Predictors of early postoperative cognitive dysfunction in middle-aged patients undergoing cardiac surgery: retrospective observational study.

PURPOSE: This study aimed to identify the incidence and risk factors of early post-operative cognitive dysfunction (POCD) in middle-aged patients undergoing cardiac surgery. METHODS: Data were examined retrospectively from 71 patients aged 46-64 years who underwent elective cardiac surgery. Magnetic resonance imaging (MRI) and MR angiography were obtained preoperatively to assess prior cerebral infarctions, carotid artery stenosis, and intracranial arterial stenosis. Patients also completed six neuropsychological tests of memory, attention, and executive function before and after surgery. Mild cognitive impairment (MCI) was defined as performance 1.5 standard deviations (SD) below the population means on any neurocognitive battery, whereas POCD was defined as a decrease of 1 SD population means on at least two in the test battery. Patient characteristics were analyzed using univariate analysis, and independent predictors were analyzed using multivariate logistic regression analysis. RESULTS: After surgery, 25 patients (35%) were assessed with POCD. Patients with POCD had significantly higher rates of preoperative MCI and cerebral infarcts on MRI. Multivariate logistic regression analysis identified preoperative MCI and cerebral infarctions detected by MRI as a predictor of POCD. CONCLUSION: More than one-third of middle-aged patients undergoing cardiac surgery developed POCD. Our findings suggested preoperative MCI and infarcts detected by MRI were risk factors for POCD in these middle-aged patients.

Evaluation of the risk factors for neurological and neurocognitive impairment after selective cerebral perfusion in thoracic aortic surgery.

PURPOSE: Neurologic complications are seen often after the surgery of the thoracic aorta that uses selective antegrade cerebral perfusion. The objective of this study was to evaluate the impact of atherosclerotic risk factors on neurologic complications in patients who underwent surgery to the thoracic aorta using SCP. METHODS: Data were collected retrospectively on 94 patients who underwent elective ascending aorta/aortic arch replacement. Concomitant procedures were performed as needed. All patients had magnetic resonance imaging (MRI), angiography (MRA) and carotid ultrasound before surgery. Individual cognitive status was measured using four neuropsychological tests before surgery and 7 days after extubation. We compared perioperative factors for risk factors associated with postoperative stroke and postoperative cognitive decline (POCD). RESULTS: 11 patients had strokes after surgery. Operation and extracorporeal circulation times were significantly longer in patients with stroke than those without stroke. Coronary artery disease and SCP time > 150 min were independently associated with postoperative stroke. Of the 83 patients without postoperative stroke, 20 suffered POCD. POCD patients had a significantly higher rate of heterogeneous carotid plaque, and operation time was significant longer in patients with POCD than those without POCD. Independent predictors of POCD were concomitant CABG, heterogeneous carotid plaque, history of cerebrovascular disease and operation time > 450 min. CONCLUSIONS: We found that prolonged SCP time and coronary artery disease increased the risk of postoperative stroke. Heterogeneous carotid plaque, history of cerebrovascular disease, concomitant CABG and prolonged operation time were further significant predictors of POCD.

Guidelines for the use of cerebral oximetry by near-infrared spectroscopy in cardiovascular anesthesia: a report by the cerebrospinal Division of the Academic Committee of the Japanese Society of Cardiovascular Anesthesiologists (JSCVA).

Cerebral Oximetry by Near-infrared Spectroscopy (NIRS) has been used in cardiovascular anesthesia, but there was no guideline of regional cerebral oxygen saturation measured by cerebral oximetry by NIRS. This guideline provides recommendations applicable to patients at a risk of developing cerebral ischemia in cardiovascular surgery. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances, and should not replace clinical judgment. The Japanese Society of Cardiovascular Anesthesiologists (JSCVA) Task Force on Guidelines make an effort to ensure that the guideline writing committee contains broad views in using cerebral oximetry. Adherence to recommendations could be enhanced by shared decision making between healthcare providers and patients. This guideline was focused on cerebral oximetry of pediatric and adult cardiovascular disease. We hope this guideline would play an important role in using cerebral oximetry by measured NIRS.

