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Ann Thorac Surg 1995;59:1336-1339
© 1995 The Society of Thoracic Surgeons

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Symposium: Conference on Cardiopulmonary Bypass

Long-Term Neurologic Outcome After Cardiac Operation

Department of Neurology, University of Oulu, Oulu, Finland

Abstract

Cardiac surgical patients face the threat of neurologic complications in all phases of their disease and its treatment. The incidence of preoperative transient ischemic attacks and stroke ranges from 5% to 14% and from 2% to 11%, respectively. The risk of preoperative cerebrovascular accidents is higher in patients with valvular disease than in those with coronary artery disease. The prevalence of postoperative neurologic disorders varies widely because of differences in defining the clinical criteria, heterogeneity of patient populations, timing of evaluation, follow-up times, study designs, and surgical and anesthesia-related procedures. Fatal cerebral damage is very rare (<0.1%). Focal cerebral deficits, or definite stroke, are encountered in 1% to 3% of patients and minor clinical abnormalities, in 5% to 10%. Recent studies have shown that contrary to previous concepts, valve replacement does not carry essentially higher neurologic risks than coronary bypass grafting. The most common causes of operation-related neurologic disorders are microembolization or macroembolization and hypoperfusion. Although most disorders resolve early postoperatively, some deficits persist. From the neurologic standpoint, a main objective of a cardiac surgical intervention is to prevent stroke. Today, the incidence of cardiogenic cerebrovascular accidents is very low after reparative cardiac procedures. Despite surgical and anesthesia-related improvements, neurologic complications do occur. Multidimensional investigatory procedures have shown that cardiopulmonary bypass often causes cerebral dysfunction. Whether the harmful consequences are detected depends on the evaluation criteria and the investigatory methods and timing used. Further methods are needed to prevent or treat preoperative cerebrovascular accidents and particularly to improve cerebral protection during operative procedures.

The functions of the heart and the brain are essentially interrelated in health and disease. Cardiac disorders are well-known risk factors for ischemic cerebral injury, which, in turn, may induce or exacerbate cardiac dysfunction. From the neurologic viewpoint, the objectives of cardiac surgical procedures are to ensure adequate cerebral blood flow and to prevent emboli originating from the heart. Although the modern reparative procedures are generally highly successful in terms of the cardiac outcome, they can be detrimental in regard to the central nervous system (CNS). The procedures themselves as well as both the necessary preparatory measures and the postoperative treatments may expose the CNS to a multiplicity of potentially harmful effects, which can cast a shadow over an otherwise successful outcome. This article surveys the incidence and characteristics of CNS complications in cardiac surgery and the features and determinants of the postoperative outcome from the neurologic viewpoint.

Preoperative Neurologic Events

As cardiac and cerebrovascular diseases are etiologically and otherwise interrelated, it is not unexpected that cardiac disease increases the risk of ischemic CNS events. The reported incidence of preoperative transient ischemic attacks and stroke in patients referred for valve operations ranges from 5% to 14% and 2% to 11%, respectively; the corresponding values are commonly somewhat higher in patients referred for coronary artery bypass grafting (CABG) [1–5]. The difference is most probably due to the more advanced age of the latter patients.

Preoperative cerebrovascular events are important because they have been shown to be among the most accurate predictors of unfavorable neurologic outcome; they clearly increase the risk of perioperative ischemic CNS injury [1, 3, 4, 6]. It is particularly important to recognize this today because of the steadily increasing number of elderly patients undergoing surgical procedures.

Concerning the neurologic aspects, the optimal timing of operative intervention for the different cardiac disease entities in various age groups has been given relatively little attention. An example of the influence of the risks associated with prolonged existence of a cardiac disease is provided by a 1985 study [7]. It reported that 7% of patients with valvular disease sustained a stroke during the period when operative treatment was being considered but was postponed because the cardiac condition was not yet thought severe enough to necessitate operative intervention. All these patients had long-term cerebral disorders postoperatively. As preoperative CNS events seem to markedly influence the outcome, they and their determinants deserve more consideration than they have been given to date.

Apart from the underlying cardiovascular disease potential, cerebrovascular risks are also increased by the preoperative diagnostic procedures. With the modern techniques and contrast media, however, the risks associated with cardiac catheterization and coronary angiography are very small [8].

