Effect of Aortic Clamping Strategy on Postoperative Stroke in Coronary Artery Bypass Grafting Operations | Cardiology | JAMA Surgery | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 18.204.227.34. Please contact the publisher to request reinstatement.
1.
Goto  T, Maekawa  K.  Cerebral dysfunction after coronary artery bypass surgery.  J Anesth. 2014;28(2):242-248.PubMedGoogle ScholarCrossref
2.
Nah  HW, Lee  JW, Chung  CH,  et al.  New brain infarcts on magnetic resonance imaging after coronary artery bypass graft surgery: lesion patterns, mechanism, and predictors.  Ann Neurol. 2014;76(3):347-355.PubMedGoogle ScholarCrossref
3.
Selnes  OA, Gottesman  RF, Grega  MA, Baumgartner  WA, Zeger  SL, McKhann  GM.  Cognitive and neurologic outcomes after coronary-artery bypass surgery.  N Engl J Med. 2012;366(3):250-257.PubMedGoogle ScholarCrossref
4.
Lattouf  OM, Adams  KN.  Current readings on off-pump coronary artery bypass.  Semin Thorac Cardiovasc Surg. 2013;25(3):228-236.PubMedGoogle ScholarCrossref
5.
Polomsky  M, Puskas  JD.  Off-pump coronary artery bypass grafting: the current state.  Circ J. 2012;76(4):784-790.PubMedGoogle ScholarCrossref
6.
van Dijk  D, Keizer  AM, Diephuis  JC, Durand  C, Vos  LJ, Hijman  R.  Neurocognitive dysfunction after coronary artery bypass surgery: a systematic review.  J Thorac Cardiovasc Surg. 2000;120(4):632-639.PubMedGoogle ScholarCrossref
7.
Chu  D, Bakaeen  FG, Dao  TK, LeMaire  SA, Coselli  JS, Huh  J.  On-pump versus off-pump coronary artery bypass grafting in a cohort of 63,000 patients.  Ann Thorac Surg. 2009;87(6):1820-1826.PubMedGoogle ScholarCrossref
8.
Marasco  SF, Sharwood  LN, Abramson  MJ.  No improvement in neurocognitive outcomes after off-pump versus on-pump coronary revascularisation: a meta-analysis.  Eur J Cardiothorac Surg. 2008;33(6):961-970.PubMedGoogle ScholarCrossref
9.
Palmerini  T, Biondi-Zoccai  G, Riva  DD,  et al.  Risk of stroke with percutaneous coronary intervention compared with on-pump and off-pump coronary artery bypass graft surgery: evidence from a comprehensive network meta-analysis.  Am Heart J. 2013;165(6):910-917, e14.PubMedGoogle ScholarCrossref
10.
Diegeler  A, Börgermann  J, Kappert  U,  et al; GOPCABE Study Group.  Off-pump versus on-pump coronary-artery bypass grafting in elderly patients.  N Engl J Med. 2013;368(13):1189-1198.PubMedGoogle ScholarCrossref
11.
Lamy  A, Devereaux  PJ, Prabhakaran  D,  et al; CORONARY Investigators.  Off-pump or on-pump coronary-artery bypass grafting at 30 days.  N Engl J Med. 2012;366(16):1489-1497.PubMedGoogle ScholarCrossref
12.
Shroyer  AL, Grover  FL, Hattler  B,  et al; Veterans Affairs Randomized On/Off Bypass (ROOBY) Study Group.  On-pump versus off-pump coronary-artery bypass surgery.  N Engl J Med. 2009;361(19):1827-1837.PubMedGoogle ScholarCrossref
13.
O’Brien  SM, Shahian  DM, DeLong  ER,  et al.  Quality measurement in adult cardiac surgery, part 2: statistical considerations in composite measure scoring and provider rating.  Ann Thorac Surg. 2007;83(4)(suppl):S13-S26.PubMedGoogle ScholarCrossref
14.
Shahian  DM, Edwards  FH, Ferraris  VA,  et al; Society of Thoracic Surgeons Quality Measurement Task Force.  Quality measurement in adult cardiac surgery, part 1: conceptual framework and measure selection.  Ann Thorac Surg. 2007;83(4)(suppl):S3-S12.PubMedGoogle ScholarCrossref
15.
Shahian  DM, He  X, Jacobs  JP,  et al.  The STS AVR+CABG composite score: a report of the STS Quality Measurement Task Force.  Ann Thorac Surg. 2014;97(5):1604-1609.PubMedGoogle ScholarCrossref
16.
Daniel  WT  III, Kilgo  P, Puskas  JD,  et al.  Trends in aortic clamp use during coronary artery bypass surgery: effect of aortic clamping strategies on neurologic outcomes.  J Thorac Cardiovasc Surg. 2014;147(2):652-657.PubMedGoogle ScholarCrossref
17.
Tsang  JC, Morin  JF, Tchervenkov  CI, Platt  RW, Sampalis  J, Shum-Tim  D.  Single aortic clamp versus partial occluding clamp technique for cerebral protection during coronary artery bypass: a randomized prospective trial.  J Card Surg. 2003;18(2):158-163.PubMedGoogle ScholarCrossref
18.
Bakaeen  FG, Dhaliwal  AS, Chu  D,  et al.  Does the level of experience of residents affect outcomes of coronary artery bypass surgery?  Ann Thorac Surg. 2009;87(4):1127-1133.PubMedGoogle ScholarCrossref
19.
Cervera  R, Bakaeen  FG, Cornwell  LD,  et al.  Impact of functional status on survival after coronary artery bypass grafting in a veteran population.  Ann Thorac Surg. 2012;93(6):1950-1954.PubMedGoogle ScholarCrossref
20.
Kim  RW, Mariconda  DC, Tellides  G,  et al.  Single-clamp technique does not protect against cerebrovascular accident in coronary artery bypass grafting.  Eur J Cardiothorac Surg. 2001;20(1):127-132.PubMedGoogle ScholarCrossref
21.
Shroyer  AL, Coombs  LP, Peterson  ED,  et al; Society of Thoracic Surgeons.  The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models.  Ann Thorac Surg. 2003;75(6):1856-1864.PubMedGoogle ScholarCrossref
22.
Grega  MA, Borowicz  LM, Baumgartner  WA.  Impact of single clamp versus double clamp technique on neurologic outcome.  Ann Thorac Surg. 2003;75(5):1387-1391.PubMedGoogle ScholarCrossref
23.
Hammon  JW, Stump  DA, Butterworth  JF,  et al.  Coronary artery bypass grafting with single cross-clamp results in fewer persistent neuropsychological deficits than multiple clamp or off-pump coronary artery bypass grafting.  Ann Thorac Surg. 2007;84(4):1174-1178.PubMedGoogle ScholarCrossref
24.
Hammon  JW, Stump  DA, Butterworth  JF,  et al.  Single crossclamp improves 6-month cognitive outcome in high-risk coronary bypass patients: the effect of reduced aortic manipulation.  J Thorac Cardiovasc Surg. 2006;131(1):114-121.PubMedGoogle ScholarCrossref
Original Investigation
Association of VA Surgeons
January 2016

