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Ann Thorac Surg 2007;83:1690
© 2007 The Society of Thoracic Surgeons
Division of Cardiac Surgery, University Clinic of Surgery, MUG, PO Box 51, Auenbruggerplatz 29, Graz, A-8036 Austria
(Email: igor.knez{at}meduni-graz.at).
Adverse neurologic outcomes after heart surgery in general, and cardiac transplantation in particular, have serious consequences: an increased risk of mortality and a diminished quality of life among survivors. They also represent a burden on the health-care system, requiring prolonged hospitalizations and additional aftercare, and as a logical consequence, higher costs.
Zierer and colleagues [1] report on a series of 200 consecutive patients who underwent orthotopic cardiac transplantation during a recent 10-year period. Despite the fact that this review was done retrospectively, specific findings were accurate: operative mortality for the entire series was 8% (17 of 200), but 15% (7 of 46) in patients suffering from neurologic complications (p = 0.074). Multivariate analysis emphasized advanced age, preoperative left ventricular assist assist device (LVAD), intraaortic balloon pump (IABP) support requirement, and prolonged cardiopulmonary bypass time as independent predictors of stroke or transient ischemic attack (TIA) for early neurologic complications. Furthermore, preoperative IABP support requirement, and postoperative renal and hepatic failure were identified as independent predictors of early neurologic complications other than stroke or TIA. Astonishingly, 5-year survival was not significantly impaired in those patients with neurologic complications (66.5 vs 78%; p = 0.149) [1].
Referring to widespread experience and published literature, 23% of all patients suffering from neurologic sequelae seem to reveal a rather high percentage, but this certainly reflects the fact that the cardiac transplant patient population has shifted to high-risk patients. We believe that a significant correlation between cardiopulmonary bypass (CPB) pressures (ie, 50 mm Hg or less) and prolonged aortic cross-clamp times were observed with development of postoperative neurologic symptoms. Unstable hemodynamic situations (both preoperatively and postoperatively) may directly cause cerebral hypoperfusion or modify patients’ cerebral autoregulation to lower pressure to adapt to the progressive systemic hypotension [2].
The presence of gaseous or particulate emboli in the CPB circuit may also represent the causes of neurologic problems. Recently a prospective study on patients undergoing cardiac surgery measuring objectively P300 auditory-evoked potentials revealed no difference between those operations whether cardiac chambers were opened or not [3].
Last, but not least, other authors stated that the number of posttransplant infections was also associated with neurologic complications [2].
Hence, according to the significant decrease of cardiac transplantations due to the broad use of long-lasting LVAD systems and cardiac resynchronization therapy (CRT), the term "bridging to transplant" has emerged with a new importance. Some investigators have speculated that there is a strong connection between infection and neurologic thromboembolic events related to devices during mechanical circulatory support. [4] As a matter of fact, seizures are a very poor prognostic indicator and are associated with a 100% mortality in this specific patient group [5].
In contrast, we were hardly able to find any corresponding literature and information about neurologic symptoms and CRT for the present invited commentary.
As congenital cardiac procedures are also of main interest, neurologic complications after orthotopic cardiac transplantation in children and adults tend to be very similar in both incidence and type. However, peripheral neuropathies tend to occur more frequently in adults differing in types of complications in the immediate posttransplant period. [6]
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