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a Medisch Spectrum Twente Enschede, Department of Cardiothoracic Surgery, Haaksbergerstraat 55, Enschede, 7500 JA, the Netherlands
b Medisch Spectrum Twente Enschede, Department of Epidemiology, Haaksbergerstraat 55, Enschede, 7500 JA, the Netherlands
c Medisch Spectrum Twente Enschede, Department of Psychiatry, Haaksbergerstraat 55, Enschede, 7500 JA, the Netherlands
d Saxion University of Applied Sciences, Expertise Center Health, Social Care and Technology, Tromplaan 28, Enschede, 7500 KB, the Netherlands
(Email: s.koster{at}ziekenhuis-mst.nl).
We thank the authors Bokeriia and colleagues [1] for their interesting comments on our article [2]. The authors reported that a range of studies in cardiac surgery patients showed that intraoperative micro emboli are an important risk factor for cerebral complications, including a postoperative delirium, according to their own data. The authors showed that postoperative delirium in cardiac surgery is associated with high cerebral microembolic load. We agree that this might be a risk factor of delirium after cardiac surgery, but we have found no evidence from the literature to support it.
In our department of cardiac surgery we do not use a transcranial Doppler system for continuous bilateral monitoring of middle cerebral artery blood flow because of a lack of clinical relevance. Therefore, in our study we examined the relationship between patients undergoing cardiac surgery with and without cardiopulmonary bypass (on-pump and off-pump, respectively). In a total of 90 patients who underwent on-pump surgery and 22 patients who underwent off-pump surgery, it is surprising that the univariate analysis showed a significantly higher incidence of delirium in off-pump patients compared with on-pump patients (25.5% vs 4.5%; p = 0.03). However, when we restricted this analysis to patients only undergoing coronary artery bypass grafting, we found that in the on-pump group, 3 of 21 patients became delirious (14.3%) compared with 1 of 21 in the off-pump group (4.8%), resulting in a relative risk of 3. Of course, this is not statistically significant due to the low numbers involved. In the multivariate analyses in the whole study group, the significant relation between on-pump and off-pump cardiac surgery and delirium disappeared.
The Octopus Study showed that during off-pump procedures there were no signals registered indicating microembolic load. Nevertheless, no difference in neurologic outcomes was observed between on-pump and off-pump procedures [3, 4].
In an earlier study by Bucerius and colleagues [5], it was observed that the increased use of off-pump cardiac surgery might lead to a lower prevalence of delirium. However, although their study was extremely large (16,184 patients), "only" 1,842 patients underwent off-pump surgery, and the diagnosis of delirium was made by physicians that was not based on the DSM-IV criteria or based on the diagnosis of a psychiatrist.
In Medisch Spectrum Twente, the "no touch technique" is also currently used. This is a surgical strategy aiming to avoid aortic manipulation by using either pedicled or composite arterial grafts (left internal mammary artery-Y grafts) combined with off-pump coronary artery bypass grafting. Even in high-risk patients, this technique results in less neurologic events [6–10]. This might also decrease the incidence of delirium. We have analyzed data from 400 patients from our hospital who were operated on with "no-touch" off-pump coronary artery bypass grafting, and we found only 1 patient with a cerebrovascular accident.
However, given the interesting data of Bokeriia and colleagues [1], cerebral micro emboli might be associated with delirium after cardiac surgery and might be a risk factor to add to a risk checklist delirium in cardiac surgery patients when the opportunity to measure these micro emboli exists.
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