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Ann Thorac Surg 2000;70:1558-1564
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Reduced neurological injury during CABG in patients with mobile aortic atheromas: a five-year follow-up study

^a Escorts Heart Institute and Research Centre, New Delhi, India

Address reprint requests to Dr Manisha Mishra, Escorts Heart Institute and Research Centre, Okhla Rd, New Delhi—110025, India
e-mail: manishamishra{at}yahoo.com

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.

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