ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Jeffrey P. Gold
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Gold, J. P.
Right arrow Articles by Wasnick, J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Gold, J. P.
Right arrow Articles by Wasnick, J.
Related Collections
Right arrow Coronary disease

Ann Thorac Surg 2004;78:1579-1585
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Improving Outcomes in Coronary Surgery: The Impact of Echo-Directed Aortic Cannulation and Perioperative Hemodynamic Management in 500 Patients

Jeffrey P. Gold, MDa,*, Kaila E. Torres, MDa, William Maldarelli, CCPb, Ilya Zhuravlev, MDc, Douglas Condit, PACa, John Wasnick, MDc

a Department of Cardiovascular and Thoracic Surgery, Albert Einstein College of Medicine, New York, New York, USA
b Department of Cardiac Perfusion, Albert Einstein College of Medicine, New York, New York, USA
c Program of Cardiac Anesthesia of the Montefiore Medical Center, The Albert Einstein College of Medicine, New York, New York, USA

Accepted for publication May 12, 2004.

* Address reprint requests to Dr Gold, Department of Cardiovascular and Thoracic Surgery, The Albert Einstein College of Medicine, 3400 Bainbridge Ave, Suite 5B, Bronx, NY 10467, USA
jgold{at}montefiore.org


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Stroke and death continue to occur perioperatively associated with on-pump and off-pump coronary artery bypass grafting surgery (CABG) procedures. We report on a prospectively implemented multifaceted strategy to improve short-term outcomes associated with on-pump CABG.

METHODS: Five hundred consecutive patients from a single teaching institution undergoing standardized on-pump nonreoperative CABG between June 1996 and July 2003 were entered into the New York State Cardiac Surgery database, a verified comprehensive clinical registry. Risk factors and outcomes were analyzed and compared with the statewide New York State CABG registry. All patients underwent intraoperative transesophageal echocardiography to guide distal aortic cannulation and high flow–high pressure cardiopulmonary bypass perfusion, arterial filtration, centrifugal pump perfusion, and membrane oxygenation. Intraoperative and early postoperative blood pressures were continuously targeted to match the patient's preoperative range.

RESULTS: The mean patient age was 63.5 years, 335 (67%) were male, and 320 (64%) were deemed to be of elective surgical priority. The mean ejection fraction was 0.434, with 255 (51%) having sustained a prior myocardial infarction. The mean cardiopulmonary bypass time was 95 minutes with an ischemic time of 51 minutes to accomplish a mean of 3.19 grafts/patient. The predicted group mortality was 2.28%, which was greater than the simultaneously measured 1.98% New York statewide CABG mortality during the same period for comparable patients (p < 0.05). There was no in-hospital or 30-day mortality nor were there any perioperative strokes in this group (p < 0.05). The mean postoperative hospital length of stay was 3.61 days with a 5.1% 30-day readmission rate.

CONCLUSIONS: A standardized approach to CABG using echocardiographic guided aortic cannulation and perioperative hemodynamic management reduces perioperative stroke and death associated with on-pump coronary surgery.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Permanent neurologic dysfunction and the frequently associated early death after any interventional procedure is devastating. The impact on the patient and the family, as well as the costs to the community and society, is enormous. Central and peripheral neurologic complications of surgical procedures assume prognostic significance exceeding almost any other periprocedural complication with the exception of perioperative death. Much has been written regarding perioperative mortality and the relationships between fixed central sensory-motor neurologic deficits or strokes and coronary artery bypass graft (CABG) surgery [1–10]. Alone, or in combination, particulate embolization, regional versus global cerebral hypoperfusion, the effects of local versus regional cerebrovascular spasm, and central nervous system inflammatory changes have been associated with the majority of the fixed neurologic deficits related to CABG surgery and a significant proportion of the perioperative deaths [11–20].

The use of cardiopulmonary bypass technology has been associated to some extent with long-standing postoperative neurologic deficits. The sets of surgical techniques associated with the use of cardiopulmonary bypass, as it related to intraoperative echocardiography [21–29], aortic manipulation, arterial filtration, blood pressure and flow rate control [30–32], temperature management, and pharmacologic support, have prompted many reports and an almost equal number of long-standing controversies.

