Impact of aortic manipulation on incidence of cerebrovascular accidents after surgical myocardial revascularization.
BACKGROUND
The impact of aortic manipulation on incidence of cerebrovascular accidents (CVAs) was evaluated in patients who underwent myocardial revascularization.


METHODS
From January 1988 to December 2000, 4,875 patients had coronary operations; 33 who survived less than 24 hours and 19 who had aortic cannulation without cross-clamping were excluded. According to the degree of aortic manipulation, patients were divided into two groups: group A, aortic cannulation, cross-clamping, with (A1, n = 597) or without (A2, n = 2,233) side-clamping, and group B, with (B1, n = 460) or without (B2, n = 1,533) side-clamping. Patients in group A (n = 2,830) were operated on with and patients in group B (n = 1,993) were operated on without cardiopulmonary bypass (CPB). Univariate and multivariate analyses were applied to identify independent predictors of higher incidence of CVAs.


RESULTS
Forty-nine patients (1.0%) had a postoperative CVA, 24 early and 25 delayed, with a 30-day mortality of 34.7%. Independent CVA predictors were low output syndrome, presence of extracoronary vasculopathy, conversion from off to on pump, and any aortic manipulation. This latter risk factor was significant in patients with extracoronary vasculopathy, but not in patients without. Side-clamping was not a risk factor in patients operated on with CPB, but it was in no-CPB cases. Patients in group B1 had the same CVA incidence as patients in group A2. Therefore CPB, per se, was not a risk factor for higher CVA incidence.


CONCLUSIONS
Aortic manipulation must be avoided in patients with extracoronary vasculopathy. Maintenance of a good hemodynamic status is crucial for any patient to reduce CVA incidence. Patients with extracoronary vasculopathy are at higher risk, and a correct surgical strategy should be tailored for each case. In no-CPB cases use of side-clamping provides the same CVA risk as in patients in whom CPB, aortic cannulation, and cross-clamping were used.
Calafiore
Antonio M
AM
Department of Cardiology and Cardiac Surgery, G. D'Annunzio University, Chieti, Italy. calafiore@unich.it
Di Mauro
Michele
M
Teodori
Giovanni
G
Di Giammarco
Gabriele
G
Cirmeni
Sergio
S
Contini
Marco
M
Iacò
Angela L
AL
Pano
Marco
M
D000368:Aged; D001013:Aorta, Thoracic / Q000601:surgery*; D002315:Cardiopulmonary Bypass / Q000009:adverse effects; D002404:Catheterization / Q000009:adverse effects*; D001026:Coronary Artery Bypass / Q000379:methods*; D005260:Female; D006801:Humans; D020766:Intracranial Embolism / Q000209:etiology* / Q000401:mortality / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology* / Q000401:mortality / Q000517:prevention & control; D012307:Risk Factors; D013525:Surgical Instruments / Q000009:adverse effects*; D015996:Survival Rate