[The First Successful Application of a Mask with a Left Side Slit for Passing the Trunk of an Endoscope In Situ and Enabling Respiratory Support during Sedation for Upper Gastrointestinal Endoscopy].

Sedation in patients during gastrointestinal (GI) endoscopy involves the risk of respiratory depression. Ventilation support with a conventional face mask without removing an endoscope is impossible. We devised a ventilation mask with a slit and membranous valve on the left side wall and the circular upper end enabling to pass the trunk of an endoscope in situ, based on an idea published in the Japanese Journal of Anesthesia "Masui" 2013; 62: 105-8. An 82-year-old woman was scheduled for GI endoscopy for severe abdominal pain. An endoscope was inserted into her GI tract through the mouth after midazolam 1.5 mg i.v. Soon after the examination began, she developed respiratory depression, and her SpO2 gradually decreased to 84%, despite oxygen insufflated around the nose and mouth. The new slit mask was applied without removing the endoscope, and respiratory support was started by bag-valve method. Her SpO2 recovered and remained above 95% thereafter as the endoscopic examination continued. The side slit mask offers important advantages allowing its application in situ after an endoscope being inserted and by enabling positive pressure ventilation without interrupting the endoscopic procedure.

Low pre-existing gray matter volume in the medial temporal lobe and white matter lesions are associated with postoperative cognitive dysfunction after cardiac surgery.

OBJECTIVES: Postoperative cognitive dysfunction (POCD) is recognized as a complication in the elderly after cardiac surgery. Imaging of the brain provides evidence of neurodegeneration in elderly patients; however, abnormalities in brain structure and their relation to POCD are uncertain. This pilot study investigated whether loss of gray matter in the bilateral medial temporal lobe (MTL), seen in preoperative MRI, was associated with POCD. METHODS: Data were collected prospectively on 28 elderly patients scheduled for elective cardiac surgery. MRI of the brains of all patients were assessed for prior cerebral infarctions, and carotid and intracranial arterial stenosis. Patients also completed six neuropsychological tests of memory, attention and executive function before and after surgery. POCD was defined as an individual decrease in more than two tests of at least 1 standard deviation from the group baseline mean for that test. The degree of gray matter loss in the MTL of each patient was calculated using voxel-based morphometry with three-dimensional, T1-weighted MRI. This represented the degree of gray matter change as a Z score. RESULTS: Postoperative cognitive dysfunction was identified in 8 of the 28 patients (29%). Patients with POCD had significantly more white matter lesions on MRI, and greater loss of gray matter in the bilateral MTL (average Z score 2.0±0.9) than patients without POCD. An analysis by stepwise logistic regression identified gray matter loss in the MTL and cerebral infarctions on MRI as independent predictors of POCD. CONCLUSIONS: These preliminary findings suggested that reduced gray matter in the bilateral MTL and white matter lesions existed in brains of elderly cardiac surgery patients who experienced POCD. Additional studies with larger sample sizes are needed to confirm these findings.

Cerebral dysfunction after coronary artery bypass surgery.

Cerebral dysfunction after cardiac surgery remains a devastating complication and is growing in importance with our aging populations. Neurological complications following cardiac surgery can be classified broadly as stroke, encephalopathy (including delirium), or postoperative cognitive dysfunction (POCD). These etiologies are caused primary by cerebral emboli, hypoperfusion, or inflammation that has largely been attributed to the use of cardiopulmonary bypass. Preventative operative strategies, such as off-pump coronary artery bypass grafting (CABG), can potentially reduce the incidence of postoperative neurological complications by avoiding manipulation of the ascending aorta. Although off-pump CABG is associated with reduced risk of stroke, there are no convincing differences in POCD between off-pump and on-pump CABG. Recently, the focus of postoperative neurological research has shifted from managing cardiopulmonary bypass to patient-related factors. Identifying changes in brains of aged individuals undergoing cardiac surgery may improve strategies for preventing cerebral dysfunction. Advanced age is associated with more undiagnosed cerebrovascular disease and is a major risk factor for stroke and POCD following cardiac surgery. Preoperative cerebrovascular evaluation and adaptation of surgical strategies will provide preventative approaches for cerebral dysfunction after CABG. This review focuses on recent findings of the relationship between perioperative stress and underlying fragility of the brain in cardiac surgical patients.

