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Division of Cardiothoracic Surgery, Emory University School of Medicine, The Emory Clinic, Inc, 1270 Prince Ave, Suite 303, Athens, GA 30606
(Email: cullen.morris{at}emoryhealthcare.org).
The article by Nishiyama and associates [1] addresses an important issue in cardiac surgery, namely, the risk factors for stroke after coronary artery bypass grafting (CABG) [1]. The purposes of the article are to: (1) identify the incidence and risk factors of strokes after CABG, and (2) examine the temporal pattern of strokes according to the surgical procedure, off-pump coronary artery bypass (OPCAB) versus on-pump CABG. To accomplish these tasks, the authors reviewed and performed post hoc analysis on a large registry of patients.
The article is unique in its analysis of early and delayed strokes and their relationships to the type of revascularization: on-pump or off-pump. Cardiac surgeons have known for some time that more than half of all strokes occurring after cardiac surgery develop after the immediate postoperative period. These delayed insults are particularly dreadful for patients, their families, and their caregivers, because they arise after a period of smooth recovery, when everything seems to be going well. Sixty-three percent of strokes in this study occurred in the delayed fashion, and whether the operation was performed on-pump or off-pump made no difference in the incidence of delayed stroke. OPCAB, however, demonstrated a lower incidence of early strokes (0.1% vs 1.1%), and this is noteworthy. OPCAB, in fact, emerged as an independent protector against the occurrence of all strokes because of the marked difference in early stroke presentation between the on-pump and off-pump groups. Epi-aortic ultrasound scanning was not mentioned by the authors, but the surgeon's identification of an atherosclerotic ascending aorta is the single most significant marker for an adverse cerebral outcome after coronary bypass operations [2]. A tenacious approach to managing patients with atherosclerotic ascending aortas identified most accurately by intraoperative, surgeon-controlled epivascular ultrasound of the ascending aorta and arch seems to reduce the risk of postoperative stroke [3, 4]. OPCAB allows for a no-touch technique on the ascending aorta, and avoiding aortic manipulation all together may prevent strokes.
So, the surgeon has tools for decreasing "early" strokes. What does the surgeon do about the delayed onset of neurologic injury? In this study, past history of stroke and atrial fibrillation (AF) were independent risk factors for stroke, and AF was a predictor of delayed stroke. Although the authors did not comment on anticoagulation or AF management, it follows that strategies allowing for (1) aggressive suppression of postoperative AF and (2) judicious anticoagulation of recalcitrant AF are important. In addition, because delayed strokes after CABG have been theorized to occur [5], at least in part, from a pro-thrombotic post-procedural milieu in patients who may be susceptible to brain ischemia (ie, patients with uncorrected carotid stenoses or microvascular cerebral disease), expanding the use of anti-platelet inhibitors (clopidogrel plus aspirin) in the post-CABG patient may be wise.
Strokes after CABG are devastating; prevention will continue to be paramount in our efforts to treat patients with corrective surgery for coronary disease. The authors are to be congratulated for pursuing a solution to this problem with vigor.
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