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THE JOURNAL OF CARDIOVASCULAR SURGERY

Rivista di Chirurgia Cardiaca, Vascolare e Toracica


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The Journal of Cardiovascular Surgery 1999 February;40(1):77-81

Copyright © 2000 EDIZIONI MINERVA MEDICA

lingua: Inglese

Atheroembolization in cardiac surgery. The need for preoperative diagnosis

Kolh Ph. H., Torchiana D. F., Buckley M. J.

From the Cardiac Surgical Unit Massachusetts General Hospital, Boston, MA, USA


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Background. Atheroembolization is a rec­og­nized com­pli­ca­tion of car­diac sur­gi­cal pro­ce­dures, and has ­been impli­cat­ed in post­op­er­a­tive ­stroke, ­renal fail­ure, mul­ti­or­gan fail­ure, and ­death. Preoperative iden­tifi­ca­tion of ­patients at ­risk for devel­op­ing ath­e­roem­bo­li is essen­tial. The aim of ­this ­study was to deter­mine pre­op­er­a­tive ­risk fac­tors for ath­e­roem­bo­li and to ­assess the post­op­er­a­tive ­course of the ­patients who devel­oped ather­oem­bol­ic syn­drome.
Methods. A ret­ro­spec­tive ­record ­review was con­duct­ed. From 1/1990 to 12/1994 5486 ­patients under­went cor­o­nary ­artery ­bypass graft­ing (­CABG), ­valve oper­a­tions, or oth­er car­diac sur­gi­cal pro­ce­dures at Massachusetts General Hospital. Of ­this pop­u­la­tion, 107 ­patients (1.9%) devel­oped ather­oem­bol­ic syn­drome.
Results. Patients who devel­op ath­e­roem­bo­li ­were old­er, ­with an ­increased inci­dence (p < 0.01) of hyper­ten­sion, cereb­ro­vas­cu­lar dis­ease, and aor­toi­liac dis­ease. Many had a com­pli­cat­ed ­course ­after cath­et­er­iza­tion, ­with ­renal insuf­fi­cien­cy (35%) and evi­dence of periph­er­al embo­li (12%). Average Intensive Care Unit ­stay, hos­pi­tal ­stay, and hos­pi­tal ­cost of ­these ­patients ­were respec­tive­ly 16.8 ­days, 48.4 ­days, and $88,000, com­pared to 1.5 ­days, 9.6 ­days and $23,000 for a con­cur­rent pop­u­la­tion under­go­ing ­CABG sur­gery. Of ­these 107 ­patients ­only 2 ­were dis­charged ­home, the oth­ers ­either ­died (48 ­patients, or 25% of all car­diac sur­gi­cal ­deaths dur­ing ­this peri­od), or ­went to reha­bil­i­ta­tion or chron­ic hos­pi­tal facil­ities. Twenty-sev­en autop­sies ­were per­formed and invar­i­ably ­showed a dif­fuse­ly dis­eased aor­ta, ­with cal­cifi­ca­tion, ­mural throm­bus, and ulcer­a­tion.
Conclusions. Atheroembolization dur­ing car­diac sur­gi­cal pro­ce­dures has pro­found med­i­cal and eco­nom­ic con­se­quenc­es. Because of the dif­fuse ­nature of aor­tic dis­ease, meas­ures approach­ing the dis­ease as a ­local pro­cess are like­ly to be unsuc­cess­ful. Appropriate eval­u­a­tion ­would ideal­ly iden­ti­fy ­patients ­with exten­sive aor­tic ath­e­rom­a­tous dis­ease, ­prior to rath­er ­than dur­ing sur­gery.

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