The Annals of thoracic surgery
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Macroscopic and microscopic emboli of gas, biologic aggregates, and inorganic debris can occur during cardiac operations with cardiopulmonary bypass and may result in end-organ ischemia. In the current era pump-generated embolism is a diminishing cause of perioperative neurologic injury, which now appears to be related mostly to atheroembolism from manipulation of the atherosclerotic ascending aorta, and presents a continuing technical challenge to the surgeon.
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Neuropsychologic assessment in the context of cardiac surgery is constrained by the clinical time available to see patients, and as such test selection needs to be carefully planned. Besides the time limitations, it differs from clinical neuropsychologic assessment primarily because it tends to involve at least two assessments, a comparison with performance before operation, and a limited number of tests. ⋯ Intervention studies involve at least two groups where one factor (eg, surgical equipment) is varied systematically. The research on neuropsychologic deficits after cardiac operations has progressed from incidence studies, which involve a conventional definition of deficit, to intervention studies, in which specific test performance can be compared.
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There have been major advancements in cardiac surgery over the past two decades and a concomitant decrease in mortality and major morbidity. The improved safety in cardiac procedures permitted 330,000 operations involving cardiopulmonary bypass in 1992. However, several recent studies have demonstrated that cardiac surgery poses substantial risk of negative neurologic and neuropsychologic outcomes. ⋯ To characterize the incidence and severity of such deficits after cardiac operations, a concise battery of neuropsychologic tests that provides reliable evidence of subtle brain trauma is essential. With an objective, valid measure of brain injury, the etiology of neuropsychologic deficits can be identified and either eliminated or the effects ameliorated. The proper selection and use of neurobehavioral tools provides a basis to evaluate the efficacy of surgical and pharmacologic interventions to further improve neurologic outcome after cardiopulmonary bypass.
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Cerebral complications represent the leading cause of morbidity after cardiac operations. With the growing awareness of their social and economic importance, increasing attention is being given to their prevention. In the coronary artery bypass population, advanced age (> or = 75 years) is associated with an 8.9% neurologic deficit rate. ⋯ Open cardiac surgical procedures, particularly in the aged population, carry a significant increased risk of adverse neurologic outcome. Postoperative arrhythmias may result in embolic neurologic deficit. A further understanding of risk factors for cerebral injury will be of value in developing therapeutic approaches to this major clinical problem.