[Postoperative cognitive dysfunction in off-pump versus on-pump coronary artery bypass surgery].

Patients referred for coronary artery bypass grafting (CABG) are older and more likely to have extensive vascular diseases than those referred for such procedures in the past. Undiagnosed cerebral small vessel diseases (SVD), such as lacunar infarctions or white matter lesions, and dementia are common. Postoperative cognitive dysfunction (POCD) remains a major concern in these elderly patients. POCD is caused by cerebral emboli, hypoperfusion, and inflammation attributed largely to the use of cardiopulmonary bypass. Off-pump CABG is a surgical strategy proposed to decrease the risk of POCD. Although some researchers have found that off-pump CABG is associated with improved cognitive outcome in the early postoperative period, many studies have shown no difference at any time points. Consequently, efforts to reduce the incidence of POCD are focusing on patient-related rather than procedure-related factors. Surgical procedures could exacerbate neuroinflammation and accelerate cognitive dysfunction, especially in patients with SVD and dementia. Mild cognitive impairment may serve as a surrogate marker for underlying SVD or dementia. Preoperative cerebrovascular evaluation, such as MRI, MRA, or cervical ultrasound, and cognitive screening may be effective to identify high-risk patients, making it possible to individualize surgical approaches aimed at reducing POCD.

Pre-existing cerebral infarcts as a risk factor for delirium after coronary artery bypass graft surgery.

OBJECTIVES: Delirium is a common and critical clinical syndrome in older patients. We examined whether abnormalities in the brain that could be assessed by magnetic resonance imaging predisposed patients to develop delirium after coronary artery bypass graft surgery. We also analysed the association between delirium and cognitive dysfunction after coronary artery bypass graft surgery. METHODS: Data were collected prospectively on 153 patients aged 60 years or older who consecutively underwent elective isolated coronary artery bypass graft surgery. All patients were assessed for prior cerebral infarctions and craniocervical artery stenosis by magnetic resonance imaging (MRI) and angiography of their brains. Atherosclerosis of the ascending aorta was examined by epiaortic ultrasound at the time of surgery. Individual cognitive status was measured using four tests in all the patients before surgery and on the seventh postoperative day. A single psychiatrist diagnosed delirium using the Diagnostic and Statistical Manual of Mental Disorders 4th edition IV criteria. RESULTS: Postoperative delirium occurred in 16 patients (10.5%). Compared with patients who did not develop postoperative delirium, delirious patients had significantly higher rates of peripheral artery disease, preoperative decline in global cognitive function and pre-existing multiple cerebral infarctions on MRI. In addition, 9 (56%) of the delirious patients suffered postoperative cognitive dysfunction. Stepwise logistic regression analysis found significant independent predictors of postoperative delirium to be preoperative cerebral infarcts on MRI (odds ratio [OR], 2.26; 95% confidence interval [CI] 1.10-4.78), preoperative decline in global cognitive function (OR 4.54; 95% CI 1.21-16.51) and atherosclerosis of the ascending aorta (OR 2.44; 95% CI 1.03-5.62). CONCLUSIONS: Our findings suggested that postoperative delirium was associated with pre-existing multiple cerebral infarctions on MRI, preoperative decline in global cognitive function and ascending aortic atherosclerosis in elderly patients undergoing coronary artery bypass graft surgery and increased risk of postoperative cognitive dysfunction.

[Transfusion-related acute lung injury caused by anti-leukocyte antibodies found in patient's serum and donor plasma].