It was hypothesized that the use of a highly standardized approach to procedure selection and technical and pharmacologic management of CABG patients on the basis of previously established principles that were uniformly implemented would reduce perioperative mortality and neurologic morbidity with time. This manuscript reviews a single teaching institution, and a single attending surgeon's experience attempting to optimize a standardized management protocol for patients undergoing cardiopulmonary bypass-facilitated CABG surgery by developing and routinely using such a standardized approach to reduce perioperative complications and death associated with systemic embolization and hypoperfusion.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Acknowledgments
 References
 
Patients
The New York State Department of Health Cardiac Surgery Recording System (NYS CSRS) was used as the primary data source for the analysis of 500 consecutive, isolated, first-time (no reoperations) CABG surgery cases in a single institution performed on cardiopulmonary bypass by a single surgeon and cardiothoracic surgery residency staff in a single academic teaching program. The NYS CSRS is a verified peer-reviewed data collection system mandated by the Department of Health (DOH) of the State of New York (NYS) recording and analyzing data in a highly controlled and widely reported fashion. The data are verified through review of risk factor and outcome reporting frequencies, cross-matching the CSRS data with other DOH administrative and vital statistics databases, and the review of hospital in-patient medical records by independent nurse reviewers (Island Peer Review Organization). The risk-adjusted outcomes for coronary bypass surgical procedures have been reported for national registry center data as well as for NYS center data [33–37] (Hannan EL, The New York State Department of Health, Coronary Artery Bypass Surgery in New York State; July 2003, personal communication).

All NYS DOH CSRS preoperative demographic and cardiac factors were retrospectively reviewed for 500 consecutive CABG cases during the period from January 1997 through June 2003. On the basis of the multivariable analysis performed by the NYS DOH, the individual and group predicted all cause 30-day mortality was calculated. These patients were compared with the demographics, risk profile, and outcomes of all patients undergoing CABG surgery from 1997 through 2001. All patients undergoing isolated valvular, congenital, thoracic vascular, combined valvular and coronary, or combined vascular and coronary surgery were excluded from this retrospective analysis. In addition, all patients undergoing isolated CABG surgery without the use of cardiopulmonary bypass were excluded as well, thus focusing on a highly selected, reproducible, highly studied cohort of cardiac surgery patients.

Patients with known preoperative cerebrovascular disease on the basis of history, symptoms, or the presence of a carotid artery bruit underwent carotid artery ultrasound duplex examination. In addition, all patients 80 years of age and older, independent of neurologic history and physical examination, underwent carotid artery ultrasound imaging. If high-grade (>70% stenosis) unilateral symptomatic or bilateral high-grade stenotic symptomatic or asymptomatic disease was identified, the patient underwent carotid thromboendarterectomy before or during the CABG surgery. The only exception to preoperative carotid thromboendarterectomy was the instances when the coronary artery disease was associated with unstable hemodynamics, medically uncontrolled angina, or evolving myocardial infarction. In these cases, which were frequently dependent on intraaortic balloon pump or transferred directly from the catheterization laboratory, carotid artery imaging was not routinely performed as described above.

Patients with advanced thoracic aortic arteriosclerosis as quantified by preoperative transesophageal echocardiography or intraoperative preincision transesophageal echocardiography were preselected to undergo either nonsurgical catheter-based therapy or, more commonly, off-pump CABG surgery. This included all patients with advanced aortic grade IV and grade V atherosclerotic changes of the ascending or transverse aorta with or without a history of significant neurologic event(s), cerebrovascular disease, or peripheral vascular disease. This latter group was excluded from this study of outcomes in on-pump CABG cases. They represented approximately 12% of the simultaneously treated surgical revascularization population, and had a 2.5-fold higher predicted risk-adjusted operative mortality than the on-pump group reported here based on the NYS DOH CSRS risk adjustment system.

Surgical Techniques
All patients underwent anesthesia induction for coronary revascularization using narcotic-based, balanced anesthesia and were instrumented with arterial, pulmonary artery, and transesophageal monitoring. The hemodynamics were managed to maintain systemic blood pressure consistent with the patient's preoperative preinduction levels with {alpha}-adrenergic stimulating agents as necessary. All patients underwent preincision transesophageal echocardiography serving as a monitoring tool as well as documenting ventricular function, valvular function, integrity of the intraatrial septum, and the extent and distribution of arteriosclerosis of the aorta. Echocardiographic evaluation of aortic arteriosclerosis was based on plaque thickness and mobility, as per the Kronzon Aortic Scale [38, 39]. All patients were surgically managed with a sternotomy incision, transsternal internal mammary artery harvesting, and minimally invasive upper leg vein or radial artery harvesting.

Careful manual palpation of the ascending aorta or the intraoperative transesophageal aortic imaging frequently suggested the need for epiaortic echocardiographic long-access and short-access imaging. This was used to guide aortic cannulation and any additional aortic manipulation including aortic clamping and proximal anastomosis. As mentioned above, the combination of aortic palpation, transesophageal echocardiography imaging, and epiaortic imaging revealing advanced local aortic arteriosclerosis suggested the need for off-bypass "no-touch" surgery using pedicled multivessel revascularization. This was subsequently performed in a relatively small group (12%) of these patients, thus eliminating analysis within this series.

