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Ann Thorac Surg 2005;79:79-80
© 2005 The Society of Thoracic Surgeons

INVITED COMMENTARY

Department of Neurology, The Johns Hopkins Hospital, 600 North Wolfe St, Meyer 100, Baltimore, MD21287

Andréll and colleagues document an important relationship between preoperative magnetic resonance imaging abnormalities and risk of adverse neurologic outcomes in high-risk patients randomized to either conventional coronary artery bypass surgery (CABG) or spinal cord stimulation. A principal finding from their study is that patients who undergo CABG are more likely than the spinal cord stimulation patients to have adverse neurologic outcomes, regardless of whether or not they have magnetic resonance imaging evidence of preoperative white matter disease (WMD).

The prevalence of preoperative magnetic resonance imaging abnormalities was high in both of the study groups; in fact, substantially higher than in the only previous large scale study by Goto and colleagues [1] who found that approximately 50% of their candidates for CABG had WMD.

Within the group of CABG patients, a similar proportion of postoperative neurocognitive impairment was observed in both groups (with and without WMD). Using a modified scale for quantifying the degree of WMD that places less emphasis on periventricular lesions, 8 of 29 patients (28%) with WMD and 6 of 16 (38%) without had neurocognitive impairment develop. None of the patients in the spinal cord stimulation group had new onset cognitive impairment develop.

The authors raise the crucial question: is the development of neurocognitive impairment related to the use of CABG by itself, or is it more directly associated with the presence of WMD? Although this is obviously a very important question, it is not clear that the data from the present study can provide an answer.

Predictors of neurocognitive impairment other than WMD are not explored in this study. For example, were the CABG patients who had neurocognitive impairment develop in the absence of WMD older than the ones who did not have such impairment develop, or were they more likely to have carotid stenosis? Not surprisingly in this group of high-risk patients, nearly one third of both groups were rated as having preoperative neurocognitive impairment. Unfortunately, no information is provided regarding the relationship between preoperative and postoperative neurocognitive impairment.

A take home message from this study is that although preoperative WMD is predictive of postoperative neurocognitive complications, the lack of preoperative WMD does not necessarily imply a postoperative course free of cognitive complications in very high-risk patients.

References

1. Goto T, Baba T, Honma K. Magnetic resonance imaging findings and postoperative neurologic dysfunction in elderly patients undergoing coronary artery bypass grafting Ann Thorac Surg 2001;72:137-142.[Abstract/Free Full Text]

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