HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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 Author home page(s): Paul Kurlansky Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kurlansky, P. Search for Related Content PubMed PubMed Citation Articles by Kurlansky, P. Related Collections Cerebral protection Coronary disease Related Article

---

Original Articles: Adult Cardiac

Invited Commentary

Florida Heart Research Institute, 4770 Biscayne Blvd, Suite 500, Miami, FL 33137

(Email: doctorwu18{at}aol.com).

It has been 7 years since Newman and colleagues' [1] article entitled, "Longitudinal Assessment of Neurocognitive Function After Coronary-Artery Bypass Surgery" sent shock waves reverberating from the pages of The New England Journal of Medicine [1] to the front pages of newspapers across the nation. The timing was ripe. Cardiac surgeons had begun a serious re-evaluation of neurologic outcomes and how they could be improved. Both the medical profession and the public were intrigued with the emergence of off-pump bypass surgery. Interventional cardiologists were enthusiastic about the introduction of drug-eluting stents as the panacea for all coronary disease. In addition, society in general had begun a long serious look at how to improve quality and value in medicine.

More sober minds, however, began to evaluate the data only to discover that there was no control data. Consensus began to emerge as to which tests might be most productive to perform. A subsequent serious study revealed that at least one third of patients undergoing coronary surgery had a measurably significant impairment in neurocognitive function prior to surgery [2]. A prospective randomized control (PRC) study failed to demonstrate a neurocognitive benefit for off-pump versus on-pump techniques [3]. Retrospective data began to suggest that patient disease rather than procedure was more important in determining long-term neurocognitive outcome. Also, surgeons began to pay more careful attention to subtleties of technique that would diminish neurologic morbidity.

It is in this milieu that Sweet and colleagues' [4] work makes a serious contribution. In a PRC study that includes coronary patients undergoing percutaneous coronary intervention (PCI), as well as healthy controls, they carefully demonstrate that there is no discernable neurocognitive decline during a 1-year period that can be specifically attributed to surgery. Of note, the similarity in the domains that change after both PCI and surgery clearly suggest a role for underlying disease rather than specific procedure. Of course, many questions remain unanswered. The select and small group of patients entered into this protocol may well have been both too "low risk" and too few to demonstrate significant difference. Perhaps the problem specifically manifests in the "high-risk" patients, which comprise an ever-increasing proportion of patients referred for surgery. Perhaps these are the patients who might best benefit from alternative approaches. Even more vexing is the fact that attempts to correlate these tests with other modalities, such as magnetic resonance imaging, have proven unsuccessful. Therefore, the ultimate clinical meaning of the findings is less secure than we would hope. However, a very important step in our journey has now been made. Hopefully the next 7 years of investigation will prove at least as fruitful as the past 7 years.

	References

Top References

 

1. Newman MF, Kirchner JL, Phillips-Bkute B, et al. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery N Eng J Med 2001;344:395-402.[Abstract/Free Full Text]
2. Lazar RM, Heitjan DF, Kurlansky P, et al. Randomized trial of on- vs. off-pump CABG reveals baseline memory dysfunction Circulation 2001;104:II-815.
3. van Dijk D, Spoor M, Hijman R, et al. Cognitive and cardiac outcomes 5 years after off-pump vs on-pump coronary artery bypass graft surgery JAMA 2007;297:701-708.[Abstract/Free Full Text]
4. Sweet JL, Finnin E, Wolfe PL, et al. Absence of cognitive decline one year after coronary bypass surgery: comparison to nonsurgical and healthy controls Ann Thorac Surg 2008;85:1571-1578.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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 Author home page(s): Paul Kurlansky Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kurlansky, P. Search for Related Content PubMed PubMed Citation Articles by Kurlansky, P. Related Collections Cerebral protection Coronary disease Related Article