Surg.,
February 1, 2005;
79(2):
589 - 595.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Schachner, G. Nagele, A. Kacani, G. Laufer, and J. Bonatti
Factors Associated With Presence of Ascending Aortic Atherosclerosis in CABG Patients
Ann. Thorac. Surg.,
December 1, 2004;
78(6):
2028 - 2032.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Bar-Yosef, M. Anders, G. B. Mackensen, L. K. Ti, J. P. Mathew, B. Phillips-Bute, R. H. Messier, H. P. Grocott, and the Neurological Outcome Research Group and CARE I
Aortic Atheroma Burden and Cognitive Dysfunction After Coronary Artery Bypass Graft Surgery
Ann. Thorac. Surg.,
November 1, 2004;
78(5):
1556 - 1562.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. P. Gold, K. E. Torres, W. Maldarelli, I. Zhuravlev, D. Condit, and J. Wasnick
Improving Outcomes in Coronary Surgery: The Impact of Echo-Directed Aortic Cannulation and Perioperative Hemodynamic Management in 500 Patients
Ann. Thorac. Surg.,
November 1, 2004;
78(5):
1579 - 1585.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Bergman, L. Hadjinikolaou, G. Dellgren, and J. van der Linden
A policy to reduce stroke in patients with extensive atherosclerosis of the ascending aorta undergoing coronary surgery
Interactive CardioVascular and Thoracic Surgery,
March 1, 2004;
3(1):
28 - 32.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Hughes, J.M. Hasenkam, I.K. Severinsen, and D.A. Steinbruchel
Right heart assist for beating heart coronary artery bypass grafting
Eur. J. Cardiothorac. Surg.,
November 1, 2003;
24(5):
762 - 769.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. C. Gilkeson, A. H. Markowitz, and L. Ciancibello
Multisection CT Evaluation of the Reoperative Cardiac Surgery Patient
RadioGraphics,
October 1, 2003;
23(90001):
S3 - 17.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. B. Hangler, G. Nagele, M. Danzmayr, L. Mueller, E. Ruttmann, G. Laufer, and J. Bonatti
Modification of surgical technique for ascending aortic atherosclerosis: impact on stroke reduction in coronary artery bypass grafting
J. Thorac. Cardiovasc. Surg.,
August 1, 2003;
126(2):
391 - 400.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Goto, T. Baba, K. Matsuyama, K. Honma, M. Ura, and T. Koshiji
Aortic atherosclerosis and postoperative neurological dysfunction in elderly coronary surgical patients
Ann. Thorac. Surg.,
June 1, 2003;
75(6):
1912 - 1918.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Boivie, M. Hansson, and K. G. Engstrom
Embolic material generated by multiple aortic crossclamping: A perfusion model with human cadaveric aorta
J. Thorac. Cardiovasc. Surg.,
June 1, 2003;
125(6):
1451 - 1460.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. J. Frumento, C. M.N. O'Malley, and E. Bennett-Guerrero
Stroke after cardiac surgery: a retrospective analysis of the effect of aprotinin dosing regimens
Ann. Thorac. Surg.,
February 1, 2003;
75(2):
479 - 483.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. S. Savino, T. F. Floyd, and A. T. Cheung
Cardiac Anesthesia
Card. Surg. Adult,
January 1, 2003;
2(2003):
249 - 281.
[Full Text]
|
|
|
|
|
|
|
V. Vijay and J. P. Gold
Late Complications of Cardiac Surgery
Card. Surg. Adult,
January 1, 2003;
2(2003):
521 - 537.
[Full Text]
|
|
|
|
|
|
|
P. Bergman, L. Hadjinikolaou, and J. van der Linden
Aortic atheroma is related to number of particulates captured by intra-aortic filtration in CABG
Eur. J. Cardiothorac. Surg.,
October 1, 2002;
22(4):
539 - 544.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. L. Karamanoukian, H. W. Donias, and J. Bergsland
Decreased incidence of postoperative stroke following off-pump coronary artery bypass
J. Am. Coll. Cardiol.,
March 6, 2002;
39(5):
917 - 917.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. van der Linden, L. Hadjinikolaou, P. Bergman, and D. Lindblom
Decreased incidence of postoperative stroke following off-pump coronary artery bypass: Reply
J. Am. Coll. Cardiol.,
March 6, 2002;
39(5):
918 - 918.
[Full Text]
[PDF]
|
|
|
|
