Digital Carotid Compression: A Simple Method to Reduce Solid Cerebral Emboli During Cardiac Surgery.

OBJECTIVES: Serious neurologic injury can be attributed to embolization of solid particles into cerebral vessels during cardiac surgery. Previous studies using transcranial Doppler (TCD) identified arterial cannulation and aortic declamping to be associated with cerebral embolization. The purpose of this study was to investigate the impact of transient compression of the carotid arteries during these maneuvers on the embolic load during cardiac surgery with cardiopulmonary bypass. DESIGN: Prospective, randomized, clinical trial/pilot study. SETTING: Single-center study at a university hospital. PARTICIPANTS: Patients with multiple types of procedures were included and they were prospectively, randomly assigned to group I (n = 20, carotid compression during arterial cannulation and aortic declamping) and group II (n = 20, no carotid compression). INTERVENTIONS: Bilateral continuous monitoring of the middle cerebral arteries was performed with a multirange, multifreqency transcranial Doppler (DopplerBoxX, DWL, Singen, Germany), allowing for discrimination between solid and gaseous emboli. For aortic cannulation the carotid arteries were compressed for 5 seconds and for declamping for 3 seconds, and microemboli signals were detected within the following 45 seconds. MEASUREMENTS AND MAIN RESULTS: A reduction of intraoperative solid emboli was detected in group I compared with group II (26±16 v 38±18; p = 0.04). Looking specifically at the maneuver of arterial cannulation, the observed difference was 0.5±0.8 in group I versus 5.7±5.8 in group II (p<0.0001). During aortic declamping, 6.6±6.2 emboli were encountered in group I and 10.8±5.2 in group II (p = 0.02). The incidence of neurologic events was not significantly different between groups (2 patients in group II had pathologic changes on magnetic resonance imaging). CONCLUSIONS: The data of this preliminary trial demonstrated that transient compression of the carotid arteries during arterial cannulation and aortic declamping led to a decreased number of solid cerebral emboli. Further prospective, randomized clinical studies should be undertaken to investigate the influence of transient carotid artery compression during specific surgical procedures.

Prospective randomized evaluation of stentless vs. stented aortic biologic prosthetic valves in the elderly at five years.

OBJECTIVES: Randomized trials comparing stentless to stented bioprostheses for aortic valve replacement in elderly are scarce. The aim of this study was early and mid-term evaluation of these bioprostheses, with regards to clinical outcome and hemodynamic performance. METHODS: Between September 1999 and January 2001, 40 patients with aortic stenosis, over the age of 75 years, were randomly assigned to receive either the stented Perimount (n=20) or the stentless Prima Plus (n=20) bioprosthesis. Clinical outcomes, left ventricular mass regression, effective orifice area, ejection fraction and mean gradients were evaluated at discharge, six months, one year and five years after surgery. RESULTS: At five years, there were 5/20 (25%) deaths in the stentless group and 6/20 (30%) deaths in the stented group (all non-valve-related). There was one case of endocarditis in each group, early postoperatively. Overall, a significant decrease in left ventricular mass was found five years postoperatively. However, there was no significant difference in the rate and completeness of LV-mass regression between the groups (LV mass index 114+/-34.1 vs. 120+/-27.2). Furthermore, hemodynamic performance of the valves (mean gradient of 9.9+/-4.8 mmHg vs. 10.2+/-4.2 mmHg) did not differ significantly between the groups. CONCLUSIONS: At five years, stentless valves were not superior to the stented valves, with regards to hemodynamic performance, regression of left ventricular mass and clinical outcome.