상계백병원 흉부외과 허재학. 3.1 % stroke in 2108 patients in a prospective study ---...
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상계백병원 흉부외과 허재학
3.1 % stroke in 2108 patients in a prospective study
--- Roach GW 1996
Stroke 2.8% in 2000 patients studied prospectively,
with an incidence in patients > 75 years (8.9%), 65 -74 years (3.6%) and < 60 years old(0.9 %)
--- Tuman KJ 1999
79% significant decrease in cognitive performance postoperatively
--- Shaw PJ 1986
53 % at discharge, 36 % at 6 wks, 24 % at 6 mo
--- Newman MF 1996
90 % cognitive impairment in pump CABG, no impairment in OPCAB
--- Diegeler A 2000
Reduced retinal and cerebral microembolization with OPCAB
--- Ascione R 2005
Hammon JW. 2008, Cohn LH ed. Cardiac Surgery in the Adult
The main risk factor for postoperative stroke --- van der Linden 2001, Hogue 1999, Roach 1996, Blauth 1995
< 2 % stroke in patients with limited or no atheroma
40 % in patients with grade IV or V atheroma
--- advanced therapy in cardiac surgery, Barbut 1997
The incidence of atherosclerosis in CABG patients
; 38 ~ 53 % ---Barbut 1996, Bolotin 2005
Preop CT / MRIDigital palpationEpiaortic ultrasonographyTEE
group I clean aorta
group II remote, stable aortic plaque
group III remote, vulnerable plaque/ulcer
group IV lesions near cannulation site
group V dangerous/impossible
cannulation or clamping
박계현 , 2009 관상동맥외과 연구회 학술 심포지움
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n=77 n= 100 n=45 n=26 n=36
preop. CT vs TEE
Berman P. Heart Surg Forum 7, 2004:E245-E249
- sensitivity 87 %, specificity 82 %Tenenbaum A. Radiology, Vol 208, 153-158
The SonoSite ultrasound device displayed alone and with monitor stand
Epiaortic Epiaortic UltrasonographyUltrasonography
Kronzon I. et al. Circulation 2006;114:63-75
Suvarna et al. J Cardiothorac and Vasc Anes. 2007: 805-809
Bolotin G et al. Chest 2005;127:60-65
reduction in neurologic complications
(Ozatik MA 1999, Royse AG 2000)
Risk FactorsOdds Ratio of
Stroke95% Confidence
Interval p Value
On-CPB CABG vs. OPCABG (matched pairs = 1915, n = 3830)
1.9 (1.16, 3.02) <0.01
Extensive aortic manipulation vs. no aortic manipulation (matched pairs = 451, n = 902)
3.1 (0.97, 9.62) 0.06
Extensive aortic manipulation vs. moderate aortic manipulation (matched pairs = 1720, n = 3440)
1.5 (0.92, 2.36) 0.10
Moderate aortic manipulation vs. no aortic manipulation (matched pairs = 470, n = 940) 1.8 (0.51, 6.10) 0.37
Kapetanakis EI et al. Ann Thorac Surg 2004;78:1564-1571
Barbut, D. et al. Stroke 1996;27:87-90
Scatterplot shows value of aortic Scatterplot shows value of aortic atheroma in predicting number of atheroma in predicting number of
emboliemboli
Barbut D. et al.; Ann Thorac Surg 1997;63:1262-1267
Barbut, D. et al. Stroke 1996;27:87-90
aortic cross clamp release accounted for 42% (TEE) and 41% (TCD) of the total number of emboli
Taylor R. L. et al.; Ann Thorac Surg 1999;68:89-93
Banbury M. K. et al.; Ann Thorac Surg 2003;76:508-515
Borger M. A. et al.; J Thorac Cardiovasc Surg 1999;118:740-745
Cannulation using a long cannula ; significant decrease in peak forward flow velocity and turbulence in the aortic arch during CPB
Grossi EA. Et al. Ann Thorac Surg 1995;59:710-712
Cook D. J. et al.; J Thorac Cardiovasc Surg 2003;125:378-384
Cook D. J. et al.; Ann Thorac Surg 2002;74:825-829
usual de-airing maneuvers
- incomplete to eliminate retained air
CO2 flooding to replace the air in the thoracic cavity
CO2 dissolves in blood and tissue >25 times faster than air
50 % heavier than air --- but, residual air in pericardial cavity 20 –
80 %, delivered in common manner (Martens S 2001, Persson M 2003)
Svenarud, P 2004
Svenarud, P 2004
Svenarud, P. et al. Circulation 2004;109:1127-1132
median number of microemboli after release of aortic cross-clampp < 0.01
Svenarud, P. et al. Circulation 2004;109:1127-1132
total numbers of microemboli present in different areas shown by TEEp < 0.01
Hogue, CW et al. Anesth Analg 2006;103:21-37
Jones T. J. et al.; Ann Thorac Surg 2002;74:2132-2137
Rodriguez R. A. et al.; Eur J Cardiothorac Surg 2006;29:175-180
r = 0.524, p < 0.0001
Schoenburg M.; J Thorac Cardiovasc Surg 2003;126:1455-60
canine brain tissue with cardiotomy suction (Brooker RF 1998)
Brain with fat emboli(Moody DM 1995)
Kincaid E. H. et al.; Ann Thorac Surg 2000;70:1296-1300
11 ± 3 vs 24 ± 5, p = 0.02
Closed bars represent arterial filter group; open bars represent cell saver group
Taylor R. L. et al.; Ann Thorac Surg 1999;68:89-93
Avoid the atherosclerotic emboli ; preop. CT, EAU Control the air entry site and remove residual air
from the heart strictly Insufflate the CO2 gas to replace the air ; inside
wound cavity, gas diffuser Eliminate the air in the venous cannula Wash the blood aspirated from the surgical
wound ; the continuous auto transfusion cell saver system
Specialized cannula or filtration device Cannulate in distal arch using a long cannula