The series of patients reported here were all managed on cardiopulmonary bypass. Anticoagulation was maintained after administering a loading dose of heparin (400 U/kg). Arterial cannulation was performed with a soft flow cannula (model 13010; Sarns, Inc, Ann Arbor, MI), which was passed under direct echocardiographic guidance into the descending aorta distal to the origin of the left subclavian artery (Fig 1). A multistage vacuum-assisted venous drainage catheter placed through the right atrial appendage (model 29202 or 29370; Edwards Lifesciences, Inc). After initiation of cardiopulmonary bypass, an activated clotting time or heparin management time of 480 seconds or more was maintained at all times. A combination of antegrade and retrograde induction cold (4°C) cardioplegia was used at 15 mL/kg, and repeated by means of a retrograde and conduit-administered route (saphenous vein graft or right atrium) after completion of all but the final anastomoses (which were usually the internal mammary artery grafts) at 3 to 5 mL/kg. Padded aortic clamps were used for the aorta under all circumstances (model N-10126; Novare, Inc) when the aorta was occluded.



View larger version (56K):
[in this window]
[in a new window]
  		Fig 1. Transesophageal echocardiographic view of distal transverse aortic arch and proximal descending aorta demonstrating aortic cannula passed through the distal ascending aorta into the proximal descending aorta under echocardiographic guidance.

 
A centrifugal pump (BP-80; Bio-Medicus, Inc)was used in all cases with a coated open system oxygenator (CXSX18RX; Terumo). High-flow and high-pressure cardiopulmonary bypass was maintained during the entire perfusion interval with pressures ranging from 75 to 95 mm Hg and flows of 2.0 to 2.4 L · min–1 · m–2. These flows and pressures were maintained as necessary with moderate-dose Neo-Synephrine administered by the perfusionists. During a typical case, patients required from 100 to 200 mL of continuous infusion 80 mg/L Neo-Synephrine diluted in normal saline solution. All patients' core temperatures were continuously maintained at normothermia during the entire perfusion interval. Minimum hematocrit on bypass was kept above 22%. Normothermia was managed with the aid of a thermistor-tipped bladder catheter. Aortic decannulation was completed immediately after the administration of protamine sulfate during measured normalization of the activated clotting time or heparin management time. All patients demonstrating an intraatrial communication on prebypass intraoperative contrast transesophageal echocardiography underwent a simultaneous suture repair of the atrial septum.

Patients were maintained in a normotensive range mirroring their preoperative hemodynamics during the early postoperative interval with a minimum heart rate of 65 beats/min. Temporary epicardial pacing was used as necessary. Multiple pharmacologic agents were used when required to adjust afterload and contractility to maintain the systolic blood pressure at a minimum in the 110 to 130 mm Hg range (many higher) and the cardiac index in the 2.5 to 3.0 L · min–1 · m–2. Perioperative aspirin was used in all nonallergic patients, with a small number taking Coumadin and a larger group taking IIB/IIIA platelet inhibiting drugs on the basis of preoperative comorbidity.

Postoperative complications were tracked by attending surgeons, critical care physicians, cardiologists, and consulting specialists including neurologists, pulmonologists, infectious diseases, nephrologists, and others as required. In addition, the cardiothoracic residents and cardiothoracic physician assistants, who also recorded any documented perioperative complication, closely managed all patients. These complications were divided into cardiac, pulmonary, gastrointestinal, neurologic, hematologic, infectious, renal, neurologic, and wound-related and recorded in the computerized registry as such. The definitions for each of these complications were developed by the Cardiac Advisory Committee of NYS, and have been widely used for more than 10 years. Complications were recorded using the CATORpro (Cornell University Medical College, Ithaca, NY) Web-based data collection system. In addition, all cause perioperative or in-hospital mortality and all cause 30-day mortality were recorded. The condition on hospital discharge and the disposition of the discharge (home, home with professional care, rehabilitation service, acute care hospital, and so forth) were recorded for every patient. All hospital readmissions for any reason to our hospital and to any other of which we were made aware during the 30-day period after hospital discharge were also recorded, as was the cause(s) of the readmission.

