Ann Thorac Surg 2001;72:1201-1202
© 2001 The Society of Thoracic Surgeons
Invited commentary
Timothy J. Gardner, MDa
a Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
e-mail: gardnert{at}uphs.upenn.edu
It is sobering to acknowledge that stroke continues to complicate contemporary cardiac surgery in over 3.5% of patients, as documented in this excellent review of nearly 6,000 consecutive patients having their heart surgery from 1992 through 1997. Over the last 25 years, cardiothoracic surgeons have mastered many challenges in achieving safer and more effective procedures. We have learned much about predictors of neurological injury during and after surgery. We have improved and modified management techniques, especially during patient exposure to cardiopulmonary bypass. Stroke rates remain high, however, perhaps because of the increasing disease burden in the ever older and sicker patients encountered today.
The present study, carried out by this experienced and focused team and making use of the Johns Hopkins Cardiac Surgery Stroke Database, both confirms and refines what is known about this devastating complication. Mortality is five times higher for patients who suffer stroke after cardiac surgery. For those surviving the stroke, hospital length of stay is two and a half times longer and hospital charges are twice as high. Having analyzed brain-imaging studies in virtually all of their stroke patients, these investigators determined that most patients experienced embolic strokes, but those whose injury pattern appeared to be diffuse and "watershed" in distribution had significantly poorer short- and long-term survival. Furthermore, the 5-year actuarial survival rate of less than 50% for postoperative stroke patients, as well as the major persistent disability for many of these survivors, emphasize the horrendous long-term consequences of stroke after heart surgery.
The stroke rate was higher in patients having coronary bypass surgery, alone or in combination with valvular surgery, than for those having valve surgery alone. This finding suggests that the presence of atherosclerosis, encountered in those with coronary artery disease, predisposes to stroke and poses a more significant risk than air embolism in truly open-heart operations. If atheroembolism, indeed, is the predominant explanation for most strokes, the prospect of reduced aortic manipulation associated with off-pump coronary grafting must be carefully considered for isolated coronary bypass procedures. Other neuroprotective strategies, in particular, pharmacological agents that could be administered immediately before surgery in higher risk patients, must be pursued and examined. With so many emerging options to conventional coronary bypass grafting, preservation of neurological and neurocognitive function must continue to be a principal goal of cardiac surgical investigators.
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Stroke after cardiac surgery: short- and long-term outcomes
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Ann. Thorac. Surg. 2001 72: 1195-1201.
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