Effect of Aortic Clamping Strategy on Postoperative Stroke in Coronary Artery Bypass Grafting Operations

Author Affiliations
  • 1University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
  • 2Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
JAMA Surg. 2016;151(1):59-62. doi:10.1001/jamasurg.2015.3097
Abstract

Importance  Aortic clamping technique has been implicated in stroke risk at the time of on-pump coronary artery bypass grafting (CABG) procedures. We hypothesized that partial aortic clamping (PAC) use in performing proximal coronary anastomosis does not increase risk of stroke.

Objective  To determine whether postoperative stroke incidence is influenced by single aortic clamping (SAC) or side-biting PAC use in performing proximal anastomosis during CABG procedures.

Design, Setting, and Participants  In a retrospective cohort study, we analyzed data from 1819 patients who underwent conventional, isolated, nonemergent, first-time, arrested-heart, on-pump CABG at a single US major academic, tertiary/quaternary medical center from January 1, 2005, to December 31, 2013. Postoperative stroke was defined according to Society of Thoracic Surgeons (STS) criteria as any confirmed neurological deficit of abrupt onset that did not resolve within 24 hours. Institutional STS data including STS predicted risk of postoperative stroke score were used to compare patients receiving proximal aortic anastomoses performed with either SAC (n = 1107) or combined PAC (n = 712) techniques.

Exposures  Use of SAC or PAC in performing proximal coronary anastomosis.

Main Outcomes and Measures  Thirty-day periprocedural postoperative stroke rates.

Results  There were no significant differences in preoperative risk or STS predicted risk of mortality between groups. Patients in the SAC group had longer myocardial ischemic time compared with those in the PAC group (mean [SD], 73.2 [22.8] vs 66.5 [22.8] minutes, respectively; P < .001) but shorter overall perfusion time (mean [SD], 96.6 [30.1] vs 102.2 [30.1] minutes, respectively; P < .001). The 30-day observed mortality rates between the SAC and PAC groups were equally low (21 of 1107 patients [1.9%] vs 13 of 712 patients [1.8%], respectively; P > .99) and congruent with STS predicted risk of mortality. Preoperative STS predicted risk of postoperative stroke scores were nearly identical between the SAC and PAC groups (mean [SD], 1.5% [1.4%] vs 1.6% [1.4%]; P = .95), and the 30-day actual observed postoperative stroke rates between the SAC and PAC groups were similar (17 of 1107 patients [1.5%] vs 10 of 712 patients [1.4%], respectively; P > .99).

Conclusions and Relevance  In this contemporary study of on-pump CABG, we did not identify any significant differences in the incidence of postoperative stroke regardless of the clamping method used to perform proximal anastomosis.

×