Atherosclerosis of the Aorta and Prevention of Neurological Dysfunction After Cardiac Surgery

  • Fellery de Lange
  • G. Burkhard Mackensen
  • Madhav Swaminathan


On May 6, 1953, John H Gibbon Jr., a Philadelphia surgeon, performed the world’s first successful open heart procedure in which total heart–lung bypass was employed.1 Since that time, aortic manipulation and postoperative neurological complications have coexisted. Aortic atherosclerosis remains a significant marker of coronary artery disease, perioperative vascular events, stroke, and even renal dysfunction. Although cardiac surgery is unique in that manipulation of the ascending aorta is almost routine, surgical handling of a diseased aorta is not always without risk.


Aortic Arch Aortic Surgery Aortic Atherosclerosis Aortic Plaque Postoperative Stroke 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    DeBakey ME. John Gibbon and the heart-lung machine: a personal encounter and his import for ­cardiovascular surgery. Ann Thorac Surg. 2003;76:S2188–2194.PubMedCrossRefGoogle Scholar
  2. 2.
    Gilman S. Cerebral disorders after open-heart operations. N Engl J Med. 1965;272:489–498.PubMedCrossRefGoogle Scholar
  3. 3.
    Javid H, Tufo HM, Najafi H, Dye WS, Hunter JA, Julian OC. Neurological abnormalities following open-heart surgery. J Thorac Cardiovasc Surg. 1969;58:502–509.PubMedGoogle Scholar
  4. 4.
    Tufo HM, Ostfeld AM, Shekelle R. Central nervous system dysfunction following open-heart surgery. J Am Med Assoc. 1970;212:1333–1340.CrossRefGoogle Scholar
  5. 5.
    Sotaniemi KA. Prevalence and causes of cerebral complications in cardiac surgery. In: Willner AE, ed. Cerebral Damage Before and After Cardiac Surgery. Dordrecht: Kluwer Academic Publishers; 1993:37–46.Google Scholar
  6. 6.
    Branthwaite MA. Prevention of neurological damage during open-heart surgery. Thorax. 1975;30:258–261.PubMedCrossRefGoogle Scholar
  7. 7.
    Coffey CE, Massey EW, Roberts KB, Curtis S, Jones RH, Pryor DB. Natural history of cerebral ­complications of coronary artery bypass graft surgery. Neurology. 1983;33:1416–1421.PubMedGoogle Scholar
  8. 8.
    Shaw PJ, Bates D, Cartlidge NE, et al. Neurologic and neuropsychological morbidity following major surgery: comparison of coronary artery bypass and peripheral vascular surgery. Stroke. 1987;18:700–707.PubMedGoogle Scholar
  9. 9.
    Sotaniemi KA, Mononen H, Hokkanen TE. ­Long-term cerebral outcome after open-heart surgery. A five-year neuropsychological follow-up study. Stroke. 1986;17:410–416.PubMedGoogle Scholar
  10. 10.
    Hindman BJ, Todd MM. Improving neurologic outcome after cardiac surgery. Anesthesiology. 1999;90:1243–1247.PubMedCrossRefGoogle Scholar
  11. 11.
    Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary bypass surgery. Multicenter study of perioperative Ischemia research group and the Ischemia research and education foundation investigators. N Engl J Med. 1996;335:1857–1863.PubMedCrossRefGoogle Scholar
  12. 12.
    Breuer AC, Furlan AJ, Hanson MR, et al. Central ­nervous system complications of coronary artery bypass graft surgery: prospective analysis of 421 patients. Stroke. 1983;14:682–687.PubMedGoogle Scholar
  13. 13.
    Sotaniemi KA. Cerebral outcome after extracorporeal circulation. Comparison between prospective and retrospective evaluations. Arch Neurol. 1983;40:75–77.PubMedGoogle Scholar
  14. 14.
    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;120:632–639.PubMedCrossRefGoogle Scholar
  15. 15.
    Katz ES, Tunick PA, Rusinek H, Ribakove G, Spencer FC, Kronzon I. Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography. J Am Coll Cardiol. 1992;20:70–77.PubMedCrossRefGoogle Scholar
  16. 16.
    Hartman GS, Yao FS, Bruefach M 3rd, et al. Severity of aortic atheromatous disease diagnosed by transesophageal echocardiography predicts stroke and other outcomes associated with coronary artery surgery: a prospective study. Anesth Analg. 1996;83:701–708.PubMedCrossRefGoogle Scholar
  17. 17.
    van der Linden J, Hadjinikolaou L, Bergman P, Lindblom D. Postoperative stroke in cardiac surgery is related to the location and extent of atherosclerotic disease in the ascending aorta. J Am Coll Cardiol. 2001;38:131–135.PubMedCrossRefGoogle Scholar
  18. 18.
