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J Thorac Cardiovasc Surg 2006;131:114-121
© 2006 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Single crossclamp improves 6-month cognitive outcome in high-risk coronary bypass patients: The effect of reduced aortic manipulation

^a Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
^b Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC
^c Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, NC

Received for publication April 7, 2005; revisions received August 16, 2005; accepted for publication August 30, 2005.

^_* Address for reprints: John W. Hammon, MD, Department of Cardiothoracic Surgery, Wake Forest University Health Sciences, Medical Center Blvd, Winston-Salem, NC 27157 (Email: jhammon{at}wfubmc.edu).

OBJECTIVE: We hypothesized that a strategy that reduced aortic manipulation would reduce the incidence of cognitive deficits in patients undergoing coronary artery bypass grafting compared with the "traditional" approach and that neurobehavioral outcomes with the reduced aortic manipulation strategy would approach those obtained with off-pump coronary artery bypass surgery.

METHODS: Consenting high-risk patients (those with older age, diabetes, or hypertension) scheduled for coronary artery bypass grafting and cardiopulmonary bypass were randomly assigned to 1 of 2 aortic management protocols: (1) a traditional approach in which distal anastomoses were accomplished while the aorta was crossclamped but in which proximal anastomoses were sewn while a partial occlusion clamp was applied to the aorta (multiple aortic clamping group) or (2) a reduced aortic manipulation approach in which the aorta was clamped a single time with a reduced-pressure clamp (single aortic clamping group) and the partial occlusion clamp was not used. A contemporaneous group of patients undergoing off-pump coronary artery bypass surgery without cardiopulmonary bypass was also enrolled. Subjects in all 3 groups underwent neurologic and neuropsychological testing before and after surgery. After randomization, patients assigned to either approach could be changed to another strategy if the attending surgeon determined that patient safety demanded this change. The study design anticipated that surgical techniques would evolve over the course of patient enrollment and anticipated that some patients would have intraoperative echocardiographic findings that would demand that the traditional approach (eg, severe aortic atherosclerosis) or the reduced manipulation protocol (eg, severe ischemia or poor left ventricular function) be abandoned. Thus, an unequal distribution of patients was expected. By surgeon decision, 20 of 84 multiple aortic clamping patients crossed over to single aortic clamping, and 3 of 85 single aortic clamping patients switched to multiple aortic clamping. Eligible patients had a battery of neuropsychological tests before surgery and at 6 months after surgery. A 20% decrement in 2 or more tests was defined as a neuropsychological deficit.

RESULTS:

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