All of the above data were tracked and analyzed by the CATORpro intranet data reporting system (Cornell University) and reported to the NYS DOH CSRS on a quarterly basis for the entire duration of the study period. The data were verified for accuracy internally, by the NYS DOH and by the Island Peer Review Organization consistent with the NYS DOH data verification and monitoring policy. As such, independent chart review audits were performed at fixed intervals verifying the completeness and accuracy of submitted data compared with chart-based documentation. All cause in-hospital and 30-day mortality was verified by the NYS DOH using the Statewide Planning and Research Cooperative System. Numerical data were expressed as mean ± standard error of the mean (when available). Comparison of continuous variables was performed with a two-sided Student's t test.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Acknowledgments
 References
 
The age, sex, surgical priority, and preoperative hemodynamic stability of the study population (500 cases) are found in Table 1. Compared with the series presented here, the NYS DOH (87,041) CABG patients included all reported isolated primary CABG procedures. As such, reoperations, 5.65% of the entire statewide CABG population (with an odds ratio for death of 2.98), were excluded from the NYS DOH data for purposes of this comparative analysis.


View this table:
[in this window]
[in a new window]
  		Table 1. Preoperative Demographic Study Population and New York State Coronary Artery Bypass Grafting Data

 
Canadian angina class, history of one or more transmural myocardial infarctions, left ventricular ejection fraction, number of coronary grafts, and cardiopulmonary bypass times and cross-clamp times are found in Table 2. These data are similar to the NYS DOH CSRS registry; however, there was a much higher incidence (51% versus 11%) of preoperative myocardial infarction (one or more) and as such a significantly lower (43.4% versus 47.4%) left ventricular ejection fraction in our study population. The mean number of vessels grafted was 3.19 per patient in our series.


View this table:
[in this window]
[in a new window]
  		Table 2. Clinical and Operative Study Population and New York State Coronary Artery Bypass Grafting Data

 
There was a moderate incidence of associated mild and mild-to-moderate valvular heart disease in our study population, which was not treated surgically. Aortic stenosis or insufficiency of mild and mild-to-moderate levels was diagnosed in 10.4% of the population, with mild and mild-to-moderate mitral stenosis or insufficiency present in 14.2% of the study population. Although this does not factor into the risk prediction, it is representative of the study patient's set of comorbidities. Patients with more significant amounts of aortic or mitral valvular heart disease did undergo combined valve and CABG surgery and as such were excluded from this study.

The expected (predicted) and measured mortality rate for this patient population and the measured mortality rates for the population of patients undergoing isolated CABG surgery in NYS during the same interval is found in Table 3. This comparison demonstrated that the population being reported here is comparable from an expected mortality perspective on the basis of multivariable risk factor analysis. The observed NYS DOH mortality for the above-described statewide reference group was 2.20%.


View this table:
[in this window]
[in a new window]
  		Table 3. Operative Mortalitya

 
Using the multivariable risk factor equation developed for the NYS population, on the basis of 17 demographic, hemodynamic, comorbidity, and left ventricular performance measures (C statistic, 0.793; intercept, –5.8622), the predicted mortality rate was 2.28% for our study population. The comparable reference NYS DOH observed mortality rate was 1.94%, below the predicted mortality in our group (p < 0.05). Our reported series of 500 consecutive patients did not have a single death perioperatively or during the first 30 days postoperatively, a significant difference from the NYS population (p < 0.05) and the predicted mortality for this study cohort (p < 0.05).

Perioperative complications, discharge status, and discharge destination, as well as total length of hospital stay, postoperative length of stay, 30-day status, readmission rate, and readmission indications are found in Table 4. Total hospital mean length of stay was 6.02 ± 3.52 days. This included all of the time for preoperative preparation, as well as for invasive and noninvasive cardiac studies as necessary. The mean postoperative length of stay was 3.61 ± 1.18 days. Twenty-seven patients required hospital readmission during this interval. Ten of these readmissions were for nonischemic chest pain, 10 for atrial arrhythmia management, and 2 for a stroke or transient ischemic attack.


View this table:
[in this window]
[in a new window]
  		Table 4. Postoperative Study Population Hospitalization and Complications

 
All patients with any suspicion of a neurologic event were evaluated by one of our neurologists. Six patients experienced a neurologic complication classified as confusion, delirium, or encephalopathy by a neurologist. In each case the syndrome was cleared before hospital discharge and showed no focal or acute changes on physical examination or on a contrast computed tomographic scan or magnetic resonance imaging of the brain. A single patient demonstrated a transient deficit manifested by dysarthria lasting several weeks. No lesion was noted on a computed tomographic scan. It was unclear whether this represented a peripheral neurologic injury or local traumatic event.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Acknowledgments
 References
 
Stroke is but one part of the entire spectrum of potential periprocedural neurologic complications that we associate with CABG surgery and other cardiac and noncardiac surgical procedures. Psychometric or cognitive changes have also been commonly associated with cardiac and noncardiac surgical procedures. They tend to be less precisely defined, and are of uncertain long-term consequence. In many studies, they may be independently progressive and to a certain extent tend to become less severe in the months and years after the procedure.

