The Annals of thoracic surgery
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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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Cardiac surgical patients face the threat of neurologic complications in all phases of their disease and its treatment. The incidence of preoperative transient ischemic attacks and stroke ranges from 5% to 14% and from 2% to 11%, respectively. The risk of preoperative cerebrovascular accidents is higher in patients with valvular disease than in those with coronary artery disease. ⋯ Multidimensional investigatory procedures have shown that cardiopulmonary bypass often causes cerebral dysfunction. Whether the harmful consequences are detected depends on the evaluation criteria and the investigatory methods and timing used. Further methods are needed to prevent or treat preoperative cerebrovascular accidents and particularly to improve cerebral protection during operative procedures.
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Standard anterior approach to the thoracic spine is by a posterolateral thoracotomy. Because of the morbidity associated with this incision, video-assisted thoracic surgery (VATS) has been used as a less invasive approach for many intrathoracic disease processes. We have applied VATS for anterior access to the thoracic spine. ⋯ We conclude that VATS offers a new, less morbid anterior approach to the thoracic spine. Although there is a significant learning period, most procedures requiring an anterior access can be performed safely by this technique. The VATS approach mandates an expanded role for the thoracic surgeon in operative spine disease.
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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.
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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.