A NEW APPROACH TO PREVENTING STROKE
DURING OPEN HEART SURGERY
By George L. Hines, MD, FACS
Chief, Division of Vascular Surgery
Department of Thoracic & Cardiovascular Surgery
Winthrop-University Hospital
Stroke occurring during open heart surgery is a devastating complication,
not only because of the resulting disability, but also because the patient
and family usually do not expect it. About 2-5% of patients undergoing open
heart surgery suffer neurologic injury, which occurs even more frequently in
older patients.
Many factors can cause the development of a stroke during heart surgery.
They include severe atherosclerosis of the aorta, a prolonged period in
surgery, and the constriction or narrowing (stenosis) of one or both carotid
arteries, which are located in the neck and carry blood to the brain.
Approximately 5-7% of patients undergoing coronary artery bypass surgery
have significant co-existing carotid artery disease. In 1994, cardiovascular
surgeons in Winthrop-University Hospital's Department of Thoracic and
Cardiovascular Surgery conducted a retrospective study to determine whether
carotid endarterectomy (the removal of fatty deposits from the vessel's
inner lining), performed along with open heart surgery, decreased the risk
of having the patient suffer a stroke during the operation. They found that
when the vascular procedure was performed along with the cardiac procedure
the danger of stroke was significantly lower.
As a result of that study, Winthrop began screening candidates for coronary
artery bypass surgery, or coronary artery bypass surgery associated with
heart valve replacement, for carotid stenosis prior to surgery. Today, the
Hospital's cardiovascular surgeons perform carotid endarterectomies along
with coronary artery bypass surgery in patients known to have severe carotid
stenosis. Patients found to have stenosis of 80% or greater undergo
prophylactic carotid endarterectomy. (Severe carotid stenosis is also
considered a leading cause of stroke in patients not undergoing heart
surgery. Therefore, prophylactic endarterectomy is regarded as a method of
reducing the long-term risk of stroke, overall.)
Over 100 patients have had the combined carotid endarterectomy and open
heart surgery procedure. The stroke rate in this group is just below 2%,
which is significantly lower than the 5-7% anticipated stroke rate in
patients with carotid stenosis of >80% undergoing coronary artery bypass
surgery. What's more, no patient has developed a local problem related to
the carotid procedure.
Winthrop's cardiac and vascular surgeons believe that combining carotid
endarterectomy and coronary artery bypass surgery is safe and can
significantly reduce the risk of perioperative stroke and long-term
neurological events.
REFERENCES
Hines, GL. Scott, WC. Schubach, SC. Kofsky E. Wehbe U. Cabasino,
E. Prophylactic Carotid Endarterectomy in Patients with High-Grade Carotid
Stenosis Undergoing Coronary Bypass: Does it Decrease the Incidence of
Perioperative Stroke? Annals of Vascular Surgery 12:23-27, 1998.
Hines, GL. Scott, WC. Schubach, SL. Tyd, D. Wehbe, U. Hemodynamically
Significant Carotid Disease and Prophylactic Carotid Endarterectomy in CABG
Patients--Impact on Perioperative Neurologic Events. Vascular Surgery
31:147-151, March/April 1997.