Postprocedural encephalopathy or confusion has also been associated with CABG surgery. This nonfocal neurologic syndrome is associated with a distinct set of risk factors, including advanced age and preoperative dementia, and multiple causes frequently related to drugs or metabolic abnormalities. It, too, has a waxing and waning course and tends to return to a baseline state when not associated with a fixed focal neurologic deficit.

The classic stroke carries the greatest prognostic significance and a natural history of limited recovery, long-standing disability, and premature death. Indeed, the association of early and intermediate-term death with periprocedural stroke is striking. A stroke is also the easiest of the neurologic complications to quantify and follow up. Measures including hospital length of stay, postprocedural length of stay, intensive care unit length of stay, 30-day readmission rates, and 30-day mortality are often considered surrogates for these less well-defined sequelae of systemic embolization but mostly for the wider spectrum of neurologic sequelae of CABG surgery [40–43].

Most visceral organ and neurologic injuries are embolic or hypoperfusion related in basis. Manipulation of the great vessels either by clamp, cannula, manual manipulation, or endoaortic "sandblast" perfusion–generated blood flow effect has been associated with the majority of embolic material and the majority of strokes, visceral organ injuries, and prolonged hospital stays, and many perioperative deaths. The turbulence generated by aortic cannula flow can be easily imaged by echocardiographic techniques and can be seen in the descending aorta region. Not subjecting the transverse aortic arch and the ascending aorta, two regions highly prone to advanced arteriosclerosis with ulcerated or mobile components, to the sandblast effect of aortic inflow is logical and may have been beneficial in this series. In the same fashion, maintaining stable intraoperative and postoperative systemic blood pressures mirroring the patients' known preoperative hemodynamics has been previously reported as beneficial [44], and may have been related to the outcomes reported here as well.

The analysis of 30-day event analysis in any study is subject to concerns related to the reliability of follow-up. This is predicated on the practices of the surgical group and the geographic distances the patients travel to undergo surgical care. In this instance, given the absolute requirement to document 30-day status of all patients, subject to verification by the Bureau of Vital Statistics statewide death records, and the highly audited nature of these data, this is likely an accurate assessment. Indeed, almost all patients were followed up for more than 6 months after surgery. Given the multicenter nature of the health-care system, the overwhelming majority of readmissions occurred within our health-care system and were therefore recorded. The large inner-city type population that our institution serves supports heavy use of our emergency medicine services and outpatient care in preference to care elsewhere.

Just as the cause of these perioperative complications is multifactorial, representing a diverse group of synergistic risk factors, intraoperative techniques, and perioperative events, so has been the surgical approach to their prevention. Each cardiac surgical program and, to a greater extent, each surgeon have developed an individualized approach to complication prevention for patients undergoing CABG surgery. These individualized variables extend from preoperative assessment of risk factors through completion of early post-CABG and postoperative care. Although it is impossible to reach absolute conclusions from this type of analysis, the fact that this is a single-institution, single-attending surgeon, consecutive series of a single, stereotyped procedure allows the focus on specific procedural-related issues. The mortality, morbidity, length of stay, and readmission rates are consistent and compare favorably to many previous series.

The age, sex, race, and ethnicity of this patient population are comparable to many published series including the NYS DOH publicly released CSRS. The ejection fraction, and the incidence of prior myocardial infarction, was significantly different, with several-fold more preoperative infarcts and a lower ejection fraction in our study group. The predicted surgical mortality for this group is higher than the simultaneously operated statewide measured average by 0.3% for the group reported.

It is difficult to separate the judgmental, clinical management, and technical factors associated with the observed outcomes. However, routine use of transesophageal and epiaortic echocardiographic imaging are important steps that guided procedure selection and influence the conduct of numerous components of the procedure. Selected use of off-pump surgery in the high-risk patients as well as minimal handling of the aorta, proximal descending aortic cannulation with the aortic cannula tip distal to the left subclavian artery, and pressure–flow management in these patients all revascularized while on cardiopulmonary bypass would seem to be among the cornerstones of the management strategy, and possibly distinguish the management of this sequential cohort of patients from other similar patients undergoing CABG surgery (Table 5). Although not randomized to separate the significance of these considerations, when combined as a standardized perioperative approach, the development of postoperative stroke and other procedural associated morbidity can be diminished.


