Re: Brain damage from coronary surgery

Posted By Jay on March 11, 1998 at 22:25:21:

In Reply to: Re: Brain damage from coronary surgery posted by Jerry Jackson on March 07, 1998 at 16:45:12:







: : : : The Harvard Heart Letter of October 1997 had some dismal statistics covering
the incidence of brain damage triggered by CABG.  The numbers were 3.1% type I
complications and an other 3% type II outcomes.  Institutional statistcs varied from  
1 to 14%.  Wow!

: : Since I am anticipating an aortic valve replacement, this is a major major
concern.  Maybe major a few more times.

: : I assume that there is nothing that I can do medically to reduce the risk?

: : So that leaves me only the options of selecting a surgeon and an institution with good
statistics.  How do I go about it?   What questions should I be asking?  

: : I assume that there are no published stats.  Even the study I mentioned did not
reveal the names of the institutions.

: : Thanks












_
Dear Jay
Your concerns are very appropriate. Central nervous system complications been divided into three different clinical syndromes: stroke, neuropsychological impairment, and encephalopathy.  As you stated in your question the incidence of focal deficits, that qualify as strokes after coronary bypass surgery ranges from 4.7% to 5.2% in various prospective series. Unfortunately the risk is higher in patients who are having valve surgery combined with other intracardiac procedures including coronary artery bypass grafting, with rates ranging from 4.2% to 13% in a number of series that looked into this. The single most important risk factor for stokes is aortic atheromatosis. Atheroma or plaque in the aorta increase significantly with age with autopsy series showing present in 20% patients in their 40s up to 80% of patients in their 80s. Clots may also arise in the heart, the carotids ( blood vessels supplying blood to the brain ), and also from debris at the surgical site. Although these numbers look grim our understanding of the mechanism of strokes has improved significantly and as a consequence there are certain techniques that can be employed to reduce this risk. When a patient has a history of prior strokes or transient ischemic attacks the work up prior to cardiac surgery becomes more vigorous. Also with known presence of atheroma in the aorta or other peripheral arteries a work up of the aorta by TEE can delineate the extent of the disease and can serve as a road map for the surgeon at the time of surgery to minimize the risk of dislodging this debris when the aorta is cross clamped at the time of bypass.
It is important that when considering the option of cardiac surgery, that you opt for an institution performs a high number of procedures. This ensures that the whole team including the perfusionist are very experienced. This limits the risk of bypass machine complications and ensures that the staff is very experienced in troubleshooting any problems. You may also need to ask what kind of intraoperative monitoring of brain perfusion is employed in the operating room.
Although this may sound overwhelming, my suggestion is that you call the institutions where you are considering to have your surgery done and ask the scheduler or who ever is responsible for their procedure rate another complication rate. This will ensure that you can choose the institution with the highest procedure rate and the relatively lower complication rate. Please take into consideration that a higher complication rate may be related to  surgeries performed on a group of patients with a higher risk profile ( redo surgeries,  older age, associated medical conditions ). The higher risk profile may indicate the level of expertise the institution may have.
I hope that this may help you in your decision, if you have any further question or would to be seen by one of our cardiovascular team here at the Cleveland Clinic please feel free to call 1-800-CCF CARE.
Information in this forum is intended for general purposes only. Specific diagnosis and treatment should be reserved for physicians directly involved in patient care.  

CCF
Thanks for the information...it was most educational.  I have also been monitoring a few other cardiac sites and lists.  There was one interesting discussion involving an aortic valve replacement on a patient with a porcelain aorta.  I am guessing that the definition of a porcelain aorta is severe aortic atheromatosis with a significant buildup of brittle calcium plaque.
The surgeon posting the information did an aortic endarterectomy but others suggested composite conduit grafting.  If it's not too much effort, could you explain the options and the risks associated with each options.  What would the Cleveland Clinic SOP for an aortic valve replacement on a patient with a porcelain aorta?  
Jay
Thanks for your post it was very interesting. I have a pig valve (aorta)
It was implnted at Riverside Hospital in 1986. This pig valve is refered to
as a porcelain valve. In other word taken from a pig. I also had a pig valve
implanted at Cleveland Clinic in 1976. It became calsified and fail in 1986.
If I can help in any way e-mail me. ***@****. Also I was able to get some
stats from http:\www.cardiacsurgery.com/html/our_data.htm.
Redding Medical Center has a outstanding record and they publish it in graft
format. Example: In hospital mortality 1991 thru 1995 3.1 % as opposed to
the National average of 5.1% also 5 area hospitals....Jerry