Intraoperative and Perioperative Neurologic Events

Both clinical and experimental studies have shown that particularly intraoperative and perioperative conditions, mainly cardiopulmonary bypass, expose the CNS to a variety of potentially harmful effects. Their causes can be mechanical, temperature-related, hemodynamic, metabolic, infectious, or pharmacologic, each independently or in various combinations [1–6, 9–12].

The clinical manifestations include almost all the possible deficits and modalities of dysfunction depending on the nature and the localization (single or multiple) of the injury [13]. The following are among the most commonly encountered abnormalities: focal motor or sensory deficits, primitive reflexes, cranial nerve signs, cerebellar and brain stem syndromes, visual defects, movement disorders, seizures, cognitive abnormalities, diffuse encephalopathy with a variety of manifestations, spinal involvement, brachial plexus involvement, and peripheral mononeuropathy or mononeuropathy multiplex [1–7, 10, 13].

For the purposes of clinical practice, neurologic disorders are often divided into three rough categories: focal ischemic injury (stroke), diffuse encephalopathy (global hypoperfusion syndrome), and peripheral nervous injury. There are, however, no commonly accepted criteria for defining these categories, particularly the diffuse encephalopathy entity. Further, the disorder categories are by no means mutually exclusive. It has become obvious that a number of neuropathologic processes are involved in the clinical categories [9, 11, 12]. Also noteworthy is that what is seen in clinical explorations represents only a limited view of the overall CNS events. This has been demonstrated in a large number of neuropsychologic, psychiatric, neurophysiologic, neuroimaging, and biochemical studies during the four decades of cardiopulmonary bypass use.

Incidence of Postoperative Neurologic Disorders

The reported incidence of postoperatively detectable neurologic disorders varies greatly, ranging from 0% to 100% [1–8, 10, 13–21]. The differences are due mainly to the variability in the definitions of the clinical criteria for abnormalities and in the timing of the postoperative evaluations. Further confusion is caused by the heterogeneity of patient populations, study designs, surgical and anesthesia-related procedures, and use of ancillary nonclinical information.

As a rule, the incidence of complications has been considerably higher in prospective studies than in retrospective ones, with a range of up to 60% in the former and 1% to 10% in the latter [8, 13]. One study [22] compared these two approaches in 100 patients having valve replacement and showed that whereas a prospective neurologic examination revealed neurologic disorders in 37% of patients, a retrospective method did so in only 6%.

It has been a common impression that neurologic complications are more frequent in valve operations than CABG procedures. However, most of the reports involving valve procedures are from the 1970s, whereas the majority of CABG studies were published in the 1980s, by which time notably more sophisticated techniques had been developed. The current belief seems to be that cardiopulmonary bypass–related CNS injury is not a function of the cardiac disease. This assumption is supported by the most recent studies, one [4] of which showed a complication rate that was actually somewhat higher in the CABG group than in the valve procedure group (11% and 7%). In that study, it was suggested that the observed difference was due to the older age and the longer cardiopulmonary bypass time in the CABG group.

Given all these considerations, defining the current rate of postoperative neurologic disorders is a complex issue. This also holds true for the long-term prognosis.

Several surgical and anesthesia-related improvements during the past two decades include safer intraoperative and postoperative treatment regimens and equipment. Their success is well reflected by the ever more rarely encountered number of deaths due to cerebral damage, which also seems to be the most reliably documented part of the outcome data. The rate of fatal cerebral injuries has decreased to less than 0.1% from the 2% to 3% reported in the 1970s.

On the other hand, it is much more difficult to define the level of development in the other CNS complications because the clinical evaluative criteria are incongruous. In the most recent studies [4, 5, 17], focal CNS injury reflecting stroke is reported in 1% to 3% of patients, which is in contrast with the 3% to 10% reported in the 1980s. At the same time, as major neurologic complications such as disabling stroke have become relatively rare, increasing attention has been given to the third clinical disorder entity, diffuse encephalopathy. This can be manifested in various clinical forms-confusion, delirium, cognitive dysfunction, memory defects, and altered mental state or personality [13]-and also as minor and transient motor or sensory abnormalities.

Diffuse encephalopathy has proved to be particularly difficult to outline and has often been overlooked in prospective evaluations and especially in retrospective studies. Disregard is the rule among authors concentrating on ``obvious'' clinical deficits, an approach that probably includes only cerebral death and unambiguous hemiplegia as the neurologic events worth mentioning.

