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Cerebral complications after cardiac surgery
Östergötlands Läns Landsting, Heart Centre, Department of Thoracic and Vascular Surgery. Linköping University, Department of Medicine and Care, Anaesthesiology. Linköping University, Faculty of Health Sciences.
2002 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Cerebral injuty remains a major cause of morbidity and mortality after cardiac surgery. Previous studies have mainly focused on preoperative risk factors and intraoperative events but cerebral complications may also occur in the postoperative period. Cognitive impairment is common after cardiac surgery but the consequences of this complication for activities of daily life are less known. Safe driving involves a complex set of skills requiring preserved cognitive function. A substantial number of patients with heart disease are active drivers. The impact of postoperative cognitive dysfunction on driving performance, however, has not previously been investigated in this large patient group.

In this thesis pre-, intra- and postoperative risk factors for focal cerebral complications were determined and the onset time of cerebral symptoms were evaluated in two cohorts of cardiac surgical patients, comprising 2480 and 3282 patients respectively. Data analysed were drafted from a clinical register and the surgical database of Linköping University Hospital Heart Center. Cerebral complication was delayed, i.e occurred after a free interval, in about one third of patients suggesting causes other than intraoperative events. Different risk factors were found for early and delayed cerebral complications suggesting different mechanisms of cerebral injury. Advanced age, preoperative hypertension, aortic surgery, prolonged cardiopulmonary bypass (CPB) time, intraoperative hypotension after completion of CPB, and arrhytlunia in the early postoperative period increased the risk for early cerebral complication. Female gender, diabetes, previous cerebrovascular disease, combined coronary artery bypass grafting (CABG) and valve surgery and arrhythmia on the thoracic ward increased the risk for delayed cerebral complication. Cognitive function and driving performance were evaluated in 27 patients before and 4-6 weeks after CABG. The patients underwent neuropsychological testing, an on-road driving test and a test in an advanced driving simulator. Twenty patients scheduled for percutaneous coronary intervention (PCI) served as controls. Complete data were obtained in 23 and 19 patients respectively. Furthermore cognitive function and driving performance in on-road driving of the 44 patients with complete tests before intervention were compared with controls of similar age without heart symptoms. Cognitive function and driving performance were already impaired in patients with coronary artery disease before intervention when compared with controls. After surgery 48% of the patients showed cognjtive decline compared to 10% after PCI. These patients also scored less in the on-road driving test to a greater extent than did patients without postoperative cognitive decline.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2002. , 83 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 736
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-27453Local ID: 12106ISBN: 91-7373-181-1 (print)OAI: oai:DiVA.org:liu-27453DiVA: diva2:248005
Public defence
2002-06-07, Elsa Brändströms salen, Universitetssjukhuset, Linköping, 09:00 (Swedish)
Opponent
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-09-12Bibliographically approved
List of papers
1. Cerebral complications after coronary artery bypass and heart valve surgery: Risk factors and onset of symptoms
Open this publication in new window or tab >>Cerebral complications after coronary artery bypass and heart valve surgery: Risk factors and onset of symptoms
1998 (English)In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 12, no 3, 270-273 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: Cerebral complications continue to be a major cause of morbidity after cardiac surgery. Earlier studies have mainly focused on intraoperative events, but symptoms may also occur later in the postoperative period. The purpose of this study was to determine the incidence and risk factors of focal neurologic complications and timing of cerebral symptoms.

Design: A retrospective study.

Setting: Linköping University Hospital.

Participants: Two thousand four hundred eighty patients who underwent cardiac surgery from 1992 to 1995.

Interventions: Standard cardiopulmonary bypass (CPB) technique was used in all patients. Anticoagulant treatment included heparin and patients with coronary artery surgery were also administered acetylsalicylic acid and valve-surgery patients received warfarin or dicumarol.

