• Michael E Halkos, Aaron Anderson, Jose Nilo G Binongo, Anthony Stringer, Yi Lasanajak, Vinod H Thourani, Omar M Lattouf, Robert A Guyton, Kim T Baio, Eric Sarin, William B Keeling, N Renee Cook, Katherine Carssow, Alexis Neill, Kathryn E Glas, and John D Puskas.
• Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga. Electronic address: mhalkos@emory.edu.
• J. Thorac. Cardiovasc. Surg. 2017 Oct 1; 154 (4): 1278-1285.e1.

ObjectiveTo determine the impact of different aortic clamping strategies on the incidence of cerebral embolic events during coronary artery bypass grafting (CABG).MethodsBetween 2012 and 2015, 142 patients with low-grade aortic disease (epiaortic ultrasound grade I/II) undergoing primary isolated CABG were studied. Those undergoing off-pump CABG were randomized to a partial clamp (n = 36) or clampless facilitating device (CFD; n = 36) strategy. Those undergoing on-pump CABG were randomized to a single-clamp (n = 34) or double-clamp (n = 36) strategy. Transcranial Doppler ultrasonography (TCD) was performed to identify high-intensity transient signals (HITS) in the middle cerebral arteries during periods of aortic manipulation. Neurocognitive testing was performed at baseline and 30-days postoperatively. The primary endpoint was total number of HITS detected by TCD. Groups were compared using the Mann-Whitney U test.ResultsIn the off-pump group, the median number of total HITS were higher in the CFD subgroup (30.0; interquartile range [IQR], 22-43) compared with the partial clamp subgroup (7.0; IQR, 0-16; P < .0001). In the CFD subgroup, the median number of total HITS was significantly lower for patients with 1 CFD compared with patients with >1 CFD (12.5 [IQR, 4-19] vs 36.0 [IQR, 25-47]; P = .001). In the on-pump group, the median number of total HITS was 10.0 (IQR, 3-17) in the single-clamp group, compared with 16.0 (IQR, 4-49) in the double-clamp group (P = .10). There were no differences in neurocognitive outcomes across the groups.ConclusionsFor patients with low-grade aortic disease, the use of CFDs was associated with an increased rate of cerebral embolic events compared with partial clamping during off-pump CABG. A single-clamp strategy during on-pump CABG did not significantly reduce embolic events compared with a double-clamp strategy.Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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