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Ann Thorac Surg 2004;78:1564-1571
© 2004 The Society of Thoracic Surgeons
a Department of Surgery, Section of Cardiac Surgery, Washington Hospital Center, Washington, DC, USA
b Department of Epidemiology and Statistics, MedStar Research Institute, Washington, DC, USA
Accepted for publication May 7, 2004.
* Address reprint requests to Dr Corso, Section of Cardiac Surgery, Department of Surgery, Washington Hospital Center, 106 Irving St NW, Suite 316, Washington, DC 20010–2975, USA
paul.j.corso{at}medstar.net
BACKGROUND: Cerebral embolization of atherosclerotic plaque debris caused by aortic manipulation during conventional coronary artery bypass grafting (CABG) is a major mechanism of postoperative cerebrovascular accidents (CVA). Off-pump CABG (OPCABG) reduces stroke rates by minimizing aortic manipulation. Consequently, the effect of different levels of aortic manipulation on neurologic outcomes after CABG surgery was examined.
METHODS: From January 1998 to June 2002, 7,272 patients underwent isolated CABG surgery through three levels of aortic manipulation: full plus tangential (side-biting) aortic clamp application (on-pump surgery; n = 4,269), only tangential aortic clamp application (OPCABG surgery; n = 2,527) or an "aortic no-touch" technique (OPCABG surgery; n = 476). A risk-adjusted logistic regression analysis was performed to establish the likelihood of postoperative stroke with each technique. Preoperative risk factors for stroke from the literature, and those found significant in a univariable model were used.
RESULTS: A significant association for postoperative stroke correspondingly increasing with the extent of aortic manipulation was demonstrated by the univariable analysis (CVA incidence respectively increasing from 0.8% to 1.6% to a maximum of 2.2%, p < 0.01). In the logistic regression model, patients who had a full and a tangential aortic clamp applied were 1.8 times more likely to have a stroke versus those without any aortic manipulation (95% confidence interval: 1.15 to 2.74, p < 0.01) and 1.7 times more likely to develop a postoperative stroke than those with only a tangential aortic clamp applied (95% confidence interval: 1.11 to 2.48, p < 0.01).
CONCLUSIONS: Aortic manipulation during CABG is a contributing mechanism for postoperative stroke. The incidence of postoperative stroke increases with increased levels of aortic manipulation.
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