Ostensibly, the disregard of diffuse encephalopathy is attributed to the fact that its clinical symptoms and signs are most commonly transient and tend to resolve within days or weeks. Rough outcome criteria may serve well as a measure of the routine standards of safety and efficacy within a given institution, but they are not adequate as a uniform measure of development of CNS complications. Because even the most thorough clinical evaluations fail to reveal neurologic disturbances in all patients, minor abnormalities can also indicate that something has gone wrong. Further evidence is provided by the findings that regardless of degree of severity, clinical signs of cerebral dysfunction may be reflected in the long-term outcome evaluated by neuropsychologic and electroencephalographic follow-up [7, 14].

Outcome of Neurologic Disorders

The postoperative follow-up most commonly covers the hospital treatment period to discharge only or through the first postoperative weeks. Reports are few on the later neurologic outcome of valve operations and are nonexistent for CABG with the exception of a number of neuropsychologic follow-up studies. The long-term outcome studies have focused mainly on the surgical and cardiac results and the general measures of quality of life.

Focal CNS deficits of varying severity have been reported to persist up to discharge [1, 2, 4, 5, 17], but less than one third of patients with definite stroke continue to have any major functional disability at that time [1, 2]. In a series of 100 patients having valve procedures [1, 7], 24 patients had focal defects attributable to CNS involvement. Thirteen (54%) recovered completely in 2 months and 22 (92%), in 5 months. The remaining 2 patients (8%) continued to have persistent moderate disability throughout the entire 5-year follow-up.

In a detailed study of 312 CABG patients [2], new neurologic abnormalities were detected in 61% after operation, the incidence of the main findings being as follows: depression of consciousness, 3.2%; definite stroke, 4.8%; signs of minor focal cerebral injury, 2.9%; ophthalmologic abnormalities, 25%; primitive reflexes, 39%; psychosis, 1.3%; and peripheral nervous system complications, 12%. Four of the 15 patients with stroke were the only patients disabled to the extent that they were unable to manage independently.

Slight to moderate focal motor deficits seem to resolve within a few weeks, whereas those severe enough to cause major disability persisting to discharge tend to have a long-term prognosis identical to that seen for stroke in general. Adequate rehabilitation programs should be formulated for the group with more severe deficits. It should be emphasized that in addition to their somatic complaints and signs, these patients often have neuropsychologic and cognitive disorders, even when the primary motor deficits have been relatively mild. This is reflected as a correlation between the clinically detectable complications and the higher cerebral functions and electroencephalographic disturbances in multidimensional long-term follow-up investigations [7, 14].

The heterogeneity of the information available on diffuse encephalopathy makes it difficult to outline the long-term outcome in this disorder. It is a common experience that a great majority of the patients who show a dysfunction of this kind during the early postoperative period seem to recover completely within a few days [1, 2, 4, 17, 20]. However, apart from the mildest forms, which may be a function of temporary pharmacologic or metabolic effects, this group obviously also includes patients with cerebral hypoperfusion resulting in neuronal injury. To date, no reliable criteria are available for the clinical differentiation between patients with and those without an organic background for the disturbances associated with the diffuse encephalopathy entity. Neuropsychologic, neuroimaging, neurophysiologic, and biochemical measures play a central role in the elucidation of this issue. The patients with diffuse encephalopathy or focal CNS involvement are among those who are most likely to sustain long-term intellectual, cognitive, and other disturbances of the higher cerebral functions.

Prevention is the most effective way of managing neurologic disorders, and further development of cardiopulmonary bypass techniques and neuroprotective measures is therefore necessary [23]. At the same time that many of the current problems (eg, warm versus cold cardioplegia and different pH regulation methods) remain unresolved with reference to cerebral outcome, new potential mechanisms of cellular injury are found. New challenges are issued, for instance, in the elucidation of the roles of inflammatory and immunologic mechanisms and endogenous toxins [24, 25]. From the neurologic viewpoint, further development is needed particularly in the prevention and treatment of preoperative cerebrovascular accidents, which are clear-cut risk factors for postoperative CNS disorders. Further, clinical criteria and timing of postoperative evaluations need standardization.

Footnotes

Presented at the Conference on CNS Dysfunction After Cardiac Surgery: Defining the Problem, Fort Lauderdale, FL, Dec 10–11, 1994.

Address reprint requests to Dr Sotaniemi, Department of Neurology, University of Oulu, FIN-90220 Oulu, Finland.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sotaniemi, K. A. Search for Related Content PubMed PubMed Citation Articles by Sotaniemi, K. A.