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Reduced neurological injury during CABG in patients with mobile aortic atheromas: a five-year follow-up study
N Trehan1, M Mishra, R R Kasliwal
1Escorts Heart Institute and Research Centre, New Delhi, India.
Insights
Mobile atheromas in the thoracic aorta are a stroke risk during coronary artery bypass grafting (CABG). Modified surgical techniques, particularly off-pump CABG, significantly reduced stroke rates in patients with mobile atheromas.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Neurosurgery
Background:
- Mobile atheromas in the thoracic aorta are a significant risk factor for stroke following coronary artery bypass grafting (CABG).
- Identifying these mobile atheromas is crucial for mitigating perioperative embolic events.
- This study aimed to assess the incidence of embolic events after specific surgical modifications.
Purpose of the Study:
- To prospectively identify mobile atheromas in the thoracic aorta.
- To determine the incidence of immediate postoperative embolic events after surgical modifications.
- To evaluate late clinical events attributable to embolization.
Main Methods:
- Intraoperative transesophageal echocardiography was used in 3,660 patients undergoing CABG to detect aortic atheromatous disease.
- Patients with grade III atheromas (mobile elements) were included.
- Surgical modifications included aortic arch atherectomy and off-pump CABG; outcomes measured were death and stroke.
Main Results:
- Mobile atheromas were identified in 104 patients (2.84%).
- The perioperative stroke rate was 0.96%, with no embolic events in 88 patients undergoing off-pump CABG.
- At 5-year follow-up, only one nonfatal stroke occurred, with no deaths related to atheromatous disease.
Conclusions:
- Modified surgical techniques, especially off-pump CABG, result in a very low stroke rate for patients with mobile aortic atheromas.
- Patients with mobile atheromas demonstrate a low incidence of spontaneous embolization over a 5-year period.
Background:
Mobile atheromas of the thoracic aorta have been identified as a major cause of stroke after coronary artery bypass grafting (CABG). This prospective study was undertaken to identify mobile atheromas and to determine the incidence of immediate postoperative embolic events after suitable surgical modifications. Late clinical events attributable to embolization were also studied.
Methods:
Between January 1993 and July 1997, 3,660 patients scheduled for CABG underwent intraoperative transesophageal echocardiography to identify aortic atheromatous disease. The disease was graded as follows: grade I, plaques extending less than 5 mm into the aortic lumen; grade II, plaques extending more than 5 mm into the aortic lumen; and grade III, plaques with a mobile element. Only patients with grade III atheromas were included in the study. Various surgical modifications were done depending on the location of the lesion, eg, aortic arch atherectomy, CABG combined with transmyocardial laser revascularization, off-pump CABG by median sternotomy, and minimally invasive direct coronary artery bypass. Measured outcomes were death, stroke, and other vascular events, both early (within 1 week) and late (1 to 5 years) after operation.
Results:
Of the 3,660 patients, 104 (2.84%) had mobile atheromas. The perioperative stroke rate was 0.96%, and the incidence of other vascular events was 1.92% at 1 week. There was no embolic event in the group of 88 patients who underwent off-pump CABG. Of the study group, 98.07% are in regular follow-up. At 5 years, 1 patient had had a nonfatal stroke, and 2 patients had died of causes unrelated to atheromatous disease.
Conclusions:
The stroke rate was very low in patients with mobile aortic atheromas who underwent CABG after modification in surgical technique, especially off-pump CABG. A follow-up of 5 years showed that patients with mobile atheromas have a very low incidence of spontaneous embolization.