View this table:
[in this window]
[in a new window]
  		Table 5. Cornerstones of Perioperative Management Used to Guide Procedure Selection and Intraoperative Care

 
Neurologic injury, prolonged hospitalization, hospital readmission, and perioperative death have all been reported to complicate CABG surgery. This series of 500 consecutive on-pump isolated CABG procedures demonstrates that intraoperative echocardiography and perioperative hemodynamic management can reduce complications and deaths associated with this procedure. In particular, the routine use of transesophageal and epiaortic echocardiography techniques, risk factor–guided procedure selection, distal aortic cannulation, and minimal aortic manipulation have been the important features of this series. The future is rich with techniques to better evaluate perioperative atheroembolic risk and prevent the neurologic sequelae of emboli. Given the durability, completeness, and overall safety associated with surgical coronary revascularization, this series underscores the fact that CABG surgery remains a safe and durable means of managing atherosclerotic coronary heart disease for many subsets of our patients.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
References
 
We thank Chuntao T. Wu, PhD, and Edward L. Hannan, PhD, of the School of Public Health of the State University of New York–Albany for review and analysis of the risk factor profile of the entire New York State Department of Health coronary surgery data registry. Doctor Hannan's ongoing encouragement, suggestions, and support have been invaluable to the completion of this manuscript. We also thank the thoracic surgery residents, physician assistants, cardiac anesthesiologists, perfusionists, consulting physicians, nurses, and data managers of the cardiothoracic surgery program for developing the protocols and maintaining the quality of patient care reported here.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Jones RH, Hannan EL, Hammermeister KE, et al. Identification of preoperative variables needed for risk adjustment of short-term mortality after coronary artery bypass graft surgery. The Working Group Panel on the Cooperative CABG Database Project. J Am Coll Cardiol. 1998;31:1214–1215[Free Full Text]
  2. Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med. 1996;335:1857–1863[Abstract/Free Full Text]
  3. Cernaianu AC, Vassilidze TV, Flum DR, et al. Predictors of stroke after cardiac surgery. J Cardi Surg. 1995;4:334–339
  4. Van Der Linden J, Hadjinikolaou L, Bergman P, et al. Postoperative stroke in cardiac surgery is related to the location and extent of atherosclerotic disease in the ascending aorta. J Am Coll Cardiol. 2001;38:131–135[Abstract/Free Full Text]
  5. Saimanen EI. Perioperative stroke with coronary artery bypass surgery: analysis of risk factors. Scand Cardiovasc J. 2000;34:41–45[Medline]
  6. Newman MF, Reves JG. Towards a new frontier in cardiac surgery. Ann Thorac Surg. 1997;632:322–323
  7. Blauth CI, Schulenberg WE, Taylor KM. Cerebral microembolism during cardiopulmonary bypass: retinal microvascular studies in-vivo with fluorescein angiography. J Thorac Cardiovasc Surg. 1988;95:668–676[Abstract]
  8. Amarenco P. Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. N Engl J Med. 1996;334:1216–1221[Abstract/Free Full Text]
  9. Taylor KM. Brain damage during cardiopulmonary bypass. Ann Thorac Surg. 1994;42:212–217
  10. Barbut D, Caplan LR. Brain complications of cardiac surgery. Curr Probl Cardiol. 1997;22:449–480[Medline]
  11. Tuman KJ, McCarthy RJ, Najafi H, Ivankovich AD. Differential effects of advanced age on neurologic and cardiac risks of coronary artery operations. J Thorac Cardiovasc Surg. 1992;104:1510–1517[Abstract]
  12. Barbut D, Lo YW, Hartman GS, et al. Aortic atheroma is related to outcome but not numbers of emboli during coronary bypass. Ann Thorac Surg. 1997;64:454–459[Abstract/Free Full Text]
  13. Rorick MB, Furan AJ. Risk of cardiac surgery in patients with prior stroke. Neurology. 1990;40:835–837[Abstract/Free Full Text]
  14. Barbut D, Hinton RB, Szatrowski TP, et al. Cerebral emboli detected during bypass surgery are associated with clamp removal. Stroke. 1994;25:2398–2402[Abstract]
  15. Rao V, Christakis GT, Weisel RD, et al. Risk factors for stroke following coronary bypass surgery. J Card Surg. 1995;4:468–474
  16. Moody DM, Bell MA, Challa VR, et al. Brain microemboli during cardiac surgery or aortography. Ann Neurol. 1990;4:477–486
  17. Newman MF, Wolman R, Kanchuger M, et al. Multicenter preoperative stroke risk index for patients undergoing coronary artery bypass graft surgery. Multicenter Study of Perioperative Ischemia (McSPI) Research Group. Circulation. 1996;94(Suppl 9):1174–1180
  18. Rady MY, Ryan T, Starr NJ. Perioperative determinants of morbidity and mortality in elderly patients undergoing cardiac surgery. Crit Care Med. 1998;2:225–235
  19. Barbut D, Gold JP. Aortic atheromatosis and risks of cerebral embolization. J Cardiothorac Vasc Anesth. 1996;10:24–29[Medline]
  20. Clark RE, Brillman J, Davis DA, et al. Microemboli during coronary artery bypass grafting: genesis and effect on outcome. J Thorac Cardiovasc Surg. 1995;109:249–258[Abstract/Free Full Text]
  21. Barbut D, Yao FS, Hager DN, et al. Comparison of transcranial Doppler ultrasonography and transesophageal echocardiography to monitor emboli during coronary artery bypass surgery. Stroke. 1996;27:87–90[Abstract/Free Full Text]
