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Published on: October 27, 2020
Neuroprotection during cardiac surgery
Niamh Conlon1, Hilary P Grocott, G Burkhard Mackensen
1Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA. niamh.conlon@duke.edu
Insights
Minimizing brain injury during cardiac surgery is crucial. While drugs show promise, evidence supports non-drug methods like ultrasound and temperature control for neuroprotection.
Area of Science:
- Neurology
- Cardiology
- Surgical Innovation
Background:
- Cardiac surgery carries a high risk of adverse cerebral outcomes, including stroke and cognitive impairment.
- Mechanisms involve cerebral embolism, hypoperfusion, and ischemia/reperfusion injury, with incomplete understanding.
- Extensive research targets minimizing perioperative brain injury through various strategies.
Purpose of the Study:
- To review current pharmacological and non-pharmacological neuroprotection strategies in cardiac surgery.
- To evaluate the evidence supporting different neuroprotective interventions.
- To discuss future research directions for preventing brain injury during cardiac procedures.
Main Methods:
- Review of preclinical and clinical studies on neuroprotection during cardiac surgery.
- Analysis of evidence for pharmacological agents and non-pharmacological techniques.
- Discussion of ongoing research and future trial requirements.
Main Results:
- No pharmacological agents are currently recommended for routine neuroprotection due to insufficient clinical trial evidence.
- Non-pharmacological strategies, including transesophageal echocardiography and epiaortic ultrasound for aortic assessment, and optimal temperature management, are evidence-based.
- Further large-scale trials are needed for optimal management of pH, glycemic control, blood pressure, and hematocrit during cardiopulmonary bypass.
Conclusions:
- Current evidence supports specific non-pharmacological interventions for neuroprotection during cardiac surgery.
- Pharmacological neuroprotection lacks sufficient clinical validation for routine use.
- Future research should focus on large randomized trials to optimize management strategies during cardiopulmonary bypass.
Abstract:
Cardiac surgery continues to be associated with significant adverse cerebral outcomes, ranging from stroke to cognitive decline. The underlying mechanism of the associated cerebral injury is incompletely understood but is believed to be primarily caused by cerebral embolism and hypoperfusion, exacerbated by ischemia/reperfusion injury. Extensive research has been undertaken in an attempt to minimize the incidence of perioperative cerebral injury, and both pharmacological and nonpharmacological strategies have been investigated. Although many agents demonstrated promise in preclinical studies, there is currently insufficient evidence from clinical trials to recommend the routine administration of any pharmacological agents for neuroprotection during cardiac surgery. The nonpharmacological strategies that can be recommended on the basis of evidence include transesophageal echocardiography and epiaortic ultrasound-guided assessment of the atheromatous ascending aorta with appropriate modification of cannulation, clamping or anastomotic technique and optimal temperature management. Large-scale randomized controlled trials are still required to address further the issues of optimal pH management, glycemic control, blood pressure management and hematocrit during cardiopulmonary bypass. Past, present and future directions in the field of neuroprotection in cardiac surgery will be discussed.
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