    Newman MF, Kirchner JL, Phillips-Bute B, et al. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J Med. 2001;344:395–402.PubMedCrossRefGoogle Scholar
  19. 19.
    Newman MF, Grocott HP, Mathew JP, et al. Report of the substudy assessing the impact of neurocognitive function on quality of life 5 years after cardiac ­surgery. Stroke. 2001;32:2874–2881.PubMedCrossRefGoogle Scholar
  20. 20.
    Stanley TO, Mackensen GB, Grocott HP, et al. The impact of postoperative atrial fibrillation on neurocognitive outcome after coronary artery bypass graft ­surgery. Anesth Analg. 2002;94:290–295.PubMedCrossRefGoogle Scholar
  21. 21.
    Mackensen GB, Ti LK, Phillips-Bute BG, Mathew JP, Newman MF, Grocott HP. Cerebral embolization ­during cardiac surgery: impact of aortic atheroma burden. Br J Anaesth. 2003;91:656–661.PubMedCrossRefGoogle Scholar
  22. 22.
    Goto T, Baba T, Yoshitake A, Shibata Y, Ura M, Sakata R. Craniocervical and aortic atherosclerosis as neurologic risk factors in coronary surgery. Ann Thorac Surg. 2000;69:834–840.PubMedCrossRefGoogle Scholar
  23. 23.
    Bar-Yosef S, Anders M, Mackensen GB, et al. Aortic atheroma burden and cognitive dysfunction after coronary artery bypass graft surgery. Ann Thorac Surg. 2004;78:1556–1562. discussion 1562–1553.PubMedCrossRefGoogle Scholar
  24. 24.
    Wolman RL, Nussmeier NA, Aggarwal A, et al. Cerebral injury after cardiac surgery: identification of a group at extraordinary risk. Multicenter study of perioperative Ischemia research group (McSPI) and the Ischemia research education foundation (IREF) investigators. Stroke. 1999;30:514–522.PubMedGoogle Scholar
  25. 25.
    Mathew JP, Podgoreanu MV, Grocott HP, et al. Genetic variants in P-selectin and C-reactive protein influence susceptibility to cognitive decline after ­cardiac ­surgery. J Am Coll Cardiol. 2007;49:1934–1942.PubMedCrossRefGoogle Scholar
  26. 26.
    Mathew JP, Rinder CS, Howe JG, et al. Platelet PlA2 polymorphism enhances risk of neurocognitive decline after cardiopulmonary bypass. Multicenter study of perioperative Ischemia (McSPI) research group. Ann Thorac Surg. 2001;71:663–666.PubMedCrossRefGoogle Scholar
  27. 27.
    Mullges W, Franke D, Reents W, Babin-Ebell J. Brain microembolic counts during extracorporeal circulation depend on aortic cannula position. Ultrasound Med Biol. 2001;27:933–936.PubMedCrossRefGoogle Scholar
  28. 28.
    Blauth C, Smith P, Newman S, et al. Retinal microembolism and neuropsychological deficit following clinical cardiopulmonary bypass: comparison of a membrane and a bubble oxygenator. A preliminary communication. Eur J Cardiothorac Surg. 1989;3:135–138.PubMedCrossRefGoogle Scholar
  29. 29.
    Deverall PB, Padayachee TS, Parsons S, Theobold R, Battistessa SA. Ultrasound detection of micro-emboli in the middle cerebral artery during cardiopulmonary bypass surgery. Eur J Cardiothorac Surg. 1988;2:256–260.PubMedCrossRefGoogle Scholar
  30. 30.
    Brown WR, Moody DM, Challa VR, Stump DA, Hammon JW. Longer duration of cardiopulmonary bypass is associated with greater numbers of cerebral microemboli. Stroke. 2000;31:707–713.PubMedGoogle Scholar
  31. 31.
    Pugsley W, Klinger L, Paschalis C, Treasure T, Harrison M, Newman S. The impact of microemboli during cardiopulmonary bypass on neuropsychological functioning. Stroke. 1994;25:1393–1399.PubMedGoogle Scholar
  32. 32.
    Davila-Roman VG, Murphy SF, Nickerson NJ, Kouchoukos NT, Schechtman KB, Barzilai B. Atherosclerosis of the ascending aorta is an independent predictor of long-term neurologic events and mortality. J Am Coll Cardiol. 1999;33:1308–1316.PubMedCrossRefGoogle Scholar
  33. 33.
