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J Thorac Cardiovasc Surg 2004;127:1759-1765
© 2004 The American Association for Thoracic Surgery
Cardiopulmonary support and physiology |
a Department of Cardiothoracic Surgery, Oxford, United Kingdom
b Department for Functional Magnetic Resonance Imaging of the Brain, John Radcliffe Hospital, Oxford, United Kingdom
Received for publication June 3, 2003; revisions received August 28, 2003; accepted for publication September 16, 2003.
* Address for reprints: David P. Taggart, MD, PhD, FRCS, Consultant Cardiothoracic Surgeon, Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
david.taggart{at}orh.nhs.uk
BACKGROUND: Neurocognitive dysfunction remains a limitation of cardiac surgery with cardiopulmonary bypass. Intraoperative cerebral microembolization is believed to be one of the most important etiologic factors. Using a new generation of transcranial Doppler ultrasonography, we compared the number and nature of intraoperative microemboli in patients undergoing on-pump and off-pump cardiac surgery procedures.
METHODS: Bilateral continuous transcranial Doppler monitoring of the middle cerebral arteries was performed in 45 patients (15 off-pump coronary artery bypass grafting, 15 on-pump coronary artery bypass grafting, and 15 open cardiac procedures). All recordings were performed using a multi-range, multifrequency system to allow both measurement of the number and discrimination of the nature of microemboli in the 3 different groups.
RESULTS: The median number (interquartile range) of microemboli in the off-pump coronary artery bypass grafting, on-pump coronary artery bypass grafting, and open procedure groups were 40 (28-80), 275 (199-472), and 860 (393-1321), respectively (P < .01). Twelve percent of microemboli in the off-pump coronary artery bypass grafting group were solid compared with 28% and 22% in the on-pump coronary artery bypass grafting and open procedure groups, respectively (P < .05). In the on-pump groups, 24% of microemboli occurred during cardiopulmonary bypass, and 56% occurred during aortic manipulation (cannulation, decannulation, application, and removal of crossclamp or sideclamp).
CONCLUSIONS: Cerebral microembolization is significantly reduced with avoidance of cardiopulmonary bypass. The majority of microemboli occurring during cardiac surgery are gaseous, with a higher proportion of solid microemboli in the on-pump group, and may have a different significance for cerebral injury than solid microemboli. The ability to reliably discriminate gas and solid microemboli may have an important role in the implementation of neuroprotective strategies.
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