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J Thorac Cardiovasc Surg 2001;121:0125-0136
© 2001 The American Association for Thoracic Surgery

Cardiopulmonary Support and Physiology

Similar neurobehavioral outcome after valve or coronary artery operations despite differing carotid embolic counts

From the Departments of Anesthesiology^a and Cardiothoracic Surgery,^b Wake Forest University School of Medicine, Winston-Salem, NC.

This research was funded in part by NIH-NS 27500-28955 and NS27500-01A2 and by the Departments of Anesthesiology and Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC.

Received for publication Feb 17, 2000. Revisions requested April 11, 2000; revisions received Aug 29, 2000. Accepted for publication Sept 5, 2000. No reprints will be available.

Objectives: The interrelationships among coronary and valvular operations, microemboli, and neurobehavioral outcome are unclear. We hypothesized that adult patients undergoing cardiac valve operations would have more total emboli delivered to the brain than patients undergoing coronary artery bypass grafting and that this would associate with worse neurobehavioral outcomes.
Methods: One hundred ninety-three patients undergoing coronary artery bypass grafting and 73 patients undergoing cardiac valve operations were compared. Patients received neurologic, neuro-ophthalmologic, and 11 standardized neurobehavioral tests preoperatively and 5 to 7 days, 1 month, and 6 months postoperatively. Left common carotid Doppler ultrasonographic embolus detection was performed intraoperatively. Repeated measures and logistic regression analyses of outcome were performed.
Results: Patients undergoing either coronary or valve operations were well matched by age (61 ± 10 and 59 ± 12 years, respectively), but a significantly greater fraction of patients undergoing valve operations were female, diabetic, or had undergone previous cardiac operations. Neurobehavioral scores of patients undergoing either coronary artery bypass grafting or cardiac valve operations did not differ significantly at any time. Total embolus counts differed significantly: the median was 105 during coronary artery bypass grafting and 479 during cardiac valve operations (geometric means of 104 and 412, respectively; P = .0001). Significantly more emboli were detected in the patients undergoing cardiac valve operations after removal of the left ventricular vent and after separation from cardiopulmonary bypass, but comparable numbers of emboli were seen in the 2 groups before cardiopulmonary bypass. In both groups decreased neurobehavioral performance was apparent at 5 to 7 days, with improvement at 1 and 6 months. Increasing numbers of carotid emboli significantly associated with worse performance on the letter cancellation test. There were no significant differences between patients undergoing valve and coronary operations in neurobehavioral outcomes, strokes, transient ischemic attacks, or deaths.
Conclusions: The significantly greater number of emboli in the group of patients undergoing cardiac valve operations is likely the result of the entrainment of intracardiac air. The greater numbers of emboli during cardiac valve operations do not appear associated with a commensurately greater risk of adverse neurologic or neurobehavioral outcome.