We report a case of transfusion-related acute lung injury (TRALI) with anti-leukocyte antibodies detected both in the patient's serum and in the causative fresh frozen plasma. The patient was a 72-year-old Japanese woman who had undergone colectomy and stoma closure under general anesthesia. Intraoperatively she received 8 units of red cell concentrate and 12 units of fresh frozen plasma. At the end of surgery she was fully awake and extubated. Shortly after extubation her oxygen saturation dropped (90%) and she developed dyspnea. A chest X-ray revealed bilateral diffuse pulmonary edema without cardiac enlargement. The patient was re-intubated and placed on respiratory support with positive end-expiratory pressure ventilation. Her pulmonary edema improved and she was extubated again at 20 hours after surgery. Antibodies to human leukocyte antigen were detected in serum from the patient and in serum samples of the freshly frozen donor plasma; a crossmatch test of the patient's lymphocytes and donor serum was positive. We believe that anti-leukocyte antibodies caused TRALI via an immune-mediated mechanism.

Postoperative neurological complications and risk factors for pre-existing silent brain infarction in elderly patients undergoing coronary artery bypass grafting.

PURPOSE: Elderly patients with multiple infarctions revealed a high prevalence of postoperative stroke after coronary artery bypass grafting (CABG). However, postoperative neurological complications and characteristics of silent brain infarction (SBI) have not been evaluated in elderly patients undergoing CABG. METHODS: Four hundred forty-nine patients (≥60 years old) scheduled for CABG underwent cerebral magnetic resonance imaging (MRI) and MR angiography preoperatively to assess cerebral infarctions and carotid and intracranial artery stenosis. Atherosclerosis of the ascending aorta was assessed by epiaortic ultrasound during surgery. Patients were sorted by their history of cerebrovascular disease (CVD) and the presence of infarction by MRI: SBI (infarction without CVD), BI (symptomatic brain infarction; CVD and infarction), and controls (no findings of either CVD or infarction). RESULTS: SBI was found in 35.5% of the 449 patients and increased with age. The prevalence of pre-existing multiple infarctions was less frequent in SBI than in BI. The incidence of postoperative stroke and cognitive dysfunction was 1.3% and 4.9% in controls (n = 225), 5.7% and 15.2% in SBI (n = 158), and 9.1% and 18.2% in BI (n = 66). Patients with SBI were older and had more renal dysfunction and preoperative cognitive impairment. Stepwise logistic regression demonstrated that age, renal dysfunction, preoperative cognitive impairment, atherosclerosis of the ascending aorta, and intracranial arterial stenosis were associated significantly with SBI. CONCLUSION: Patients with SBI were ranked at moderate risk of neurological complications after CABG between control and BI. Increased age, renal dysfunction, and preoperative cognitive impairment appeared to be strongly associated with SBI.

Impaired cognition preceding cardiac surgery is related to cerebral ischemic lesions.

PURPOSE: Cognitive dysfunction is more frequent after cardiac surgery. However, the preoperative cognitive state is seldom assessed when the effects of cardiac surgery on cognition are investigated. Postoperative cognitive dysfunction may be associated with the preoperative cognitive state and the existence of cerebral ischemic lesions in patients who undergo cardiac surgery. METHODS: Data were collected prospectively on 362 consecutive patients scheduled to undergo elective cardiac surgery. The brains of all patients were imaged by magnetic resonance imaging (MRI) to assess prior cerebral infarctions, carotid artery stenosis and intracranial arterial stenosis, and diffusion-weighted imaging (DWI) was used to assess acute cerebral ischemia. Patients were classified with impaired cognitive function prior to surgery if their score on the Hasegawa dementia rating scale was <24. Postoperative cognitive dysfunction from baseline was determined using four neuropsychological tests. RESULTS: Prior to surgery 40 patients (11%) were assessed with impaired cognition. Relative to the other patients, these patients were older and less well educated, and they had significantly higher rates of peripheral vascular disease, white matter lesions, cerebral infarction on MRI, carotid artery stenosis and postoperative cognitive dysfunction. Of these 40 cognitively impaired patients, seven (18%) had cerebral ischemia, based on DWI images before surgery; in comparison, nine of the 322 patients (3%) without preoperative cognitive impairment were found to have abnormalities on the DWI images (P < 0.001). An analysis by stepwise logistic regression demonstrated that the significant risks for preoperative cognitive impairment were advanced age, lower attained level of education, peripheral artery disease, prior cerebral infarctions, and abnormalities on DWI images. CONCLUSIONS: These findings suggest that preoperative cognitive impairment associated with cerebral ischemic lesions and an increased risk of postoperative cognitive dysfunction existed in our patient cohort undergoing cardiac surgery.

