Ann Thorac Surg 2007;83:2092
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Thomas V. Bilfinger, MD, ScD
Department of Surgery, SUNY at Stony Brook, HSC T19 Rm 80, Stony Brook, NY 11794
(Email: tbilfinger{at}notes.cc.sunysb.edu).
The risk of stroke with cardiac surgery has been well documented particularly in the perioperative period. With the advent of transesophageal echocardiography and epiaortic imaging, a long-term association between the degree of aortic atheromatous disease and the subsequent risk of stroke has become clear; although there is still controversy regarding the quality of either modality to assess the ascending aorta and proximal arch adequately. Two dimensional epiaortic imaging of the ascending aorta seems to be superior. Less controversy exists about the superiority of these modalities in assessing the distal arch and descending aorta. There are numerous grading systems used to measure the severity of atheroma. All recognize the increasing risk associated with plaque thickness and plaque mobility. In this issue, van der Linden and colleagues [1] add to our knowledge by carefully quantifying the anatomic location and extent of atheroma and correlating that data to the long-term stroke risk in a group of coronary artery bypass grafting patients using cardiopulmonary bypass [1]. With significant atheroma (> 50% circumference) centered in the proximal lesser curve of the aorta, a third of patients experienced a stroke within 5 years. Incidence data from general population-based studies suggest lower stroke risks for similar atheromatous involvement, although with less careful anatomic delineation, implying that the need for coronary artery bypass grafting may be a long-term risk factor. So far the modification of surgical practice consists of replacement, endarterectomy, or avoidance of the aorta by off-pump coronary artery bypass or modifications, with modest results in the former two, and lack of good randomized data in the latter. The challenge remains for surgeons to find an effective surgical treatment plan for these patients and a postoperative management strategy that improves quality and duration of life.
 |
References
|
|---|
- van der Linden J, Bergman P, Hadjinikolaou L. The topography of aortic atherosclerosis enhances its precision as a predictor of stroke Ann Thorac Surg 2007;83:2087-2092.[Abstract/Free Full Text]
Top
References