    Amarenco P, Cohen A, Tzourio C, et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med. 1994;331:1474–1479.PubMedCrossRefGoogle Scholar
  34. 34.
    Brooker RF, Brown WR, Moody DM, et al. Cardiotomy suction: a major source of brain lipid emboli during cardiopulmonary bypass. Ann Thorac Surg. 1998;65:1651–1655.PubMedCrossRefGoogle Scholar
  35. 35.
    Moody DM, Brown WR, Challa VR, Stump DA, Reboussin DM, Legault C. Brain microemboli ­associated with cardiopulmonary bypass: a histologic and magnetic resonance imaging study. Ann Thorac Surg. 1995;59:1304–1307.PubMedCrossRefGoogle Scholar
  36. 36.
    Taylor RL, Borger MA, Weisel RD, Fedorko L, Feindel CM. Cerebral microemboli during cardiopulmonary bypass: increased emboli during perfusionist interventions. Ann Thorac Surg. 1999;68:89–93.PubMedCrossRefGoogle Scholar
  37. 37.
    Selim M. Perioperative stroke. N Engl J Med. 2007;356:706–713.PubMedCrossRefGoogle Scholar
  38. 38.
    Gold JP, Charlson ME, Williams-Russo P, et al. Improvement of outcomes after coronary artery bypass. A randomized trial comparing intraoperative high versus low mean arterial pressure. J Thorac Cardiovasc Surg. 1995;110:1302–1311.PubMedCrossRefGoogle Scholar
  39. 39.
    Barone FC, Feuerstein GZ, White RF. Brain cooling during transient focal ischemia provides complete neuroprotection. Neurosci Biobehav Rev. 1997;21:31–44.PubMedCrossRefGoogle Scholar
  40. 40.
    Busto R, Dietrich WD, Globus MY, Valdes I, Scheinberg P, Ginsberg MD. Small differences in intraischemic brain temperature critically determine the extent of ischemic neuronal injury. J Cereb Blood Flow Metab. 1987;7:729–738.PubMedGoogle Scholar
  41. 41.
    Minamisawa H, Nordstrom CH, Smith ML, Siesjo BK. The influence of mild body and brain hypothermia on ischemic brain damage. J Cereb Blood Flow Metab. 1990;10:365–374.PubMedGoogle Scholar
  42. 42.
    Randomised trial of normothermic versus hypothermic coronary bypass surgery. The warm heart investigators. Lancet. 1994;343:559–563.Google Scholar
  43. 43.
    Grigore AM, Mathew J, Grocott HP, et al. Prospective randomized trial of normothermic versus hypothermic cardiopulmonary bypass on cognitive function after coronary artery bypass graft surgery. Anesthesiology. 2001;95:1110–1119.PubMedCrossRefGoogle Scholar
  44. 44.
    McLean RF, Wong BI, Naylor CD, et al. Cardiopulmonary bypass, temperature, and central nervous system dysfunction. Circulation. 1994;90:II250–255.PubMedGoogle Scholar
  45. 45.
    Grocott HP, Mackensen GB, Grigore AM, et al. Postoperative hyperthermia is associated with cognitive dysfunction after coronary artery bypass graft surgery. Stroke. 2002;33:537–541.PubMedCrossRefGoogle Scholar
  46. 46.
    de Lange F, Yoshitani K, Proia AD, Mackensen GB, Grocott HP. Perfluorocarbon administration during cardiopulmonary bypass in rats: an inflammatory link to adverse outcome? Anesth Analg. 2008;106:24–31.PubMedCrossRefGoogle Scholar
  47. 47.
    Grigore AM, Grocott HP, Mathew JP, et al. The rewarming rate and increased peak temperature alter neurocognitive outcome after cardiac surgery. Anesth Analg. 2002;94:4–10.PubMedCrossRefGoogle Scholar
  48. 48.
    Boodhwani M, Rubens F, Wozny D, Rodriguez R, Nathan HJ. Effects of sustained mild hypothermia on neurocognitive function after coronary artery bypass surgery: a randomized, double-blind study. J Thorac Cardiovasc Surg. 2007;134:1443–1450.PubMedCrossRefGoogle Scholar
  49. 49.
    Nathan HJ, Wells GA, Munson JL, Wozny D. Neuroprotective effect of mild hypothermia in patients undergoing coronary artery surgery with cardiopulmonary bypass: a randomized trial. Circulation. 2001;104(12 Suppl 1):I85–91.PubMedGoogle Scholar
  50. 50.