[A case of Vibrio vulnificus infection presenting with invagination].

A 73-year-old man with advanced lung cancer ate raw fish the day before being admitted to our hospital with severe abdominal pain, fever and vomiting. Soon afterward he fell into shock and disseminated intravenous coagulation. A CT scan revealed invagination and emergency surgery was performed. On the first day after surgery, Vibrio vulnificus was cultured from his ascites and blood. The infection was controlled by antibiotic treatment and he was discharged 23 days after the surgery. Vibrio vulnificus infection is an opportunistic infection that develops mostly in patients with liver cirrhosis within two days after eating raw seafood or having the injured skin exposed to sea water in the summer. Mortality is 70%, and more than half of these patients die within 72 hours of onset. Early diagnosis and treatment are very important. In addition, the public should be educated to protect immuno-compromised individuals from this infection.

Abnormalities in the brain before elective cardiac surgery detected by diffusion-weighted magnetic resonance imaging.

BACKGROUND: Diffusion-weighted magnetic resonance imaging (DWI) has found ischemic lesions in the brain after cardiac surgery. However, preoperative cerebral injury has not been studied closely. In this study, we used DWI to assess the prevalence of abnormalities in patients scheduled for cardiac surgery. METHODS: We used conventional magnetic resonance imaging and DWI to study 247 consecutive patients scheduled for elective cardiac surgery. Clinical characteristics, neuropsychological test performance, and radiographic data were collected and compared with a group of patients who had normal findings on DWI. RESULTS: Eleven of the 247 patients (4.5%) had cerebral ischemic lesions on DWI before surgery. Compared with patients who had normal findings on DWI, patients who had abnormalities had significantly higher rates of history of cerebrovascular disease (64% versus 12%), cardiac catheterization within 14 days before DWI (91% versus 54%), preoperative cerebral infarctions (45% versus 5%), carotid artery stenosis (36% versus 5%), and preoperative cognitive impairment (55% versus 9%). Of the 11 patients with DWI abnormalities, 5 had delayed elective surgery and follow-up image studies; of these 5, 4 showed no relevant ischemic lesion on preoperative follow-up imaging. Among the other 6 patients, 1 had an infarction due to expansion of the same lesion that was detected on the preoperative DWI. There was no significant difference with regard to the incidence of postoperative stroke and cognitive dysfunction. CONCLUSIONS: In all, 4.5% of cardiac surgery patients had existing cerebral ischemic lesions on DWI without obvious neurologic defects. Further studies are required to determine whether the lesions are associated with postoperative cognitive dysfunction or stroke.

Early neuropsychological dysfunction in elderly high-risk patients after on-pump and off-pump coronary bypass surgery.

PURPOSE: Advanced age is associated with systemic atherosclerosis and is a risk factor for neurological dysfunction after coronary artery bypass grafting (CABG). However, few studies have investigated early neurological dysfunction after off-pump CABG in elderly patients. METHODS: Data were collected prospectively on 218 patients (>/=60 years) who underwent elective off-pump (n = 89) or on-pump CABG (n = 129). Four cognitive tests were performed preoperatively and 1 week postoperatively. Neuropsychological (NP) dysfunction was defined as a decrease in an individual's performance in more than two tests of at least 20% from baseline. We compared the incidence of NP dysfunction, stroke, graft patency grading, and systemic atherosclerosis between patients who underwent off-pump and on-pump CABG. RESULTS: Off-pump patients were more likely to have a history of cerebrovascular disease, peripheral vascular disease, smoking, multiple cerebral infarctions, and severe aortic atherosclerosis. None of the off-pump and three on-pump patients suffered intraoperative strokes (P = 0.27). The incidence of NP dysfunction was 11.2% in the off-pump group and 22.5% in the on-pump group, (P = 0.02). Multivariate analysis revealed that NP dysfunction was associated with cardiopulmonary bypass (CPB) and multiple cerebral infarctions. The off-pump group had fewer vessels grafted (2.4 vs 3.4; P < 0.01), and a higher rate of stenosis (>50%) and occlusion of the grafted vessels (13.0% vs 7.4%; P = 0.01) than the on-pump group. CONCLUSION: Off-pump CABG reduced postoperative NP dysfunction in elderly patients with severe systemic atherosclerosis compared to on-pump CABG.