  22. Barbut D, Lo YW, Gold JP, et al. Impact of embolization during coronary artery bypass grafting on outcome and length of stay. Ann Thorac Surg. 1997;63:998–1002[Abstract/Free Full Text]
  23. Konstadt SN, Reich DL, Kahn R, Viggiani RF. Transesophageal echocardiography can be used to screen for ascending aortic atherosclerosis. AnesthAnalg. 1995;81:225–228[Abstract]
  24. Hartman GS, Peterson J, Konstadt SN, et al. High reproducibility in the interpretation of intraoperative transesophageal echocardiographic evaluation of aortic atheromatous disease. Anesth Analg. 1996;82:539–543[Abstract]
  25. Murphy PM. Pro: intraoperative transesophageal echocardiography is a cost effective strategy for cardiac surgical procedures. J Cardiothorac Vasc Anesth. 1997;2:246–249
  26. Nicolosi AC, Aggarwal A, Almassi GH, Olinger GN. Intraoperative epiaortic ultrasound during cardiac surgery. J Card Surg. 1996;11:49–55[Medline]
  27. Trehan N, Mishra M, Dhole S, et al. Significantly reduced incidence of stroke during coronary artery bypass grafting using transesophageal echocardiography. Eur J Cardiothorac Surg. 1997;2:234–242
  28. Davila-Roman VG, Phillips KJ, Daily NN, et al. Intraoperative transesophageal echocardiography and epiaortic ultrasound for assessment for atherosclerosis of the thoracic aorta. J Am Coll Cardiol. 1996;28:942–947[Abstract]
  29. Marschall K, Kanchuger M, Kessler K, et al. Superiority of transesophageal echocardiography in detecting aortic arch atheromatous disease: identification of patients at increased risk of stroke during cardiac surgery. J Cardiothorac Vasc Anesth. 1994;1:5–13[Abstract/Free Full Text]
  30. Plestis KA, Gold JP. Importance of blood pressure regulation in maintaining adequate tissue perfusion during cardiopulmonary bypass. Semin Thorac Cardiovasc Surg 200;12:170–5
  31. Murkin JM, Martzke JS, Buchan AM, et al. A randomized study of the influence of perfusion techniques and pH management strategy in 316 patients undergoing coronary artery bypass surgery. II: neurologic and cognitive outcomes. J Thorac Cardiovasc Surg. 1995;110:349–362[Abstract/Free Full Text]
  32. McLean RF, Wong BI, Naylor CD, et al. Cardiopulmonary bypass, temperature and central nervous system dysfunction. Circulation. 1994;90(Suppl 2):II-250–255[Medline]
  33. Hannan EL, Wu C, Ryan TJ, et al. Do hospitals and surgeon with higher coronary artery bypass graft surgery volumes still have lower risk-adjusted mortality rates? Circulation. 2003;108:795–801[Abstract/Free Full Text]
  34. Block PC, Peterson ED, Krone R, et al. Identification of variables needed to risk adjust outcomes of coronary interventions: evidence-based guidelines for efficient data collection. J Am Coll Cardiol. 1998;32:275–282[Abstract/Free Full Text]
  35. The New York State Department of Health. Coronary Artery Bypass Surgery in New York State 1997–1999. September 2002
  36. Ferguson TB Jr, Hammill BG, DeLong ER, Peterson ED, Grover FL. A decade of change: risk profiles and outcomes for isolated CABG procedures, 1990–1999. Ann Thorac Surg. 2002;73:480–490[Abstract/Free Full Text]
  37. Shroyer AL, Coombs LP, Peterson ED, et al. The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models. Ann Thorac Surg. 2003;75:1856–1864[Abstract/Free Full Text]
  38. Grossi EA, Bizekis CS, Sharony R, et al. Routine intraoperative transesophageal echocardiography identifies patients with atheromatous aortas: impact on "off-pump" coronary artery bypass and perioperative stroke. J Am Soc Echocardiogr. 2003;16:751–755[Medline]
  39. Kronzon I, Tunick PA. Transesophageal echocardiography in thoracic aortic atherosclerosis. Echocardiography. 1996;13:233–246[Medline]
  40. Sheikhzadeh A, Ehlermann P. Atheromatous disease of the thoracic aorta and systemic embolism. Clinical picture and therapeutic challenge. Z Kardiol. 2004;93:10–17[Medline]
  41. Lev-Ran O, Loberman D, Matsa M, et al. Reduced strokes in the elderly: the benefits of untouched aorta off-pump coronary surgery. Ann Thorac Surg. 2004;77:102–107[Abstract/Free Full Text]
  42. Barbut D, Lo YW, Gold JP, et al. Impact of embolization during coronary artery bypass grafting on outcome and length of stay. Ann Thorac Surg. 1997;63:998–1002[Abstract/Free Full Text]
  43. Hartman GS, Yao FS, Bruefach M III, et al. Severity of aortic atheromatous disease diagnosed by transesophageal echocardiography predicts stroke and other outcomes associated with coronary artery surgery: a prospective study. Anesth Analg. 1996;83:701–708[Abstract]
  44. Gold JP, Charlson ME, Williams-Russo P, et al. Improvement of outcomes after coronary artery bypass. A randomized trial comparing intraoperative high versus low mean arterial pressure. J Thorac Cardiovasc Surg. 1995;110:1302–1314[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Anesth. Analg.Home page
K. E. Glas, M. Swaminathan, S. T. Reeves, J. S. Shanewise, D. Rubenson, P. K. Smith, J. P. Mathew, S. K. Shernan, and Council for Intraoperative Echocardiography of the
Guidelines for the Performance of a Comprehensive Intraoperative Epiaortic Ultrasonographic Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists; Endorsed by the Society of Thoracic Surgeons
Anesth. Analg., May 1, 2008; 106(5): 1376 - 1384.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
S. Goland, A. Trento, L. S.C. Czer, S. Eshaghian, K. Tolstrup, T. Z. Naqvi, M. A. De Robertis, J. Mirocha, K. Iida, and R. J. Siegel
Thoracic Aortic Arteriosclerosis in Patients With Degenerative Aortic Stenosis With and Without Coexisting Coronary Artery Disease
Ann. Thorac. Surg., January 1, 2008; 85(1): 113 - 119.
[Abstract] [Full Text] [PDF]