Measurements and Main Results: Seventy-five patients (3%) had focal neurologic deficits and/or confusion postoperatively. In 32 patients (43%), the onset was not intraoperative but occurred later in the postoperative period. The lowest incidence of cerebral complications was found in patients who underwent single-valve replacement (1.2%) and the highest incidence was found in patients who underwent combined procedures (valve and coronary artery surgery; 7.6%). Patients greater than 70 years of age had a complication rate of 4.1% compared with 2.5% in patients aged 70 years and less (p < 0.05). The incidence of diabetes mellitus was 11.4% in the entire series, but was more common (18.7%; p < 0.05) in patients with cerebral symptoms. Also, 5.9% of all patients had a history of cerebrovascular disease compared with 14.7% (p < 0.01) of patients with cerebral complications.

Conclusion: Cerebral complications may be delayed after cardiac surgery, suggesting causes of cerebral damage other than intraoperative events. Valve-surgery patients had the lowest incidence and patients with combined procedures had the highest incidence of cerebral complications. Advanced age, diabetes mellitus, and preexisting cerebrovascular disease increased the risk.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81345 (URN)10.1016/S1053-0770(98)90004-0 (DOI)
Available from: 2012-09-12 Created: 2012-09-12 Last updated: 2017-12-07Bibliographically approved
2. Risk factor analysis of early and delayed cerebral complications after cardiac surgery
Open this publication in new window or tab >>Risk factor analysis of early and delayed cerebral complications after cardiac surgery
2002 (English)In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 16, no 3, 278-285 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To report the incidence, severity, and possible risk factors for early and delayed cerebral complications.

Design: Retrospective study.

Setting: Linköping University Hospital, Sweden.

Participants: Consecutive patients who underwent cardiac surgery in the period July 1996 through June 2000 (n = 3,282).

Interventions: A standard cardiopulmonary bypass (CPB) technique was used for most patients. Postoperative anticoagulant treatment included heparin or anti-Xa dalteparin. Patients undergoing coronary artery bypass graft surgery received acetylsalicylic acid, and patients undergoing valve surgery received warfarin.

Measurements and Main Results: Cerebral complications occurred in 107 patients (3.3%). Of these, 60 (1.8%) were early, and 33 (1.0%) were delayed, and in 14 (0.4%) patients the onset was unknown. There were 37 variables in univariate analysis (p < 0.15) and 14 variables in multivariate analysis (p < 0.05) associated with cerebral complications. Predictors of early cerebral complications were older age, preoperative hypertension, aortic aneurysm surgery, prolonged CPB time, hypotension at CPB completion and soon after CPB, and postoperative arrhythmia and supraventricular tachyarrhythmia. Predictors of delayed cerebral complications were female gender, diabetes, previous cerebrovascular disease, combined valve surgery and coronary artery bypass graft surgery, postoperative supraventricular tachyarrhythmia, and prolonged ventilator support. Early cerebral complications seem to be more serious, with more permanent deficits and a higher overall mortality (35.0% v 18.2%).

Conclusion: Most cerebral complications had an early onset. The results of this study suggest that aggressive antiarrhythmic treatment and blood pressure control may imfurther prove the cerebral outcome after cardiac surgery.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-29550 (URN)10.1053/jcan.2002.124133 (DOI)14921 (Local ID)14921 (Archive number)14921 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2017-12-13Bibliographically approved
3. Patients with Coronary Artery Disease Are Active Car Drivers Both Before and Soon After Heart Surgery
Open this publication in new window or tab >>Patients with Coronary Artery Disease Are Active Car Drivers Both Before and Soon After Heart Surgery
2002 (English)In: Traffic Injury Prevention, ISSN 1538-9588, E-ISSN 1538-957X, Vol. 3, no 3, 205-208 p.Article in journal (Refereed) Published
Abstract [en]

