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J Thorac Cardiovasc Surg 2004;127:7-9
© 2004 The American Association for Thoracic Surgery

Editorial

Off-pump surgery and cerebral injury

^a John Radcliffe Hospital, Oxford Heart Centre, Oxford, United Kingdom

Received for publication September 15, 2003; revisions received September 16, 2003; accepted for publication September 18, 2003.

^* Address for reprints: David Taggart, MD, PhD, FRCS, John Radcliffe Hospital, Oxford Heart Centre, 71 Plantation Rd, Oxford OX3 9DU, United Kingdom
david.taggart@orh.nhs.uk

The first 20% of the full text of this article appears below.

Despite improvements in the conduct and clinical outcome of cardiac surgery during the last decade, cerebral injury remains a particularly important limitation for the patient, the physician, and—increasingly—the lay press. Furthermore, as patients of advanced age and those with other risk factors for neurologic complications increasingly constitute the surgical population, the challenge of minimizing cerebral injury will continue to grow. Cerebral injury can be broadly classified, in a decreasing spectrum of severity, as stroke, delirium (encephalopathy), or cognitive dysfunction. Although these patterns of injury constitute distinct clinical entities regarding pathophysiology, incidence, and clinical consequences, they also share certain common pathologic etiologies.¹

To date, most studies of cerebral injury have concentrated on stroke and cognitive dysfunction, while the incidence and consequences of delirium have been less well defined. Stroke is relatively uncommon but has a major adverse effect on postoperative mortality and morbidity.^2-4 On the other hand, cognitive dysfunction is common,⁵ and although it has no obvious immediate undesirable impact on clinical outcome, it does correlate with late impairment in quality of life measures.⁶ Between these extremes lies delirium, which has traditionally been considered a self-limiting condition. Any such complacency is, however, sharply dispelled by three recent prospective studies summarized in Table1. ^2-4 Stroke affects around 3% of patients undergoing coronary artery bypass grafting (CABG) and increases hospital mortality 10-fold, whereas delirium occurs in 3% to 7% and increases mortality 5-fold. Both at least double the hospital stay among survivors, before even considering their long-term functional and economic impacts.