    Nathan HJ, Rodriguez R, Wozny D, et al. Neuroprotective effect of mild hypothermia in patients undergoing coronary artery surgery with cardiopulmonary bypass: five-year follow-up of a randomized trial. J Thorac Cardiovasc Surg. 2007;133:1206–1211.PubMedCrossRefGoogle Scholar
  51. 51.
    Warner DS, McFarlane C, Todd MM, Ludwig P, McAllister AM. Sevoflurane and halothane reduce focal ischemic brain damage in the rat. Possible influence on thermoregulation. Anesthesiology. 1993;79:985–992.PubMedCrossRefGoogle Scholar
  52. 52.
    Hall RI, Smith MS, Rocker G. The systemic inflammatory response to cardiopulmonary bypass: pathophysiological, therapeutic, and pharmacological considerations. Anesth Analg. 1997;85:766–782.PubMedCrossRefGoogle Scholar
  53. 53.
    Paparella D, Yau TM, Young E. Cardiopulmonary bypass induced inflammation: pathophysiology and treatment. An update. Eur J Cardiothorac Surg. 2002;21:232–244.PubMedCrossRefGoogle Scholar
  54. 54.
    Hindman BJ, Moore SA, Cutkomp J, et al. Brain expression of inducible cyclooxygenase 2 messenger RNA in rats undergoing cardiopulmonary bypass. Anesthesiology. 2001;95:1380–1388.PubMedCrossRefGoogle Scholar
  55. 55.
    Sato Y, Laskowitz DT, Bennett ER, Newman MF, Warner DS, Grocott HP. Differential cerebral gene expression during cardiopulmonary bypass in the rat: evidence for apoptosis? Anesth Analg. 2002;94:1389–1394.PubMedCrossRefGoogle Scholar
  56. 56.
    Westaby S. Organ dysfunction after cardiopulmonary bypass. A systemic inflammatory reaction initiated by the extracorporeal circuit. Intensive Care Med. 1987;13:89–95.PubMedCrossRefGoogle Scholar
  57. 57.
    Grocott HP, Newman MF, El-Moalem H, Bainbridge D, Butler A, Laskowitz DT. Apolipoprotein E genotype differentially influences the proinflammatory and anti-inflammatory response to cardiopulmonary bypass. J Thorac Cardiovasc Surg. 2001;122:622–623.PubMedCrossRefGoogle Scholar
  58. 58.
    Whitley WS, Glas KE. An argument for routine ultrasound screening of the thoracic aorta in the cardiac surgery population. Semin Cardiothorac Vasc Anesth. 2008;12:290–297.PubMedCrossRefGoogle Scholar
  59. 59.
    Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American college of cardiology/American heart association task force on practice guidelines (ACC/AHA/ASE committee to update the 1997 guidelines for the clinical application of echocardiography). Circulation. 2003;108:1146–1162.PubMedCrossRefGoogle Scholar
  60. 60.
    Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American society of echocardiography council for intraoperative echocardiography and the society of cardiovascular anesthesiologists task force for certification in perioperative transesophageal echocardiography. Anesth Analg. 1999;89:870–884.PubMedCrossRefGoogle Scholar
  61. 61.
    Swaminathan M, Grocott HP, Mackensen GB, Podgoreanu MV, Glower DD, Mathew JP. The “sandblasting” effect of aortic cannula on arch atheroma during cardiopulmonary bypass. Anesth Analg. 2007;104:1350–1351.PubMedCrossRefGoogle Scholar
  62. 62.
    Konstadt SN, Reich DL, Quintana C, Levy M. The ascending aorta: how much does transesophageal echocardiography see? Anesth Analg. 1994;78:240–244.PubMedCrossRefGoogle Scholar
  63. 63.
    Van Zaane B, Zuithoff NP, Reitsma JB, Bax L, Nierich AP, Moons KG. Meta-analysis of the diagnostic accuracy of transesophageal echocardiography for assessment of atherosclerosis in the ascending aorta in patients undergoing cardiac surgery. Acta Anaesthesiol Scand. 2008;52:1179–1187.PubMedCrossRefGoogle Scholar
  64. 64.
    Nierich AP, van Zaane B, Buhre WF, Coddens J, Spanjersberg AJ, Moons KG. Visualization of the distal ascending aorta with A-Mode transesophageal echocardiography. J Cardiothorac Vasc Anesth. 2008;22:766–773.PubMedCrossRefGoogle Scholar
  65. 65.