Home page
 Card Surg AdultHome page
M. Enriquez-Sarano, V. T. Nkomo, and H. Michelena
Principles and Practice of Echocardiography in Cardiac Surgery
Card. Surg. Adult, January 1, 2008; 3(2008): 315 - 348.
[Full Text]

Home page
 Eur Respir JHome page
R. A. Oeckler and R. D. Hubmayr
Ventilator-associated lung injury: a search for better therapeutic targets
Eur. Respir. J., December 1, 2007; 30(6): 1216 - 1226.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
R. Lee, N. Matsutani, A. C. Polimenakos, L. C. Levers, M. Lee, and R. G. Johnson
Preoperative Noncontrast Chest Computed Tomography Identifies Potential Aortic Emboli
Ann. Thorac. Surg., July 1, 2007; 84(1): 38 - 42.
[Abstract] [Full Text] [PDF]

Home page
 NEJMHome page
M. Selim
Perioperative Stroke
N. Engl. J. Med., February 15, 2007; 356(7): 706 - 713.
[Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
K. G. Shann, D. S. Likosky, J. M. Murkin, R. A. Baker, Y. R. Baribeau, G. R. DeFoe, T. A. Dickinson, T. J. Gardner, H. P. Grocott, G. T. O'Connor, et al.
An evidence-based review of the practice of cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response.
J. Thorac. Cardiovasc. Surg., August 1, 2006; 132(2): 283 - 290.e3.
[Full Text] [PDF]

Home page
 CirculationHome page
I. Kronzon and P. A. Tunick
Aortic Atherosclerotic Disease and Stroke
Circulation, July 4, 2006; 114(1): 63 - 75.
[Full Text] [PDF]

Home page
 Anesth. Analg.Home page
C. W. Hogue Jr, C. A. Palin, and J. E. Arrowsmith
Cardiopulmonary bypass management and neurologic outcomes: an evidence-based appraisal of current practices.
Anesth. Analg., July 1, 2006; 103(1): 21 - 37.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Jeffrey P. Gold
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Gold, J. P.
Right arrow Articles by Wasnick, J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Gold, J. P.
Right arrow Articles by Wasnick, J.
Related Collections
Right arrow Coronary disease

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS