Clinically Silent Cerebral Ischemic Events After Cardiac Surgery: Their Incidence, Regional Vascular Occurrence, and Procedural Dependence

doi:10.1016/j.athoracsur.2006.01.080

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Original article: Cardiovascular

Clinically Silent Cerebral Ischemic Events After Cardiac Surgery: Their Incidence, Regional Vascular Occurrence, and Procedural Dependence

Thomas F. Floyd, MD^a^,
_*, Pallav N. Shah, MD^b, Catherine C. Price, PhD^c, Francis Harris, MD^a, Sarah J. Ratcliffe, PhD^d, Michael A. Acker, MD^e, Joseph E. Bavaria, MD^e, Hind Rahmouni, MD^f, Bettina Kuersten, MD^f, Susan Wiegers, MD^f, Michael L. McGarvey, MD^g, Joseph Y. Woo^a^,
b^,
c^,
d^,
e^,
f^,
g^,
h, Alberto A. Pochettino, MD^e, Elias R. Melhem, MD^h

^a Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
^h Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
^d Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
^e Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
^f Department of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania
^g Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
^b Department of Radiology, Temple University Hospital, Philadelphia, Pennsylvania
^c Department of Anesthesiology and Clinical and Health Psychology, University of Florida, Gainesville, Florida

Accepted for publication January 13, 2006.

^_* Address correspondence to Dr Floyd, Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104-4283. (Email: floydt{at}uphs.upenn.edu).

BACKGROUND: The reported frequency of stroke after coronary artery bypassgrafting varies between 1.5% and 6%, approaches 10% after aorticvalve replacement, and may occur in between 40 to 70% in high-riskgroups. Clinically silent infarction may be far more frequentand could contribute to long-term cognitive dysfunction in patientsafter cardiac procedures. Using diffusion-weighted magneticresonance imaging we document the occurrence, vascular distribution,and procedural dependence of silent infarction after cardiacsurgery with cardiopulmonary bypass. We also document the associationof preexisting white matter lesions with new postoperative ischemiclesions.

METHODS: Thirty-four patients underwent T2-weighted fluid attenuatedinversion recovery and diffusion-weighted magnetic resonanceimaging before and after cardiac surgery with cardiopulmonarybypass for coronary artery bypass grafting, aortic valve replacement,and mitral valve repair or replacement surgery. Images wereevaluated by experienced neuroradiologists for number, size,and vascular distribution of lesions.

RESULTS: Mean age of participants was 67 ± 15 years. Imaging occurredbefore and 6 ± 2 days after surgery. New cerebral infarctionswere evident in 6 of 34 patients (18%), were often multiple,and in 67% of patients were clinically silent. The occurrenceof new infarctions by surgical procedure was as follows: aorticvalve replacement (2 of 6), coronary artery bypass graftingand aortic valve replacement (3 of 8), aortic valve replacementwith root replacement (1 of 1), coronary artery bypass graftingand mitral valve repair or replacement (0 of 4), mitral valverepair or replacement (0 of 2), and isolated coronary arterybypass grafting (0 of 13). New infarction occurred in 6 of 15(40%) of all procedures involving aortic valve replacement.The severity of preexisting white matter lesions trended towardpredicting the occurrence of new lesions (p = 0.055).

CONCLUSIONS: Diffusion-weighted imaging reveals new cerebral infarctionsin nearly 40% of patients after aortic valve replacement.

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