Operative strategies to reduce cerebral embolic events during on- and off-pump coronary artery bypass surgery: A stratified, prospective randomized trial

• Authors: Michael Halkos, Emory University; Aaron Anderson, Emory University; Jose Nilo G. Binongo, Emory University; Anthony Stringer, Emory University; Yi Lasanajak, Emory University; Vinod Thourani, Emory University; Omar Lattouf, Emory University; Robert Guyton, Emory University; Kim T. Baio, Emory University; Eric Sarin, Inova Fairfax Healthcare System; William Keeling, Emory University; N. Renee Cook, Emory University; Katherine Carssow, Emory University; Alexis Neill, Emory University; Kathryn Glas, Emory University; John D. Puskas, Mt. Sinai University
• Journal Title: Journal of Thoracic and Cardiovascular Surgery
• Volume: Volume 154, Number 4
• Publisher: Elsevier | 2017-10-01, Pages 1278-+
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1016/j.jtcvs.2017.04.089
• Subjects: Health Sciences, Medicine and Surgery; Biology, Neuroscience; Health Sciences, Epidemiology
• Keywords: Science & Technology; Life Sciences & Biomedicine; Cardiac & Cardiovascular Systems; Respiratory System; Surgery; Cardiovascular System & Cardiology; CABG; stroke; neurocognitive outcomes; ON-PUMP; AORTIC MANIPULATION; GRAFT-SURGERY; MICROEMBOLI; CLAMP; STROKE

Abstract

Objective To determine the impact of different aortic clamping strategies on the incidence of cerebral embolic events during coronary artery bypass grafting (CABG). Methods Between 2012 and 2015, 142 patients with low-grade aortic disease (epiaortic ultrasound grade I/II) undergoing primary isolated CABG were studied. Those undergoing off-pump CABG were randomized to a partial clamp (n = 36) or clampless facilitating device (CFD; n = 36) strategy. Those undergoing on-pump CABG were randomized to a single-clamp (n = 34) or double-clamp (n = 36) strategy. Transcranial Doppler ultrasonography (TCD) was performed to identify high-intensity transient signals (HITS) in the middle cerebral arteries during periods of aortic manipulation. Neurocognitive testing was performed at baseline and 30-days postoperatively. The primary endpoint was total number of HITS detected by TCD. Groups were compared using the Mann–Whitney U test. Results In the off-pump group, the median number of total HITS were higher in the CFD subgroup (30.0; interquartile range [IQR], 22-43) compared with the partial clamp subgroup (7.0; IQR, 0-16; P <.0001). In the CFD subgroup, the median number of total HITS was significantly lower for patients with 1 CFD compared with patients with >1 CFD (12.5 [IQR, 4-19] vs 36.0 [IQR, 25-47]; P =.001). In the on-pump group, the median number of total HITS was 10.0 (IQR, 3-17) in the single-clamp group, compared with 16.0 (IQR, 4-49) in the double-clamp group (P =.10). There were no differences in neurocognitive outcomes across the groups. Conclusions For patients with low-grade aortic disease, the use of CFDs was associated with an increased rate of cerebral embolic events compared with partial clamping during off-pump CABG. A single-clamp strategy during on-pump CABG did not significantly reduce embolic events compared with a double-clamp strategy.