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

0 0

2.2

3.8

8.3

0

2

4

6

8

10

early

mor

talit

y (%

)

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