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Ann Thorac Surg 2001;71:397
© 2001 The Society of Thoracic Surgeons

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Correspondence

Epiaortic ultrasound, Y graft, and postoperative neuropsychological dysfunction

^a Department of Cardiothoracic Surgery, Uppsala University Hospital, S-751 85, Uppsala, Sweden

e-mail: christian.olsson{at}thorax.uas.lul.se

To the Editor

Royse and associates [1] reported their efforts to reduce postoperative neuropsychological dysfunction after coronary artery bypass grafting (CABG) in the May 2000 issue of The Annals of Thoracic Surgery. They conclude that the combined techniques of epiaortic ultrasound screening and exclusive Y grafting resulted in a low incidence of late neuropsychological dysfunction compared with standard management.

The study design and conduction raises several questions. Patients were not randomized to either group. This inevitably introduces the possibility of bias, regardless of apparent matching between groups. It is not stated whether the same surgical team performed both types of operations, or if the two teams performed each procedure in isolation. Blinding of the medical investigator and neuropsychologist performing postoperative tests is not stated. Anesthetic techniques varied considerably between groups, with medium-dose opioid-based anesthesia in control patients versus propofol sedation with the adjunct of volatile gas and epidural anesthesia in the echo/Y group. Carbon dioxide insufflation was used only in the echo/Y group. The potential benefit of excluding air from the pericardium, and consequently from the bloodstream, is probably larger in standard CABG, where one or more openings are made in the aortic root for construction of the proximal anastomoses. Perioperative perfusion pressures were kept higher in the echo/Y group, influencing cerebral circulation and autoregulation and potentially the neuropsychological outcome. Information is not provided on standard perioperative data such as cross-clamp and ECC times, duration of mechanical ventilation and parenteral sedation, and use of peroral sedative, anxiolytic, and tranquilizing drugs. Late outcome was defined as test results at 64 days in the echo/Y group or at 47 days in the control group (p < 0.001). There is no unequivocal consensus regarding the timing for tests judging late neuropsychological outcome; 3 months may not be sufficient time for measurable but reversible deficits to abate. Certainly, another 17 days (in this study equal to 30% of mean follow-up time) can make a difference in subtle neurological functions. At no point of the study were the patients’ own perceptions of neurological deficits and their putative impact on their overall well-being and health perception measured. It remains to be proven that scoring 20% lower on a postoperative neuropsychological test translates to a self-perceived significant reduction of neurological or mental function.

Royse and associates present compelling evidence that an important source of perioperative cerebrovascular emboli, the atheromas of the ascending aorta, are ubiquitous in CABG patients and can fairly easily be avoided. As part of a multimodality strategy to prevent neurological damage, involving anesthetic, perfusion, and surgical techniques as well, epiaortic ultrasound and Y-graft technique seems to confer a benefit in neuropsychological outcome primarily related to reduced embolic burden. These and other steps to prevent embolization from inadvertently manipulated atheromas of the aorta should always be contemplated in patients undergoing CABG.

References

1. Royse A.G., Royse C.F., Ajani A.E., et al. Reduced neuropsychological dysfunction using epiaortic echocardiography and the exclusive Y graft. Ann Thorac Surg 2000;69:1431-1438.[Abstract/Free Full Text]

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