Gender differences in stroke risk among the elderly after coronary artery surgery.

BACKGROUND: Previous studies have shown that women are at higher risk than men for stroke after coronary artery bypass graft (CABG) surgery, but gender differences in systemic atherosclerosis have not been studied adequately. We investigated gender differences in the incidence of craniocervical and ascending aortic atherosclerosis and other risk factors for stroke in elderly patients (age > or =60 yr) undergoing CABG surgery. METHODS: Data were prospectively collected on 720 patients (31.8% women) undergoing CABG surgery. All patients underwent preoperative brain magnetic resonance imaging and angiography to assess for prior cerebral infarctions, carotid artery stenosis, and intracranial arterial stenosis. Epiaortic ultrasound was performed at the time of surgery to assess for atherosclerosis of the ascending aorta. Cognitive status was measured using the Hasegawa-dementia score in all patients before surgery and on the seventh postoperative day. RESULTS: Women were older and had more hypertension and intracranial arterial stenosis than did men. Men had significantly higher rates of hyperlipidemia, peripheral vascular disease, abdominal aortic aneurysm, smoking history, severe carotid artery stenosis, and severe aortic atherosclerosis than did women. Although there were no differences in prior cerebral infarction or preoperative cognitive impairment, the rate of perioperative stroke was marginally higher in men than in women (3.9% vs 1.3%, P = 0.066). Univariate predictors of perioperative stroke were prior cerebral infarctions, ascending aortic atherosclerosis, preexisting cognitive impairment, and peripheral vascular disease. Stepwise logistic regression analysis demonstrated that significant independent predictors of perioperative stroke were prior cerebral infarctions and aortic atherosclerosis. CONCLUSIONS: These data suggest that men are more likely than women to have risk factors for stroke, including severe carotid artery stenosis, severe aortic atherosclerosis, and peripheral vascular disease. The rates of prior cerebral infarction and preoperative cognitive impairment were similar between genders.

[Perioperative mangement of surgery for abdominal aortic aneurysm associated with coronary artery disease].

BACKGROUND: Patients undergoing abdominal aortic aneurysm (AAA) surgery are at increased risk of perioperative cardiovascular complications due to underlying coronary artery disease (CAD). We determined retrospectively the incidence of CAD and the influence of coronary revascularization and perioperative cardiovascular complications in patients for AAA surgery. METHODS: Routine coronary angiography (CAG) was performed in 159 patients prior to elective AAA surgery to estimate the presence of CAD. To compare risk factors and perioperative cardiovascular complications the patients were divided at the time of CAG into three groups: previously diagnosed CAD, newly diagnosed CAD and non-CAD. RESULTS: Preoperative CAG found 129 patients (81%) with CAD. Among newly diagnosed patients 82% were asymptomatic of CAD. Forty-four patients (28%) underwent coronary revascularization (17 percutaneous coronary intervention, 3 preoperative coronary artery bypass grafting, and 24 combined coronary artery bypass grafting). Perioperative cardiac complications occurred in 35 patients (22%). No significant difference was found among the three groups in the incidence of perioperative cardiovascular complications. Two patients with severe CAD not treated with coronary revascularization died of cardiac events. CONCLUSIONS: Perioperative management and coronary revascularization should be carried out with more cautions in AAA patients to reduce the incidence of cardiovascular complications after AAA surgery.