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The cerebro-vascular problem in coronary by-pass surgery
P Van Cauwelaert1, P Muylaert, J Tombeur
1Afdeling Cardio-vasculaire en Thoracale Heelkunde en Anesthesie-Reanimatie, Algemeen Ziekenhuis Middelheim, O.C.M.W., Antwerpen.
Insights
Carotid endarterectomy (CE) before cardiopulmonary bypass (CPB) may reduce post-operative neurologic deficits. Pre-existing cerebrovascular disease (CVD) is a likely cause of these deficits, highlighting the need for improved pre-operative screening and intervention.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Surgery
Background:
- Cerebrovascular disease (CVD) is a significant concern in patients undergoing cardiopulmonary bypass (CPB).
- Detecting CVD solely through auscultation is insufficient, potentially leading to underdiagnosis.
- Post-CPB neurologic deficits (POND) occur in a notable percentage of patients.
Purpose of the Study:
- To investigate the incidence of CVD in patients undergoing CPB.
- To evaluate the effectiveness of carotid endarterectomy (CE) in reducing POND.
- To determine the optimal timing for CE in relation to CPB.
Main Methods:
- Retrospective analysis of 2250 consecutive CPB cases.
- Identification of patients with pre-existing CVD.
- Comparison of POND rates in patients treated with CE (pre-CPB or simultaneous) versus those not treated.
Main Results:
- CVD was detected in 3.9% of patients on admission.
- 17 patients (0.75%) experienced POND, including 15 strokes and 2 transient ischemic attacks (TIAs).
- No complications were observed in 26 patients treated with CE before or during CPB, while 5 untreated patients experienced strokes or TIAs.
Conclusions:
- Pre-existing CVD is a probable cause of POND.
- Pre-operative CE, particularly before CPB, appears to be a safe and potentially effective strategy to reduce POND.
- Further research is needed to definitively establish the benefits of simultaneous CE and CPB.
Abstract:
In 99 of 2250 consecutive C.B.P. cases, signs of cerebro-vascular disease (C.V.D.) were recorded in 87 (3.9%) on admission and in 12 post-operatively. The detection of C.V.D. by auscultation alone is very incomplete. There were 17 post-C.B.P. neurologic deficits (P.O.N.D.) (0.75%): 15 strokes (0.67%) and 2 T.I.A.'s. 26 patients (out of 87 detected on admission) were treated by carotid endarterectomy (C.E.) either pre-by-pass or simultaneously. There were no complications. The remaining 61 patients, who were not treated, had 4 strokes and 1 T.I.A. after their C.B.P. The most probable cause of these deficits was pre-existing C.V.D. Could more extensive pre-operative investigation, and treating the serious lesions by C.E., improve the P.O.N.D. incidence? The published series on simultaneous C.E. + C.B.P. are not yet conclusive. We favour C.E. done before the C.P.B. procedure except in very serious coronary disease when simultaneous operation is preferred.