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[Influence of carotid atheroma on the neurologic status after myocardial revascularization]
R Cartier1, I Hamani, Y Leclerc
1Département de Chirurgie Cardiovasculaire, Institut de Cardiologie de Montréal, Québec, Canada.
Insights
Coronary artery bypass surgery in patients with carotid disease had a low incidence of neurologic complications. Carotid disease did not increase stroke risk, but oxygen debt indicators suggest caution with certain medications.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Disease
Context:
- Surgical management of carotid disease in patients with coronary artery disease is debated.
- 501 patients undergoing coronary revascularization were analyzed for neurologic events.
- Prevalence of hypertension (35%) and smoking (48%) were noted risk factors.
Purpose:
- To evaluate the influence of carotid disease on postoperative neurologic events after coronary revascularization.
- To determine if concurrent prophylactic carotid surgery is necessary during coronary artery bypass grafting.
Summary:
- The study found a low incidence of perioperative neurologic disturbances (2.5%) after coronary revascularization.
- Carotid atheromatosis did not elevate the risk of cerebrovascular accidents post-surgery.
- Increased neurologic events correlated with vasopressor use and elevated arterial lactate, suggesting systemic oxygen debt.
Impact:
- The findings suggest that prophylactic carotid surgery is not recommended concurrently with coronary artery revascularization.
- Identified vasopressor drugs and elevated arterial lactate as predictive factors for neurologic complications.
- Highlights the importance of managing systemic oxygen debt to minimize neurologic risks in cardiac surgery patients.
Abstract:
Surgical management of the carotid disease remains controversial in patients affected with coronary artery atheromatous disease. We report the Montreal Heart Institute experience on the influence of carotid disease on postoperative neurologic events of 501 consecutive patients operated on for coronary revascularization during the period from January 1994 to December 1994. There were 381 men and 114 women averaging 62 +/- 9 years old. Major risk factors were high blood pressure (35%), and smoking habit (48%). Fifty-nine patients presented clinical signs of carotid atheromatosis and among them 21 had significant carotid stenosis (> 80% decrease of cross sectional area). During surgery, the mean duration of extracorporeal circulation (ECC) was 76 +/- 31 minutes and the mean perfusion pressure (MPP) was 70 +/- 11 mmHg. The use of inotropic drugs was mandatory in 26% of the cases and the mean arterial lactate (AL) dosage during ECG was 3.07 +/- 1.35 mM/L. During the perioperative period, 13 (2.5%) patients sustained neurologic disturbances of which 5 (1%) were lateralized. Among them, 8 completely recovered whereas 3 of the 5 with permanent damage died. None of the patients with preoperative stigmata of carotid disease experienced lateralized neurologic deficit. Multivariate regression analysis identified the use of vasopressor drugs and perioperative increase of AL as predictive factors. We conclude that in our series, the incidence of neurologic complications was low. The presence of carotid atheromatosis did not increase the postsurgical risk of cerebrovascular accident, however, the increased incidence of neurologic events associated with inotropic drugs and increased AL suggests a direct link with a systemic oxygen debt. Consequently, we do no recommend concurrent prophylactic surgery during coronary artery revascularization.