Approval Sheet Impact of Aortic Manipulation During Coronary Artery Bypass Surgery: The Effect of Aortic Clamping Strategies on Postoperative Stroke 公开
Halkos, Michael (2012)
Published
Abstract
Objectives: The purpose of this study was to determine
the impact of different aortic
clamping strategies during coronary artery bypass graft surgery
(CABG) on incidence of
postoperative stroke.
Methods: In this case-control study, all patients at Emory
hospitals from 2002-2009
(N=140) with postoperative stroke after isolated CABG were matched
4:1 to a
contemporaneous cohort of patients without postoperative stroke
(N=565). Patients were
matched according to the Society of Thoracic Surgeons (STS)
Predicted Risk of
Postoperative Stroke (PROPS) based on 26 variables. On- and
off-pump CABG patients
were matched separately. Operative notes were reviewed to document
operative
technique. Multiple logistic regression analysis with adjusted odds
ratios (OR) was
performed to identify operative variables associated with
postoperative stroke.
Results: Within the on-pump CABG cohort, the single
cross-clamp technique was
associated with a decreased risk of postoperative stroke compared
to the cross clamp and
partial clamp (double clamp) technique (OR=0.385, p=0.044). Within
the off-pump
cohort, no significant difference was found between partial
clamping and no clamping.
In 2002, 47/86 patients (54.6%) did not have epiaortic exam
performed, compared to only
7/66 (10.6%) in 2009. Epiaortic ultrasound grading was performed in
525 patients
(74.4%): 75(14.3%) had grade 3-5 and 450(85.7%) had grade 1-2
aortic disease. In
patients with epiaortic grades 3-5, a clampless technique was used
in 59.5%, 83.3%, and
93.3% of cases, respectively. In patients with epiaortic grades
1-2, clampless techniques
were used in 3.8% and 7.8%, respectively. No grade 5 patients had a
postoperative
stroke. Clamp use in general trended downwards from 97.7% of cases
in 2002 to 72.7%
of cases in 2009.
Conclusions: Aortic clamping during CABG may increase the
risk of postoperative
stroke. Epiaortic ultrasound use has trended upwards from 2002 to
2009, indicating a
greater awareness of potential complications from aortic clamping
and allowing for
changes in operative technique. A single cross-clamp strategy was
associated with a
lower risk of postoperative stroke compared to the double clamp
strategy in on-pump
patients. Using a no clamp technique may reduce the risk of
postoperative stroke in off-
pump patients with grade 3-5 aortic disease by eliminating the need
for aortic clamping
during CABG.
Table of Contents
Table of Contents
Title
page 1
Abstract
pages 2-3
Introduction
pages 4-5
Background
pages 6-8
Methods
pages 9-13
Results
pages 14-15
Discussion
pages 16-23
References
pages 24-28
Tables
pages 29-36
Figures
pages 37-41
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