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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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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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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The value of the immediate postoperative chest radiograph upon a patient's return to the intensive care unit after a cardiac surgical procedure is uncertain. This study represents a prospective analysis of the immediate postoperative radiograph in 100 consecutive adult patients undergoing cardiac operations. In 11 patients it was found that the routine postoperative radiograph was of value when it was necessary either to clarify or confirm clinical findings or to check the position of an intraaortic balloon catheter. ⋯ Furthermore, in those situations in which an emergency radiograph was obtained, the routine radiograph was not found to be contributory to patient management. We conclude that the policy of obtaining routine, immediate postoperative chest radiographs in the absence of a specific clinical indication provides virtually no additional clinical yield. Residents should therefore request radiographs only to check the position of an intraaortic balloon catheter, and to clarify or confirm a clinical diagnosis.