Cognitive ability is essential for the fitness to drive. Impaired cognitive functions are common after cardiac surgery. Little is known about driving habits and influence of postoperative cognitive decline on driving performance in these patients. The aim of this study was to investigate the extent of driving activity of patients before and after cardiac surgery. Ninety-seven cardiac surgical patients were interviewed about their driving habits before and 12 weeks after surgery. The mean age was 66. Before the operation, 78% were active car drivers. They drove several times a week including longer than 100 km distances. After the operation, 64% continued to drive and most of them (69%) had commenced driving within 6 weeks. The majority (79%) reported unchanged driving habits, while 13 patients (21%) had reduced their driving activity due to the cognitive symptoms they experienced. Patients with coronary artery disease are active car drivers both before and after heart surgery. Further evaluation of the ability of these patients to drive is required if we are to give advice and apply restrictions in the interest of traffic safety.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-26733 (URN)10.1080/15389580213649 (DOI)11328 (Local ID)11328 (Archive number)11328 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
4. Neurocognitive impairment and driving performance after coronary artery bypass surgery
Open this publication in new window or tab >>Neurocognitive impairment and driving performance after coronary artery bypass surgery
Show others...
2003 (English)In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 23, no 3, 334-340 p.Article in journal (Refereed) Published
Abstract [en]

Objective: Neurocognitive impairment is common after cardiac surgery but few studies have examined the relationship between postoperative neuropsychological test performance and everyday behavior. The influence of postoperative cognitive impairment on car driving has previously not been investigated. The purpose of this study was to evaluate neurocognitive function and driving performance after coronary artery bypass grafting (CABG).

Methods: Twenty-seven patients who underwent coronary artery bypass grafting with standard cardiopulmonary bypass technique and 20 patients scheduled for percutaneous coronary intervention (PCI) under local anesthesia (control group) were enrolled in this prospective study conducted from April 1999 to September 2000. Complete data were obtained in 23 and 19 patients, respectively. The patients underwent neuropsychological examination with a test battery including 12 tests, a standardized on-road driving test and a test in an advanced driving simulator before and 4–6 weeks after intervention.

Results: More patients in the coronary artery bypass grafting group (n=11, 48%) than in the percutaneous coronary intervention group (n=2, 10%) showed a cognitive decline after intervention (P=0.01). In the on-road driving test, patients who underwent coronary artery bypass grafting deteriorated after surgery in the cognitive demanding parts like traffic behavior (P=0.01) and attention (P=0.04). Patients who underwent percutaneous intervention deteriorated in maneuvering of the vehicle (P=0.04). No deterioration was detected in the simulator in any of the groups after intervention. Patients with a cognitive decline after intervention also tended to drop in the on-road driving scores to a larger extent than did patients without a cognitive decline.

Conclusion: This study indicates that cognitive functions important for safe driving may be influenced after cardiac surgery.

Keyword
Cardiac surgery, Cerebral complications, Cognitive decline, Driving performance
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-26290 (URN)10.1016/s1010-7940(02)00807-2 (DOI)10806 (Local ID)10806 (Archive number)10806 (OAI)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
5. Driving performance of patients with coronary artery disease
Open this publication in new window or tab >>Driving performance of patients with coronary artery disease
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Objectives To compare patients with coronary artery disease and healthy controls with respect to cognitive function and driving performance.

Design and setting A controlled study conducted between April 1999 and January 2001.

Subjects Forty-four patients with stable coronary artery disease scheduled for cardiac intervention with coronary artery bypass surgery or percutaneous coronary intervention. Forty volunteers of similar age without symptoms of coronary artery disease served as controls.

Main outcome measures On-road driving scores in five specific test areas with a rating scale from 1 to 5. Neuropsychological test scores, including 12 tests.

Results Compared with controls, patients with coronary artery disease had lower scores in all areas of the on-road driving test (p<0.05) and in the neuropsychological tests assessing psychomotor speed, visual and verbal memory, focused attention and simultaneous capacity (p<0.05). The difference between the groups in the on-road driving test appeared to be more pronounced among those above 65 years-of-age. Both patients and controls rated their performance significantly higher than the traffic inspector (p<0.05).

Conclusions Cognitive function and driving performance may be impaired in patients with coronary artery disease.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81348 (URN)
Available from: 2012-09-12 Created: 2012-09-12 Last updated: 2012-09-12Bibliographically approved

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