    Van Zaane B, Nierich AP, Buhre WF, Brandon Bravo Bruinsma GJ, Moons KG. Resolving the blind spot of transoesophageal echocardiography: a new diagnostic device for visualizing the ascending aorta in cardiac surgery. Br J Anaesth. 2007;98:434–441.PubMedCrossRefGoogle Scholar
  66. 66.
    Marshall WG Jr, Barzilai B, Kouchoukos NT, Saffitz J. Intraoperative ultrasonic imaging of the ascending aorta. Ann Thorac Surg. 1989;48:339–344.PubMedCrossRefGoogle Scholar
  67. 67.
    Suvarna S, Smith A, Stygall J, et al. An intraoperative assessment of the ascending aorta: a comparison of digital palpation, transesophageal echocardiography, and epiaortic ultrasonography. J Cardiothorac Vasc Anesth. 2007;21:805–809.PubMedCrossRefGoogle Scholar
  68. 68.
    Glas KE, Swaminathan M, Reeves ST, et al. Guidelines for the performance of a comprehensive intraoperative epiaortic ultrasonographic examination: recommendations of the American society of echocardiography and the society of cardiovascular anesthesiologists; endorsed by the society of thoracic surgeons. J Am Soc Echocardiogr. 2007;20:1227–1235.PubMedCrossRefGoogle Scholar
  69. 69.
    Bainbridge D. 3-D imaging for aortic plaque assessment. Semin Cardiothorac Vasc Anesth. 2005;9:163–165.PubMedCrossRefGoogle Scholar
  70. 70.
    Bainbridge DT, Murkin JM, Menkis A, Kiaii B. The use of 3D epiaortic scanning to enhance evaluation of atherosclerotic plaque in the ascending aorta: a case series. Heart Surg Forum. 2004;7:E636–638.PubMedCrossRefGoogle Scholar
  71. 71.
    Ferrari E, Vidal R, Chevallier T, Baudouy M. Atherosclerosis of the thoracic aorta and aortic debris as a marker of poor prognosis: benefit of oral ­anticoagulants. J Am Coll Cardiol. 1999;33:1317–1322.PubMedCrossRefGoogle Scholar
  72. 72.
    Trehan N, Mishra M, Kasliwal RR, Mishra A. Reduced neurological injury during CABG in patients with mobile aortic atheromas: a five-year follow-up study. Ann Thorac Surg. 2000;70:1558–1564.PubMedCrossRefGoogle Scholar
  73. 73.
    Davila-Roman VG, Barzilai B, Wareing TH, Murphy SF, Schechtman KB, Kouchoukos NT. Atherosclerosis of the ascending aorta. Prevalence and role as an independent predictor of cerebrovascular events in cardiac patients. Stroke. 1994;25:2010–2016.PubMedGoogle Scholar
  74. 74.
    Gold JP, Torres KE, Maldarelli W, Zhuravlev I, Condit D, Wasnick J. Improving outcomes in coronary ­surgery: the impact of echo-directed aortic ­cannulation and perioperative hemodynamic management in 500 patients. Ann Thorac Surg. 2004;78:1579–1585.PubMedCrossRefGoogle Scholar
  75. 75.
    Royse AG, Royse CF, Ajani AE, et al. Reduced ­neuropsychological dysfunction using epiaortic echocardiography and the exclusive Y graft. Ann Thorac Surg. 2000;69:1431–1438.PubMedCrossRefGoogle Scholar
  76. 76.
    Glas KE, Swaminathan M, Reeves ST, et al. Guidelines for the performance of a comprehensive intraoperative epiaortic ultrasonographic examination: recommendations of the American society of echocardiography and the society of cardiovascular anesthesiologists; endorsed by the society of thoracic surgeons. J Am Soc Echocardiogr. 2007;20:1227–1235.PubMedCrossRefGoogle Scholar
  77. 77.
    Scharfschwerdt M, Richter A, Boehmer K, Repenning D, Sievers HH. Improved hydrodynamics of a new aortic cannula with a novel tip design. Perfusion. 2004;19:193–197.PubMedCrossRefGoogle Scholar
  78. 78.
    Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg. 1995;109:885–890.PubMedCrossRefGoogle Scholar
  79. 79.
    Stern A, Tunick PA, Culliford AT, et al. Protruding aortic arch atheromas: risk of stroke during heart surgery with and without aortic arch endarterectomy. Am Heart J. 1999;138:746–752.PubMedCrossRefGoogle Scholar
  80. 80.
    Wareing TH, Davila-Roman VG, Daily BB, et al. Strategy for the reduction of stroke incidence in cardiac surgical patients. Ann Thorac Surg. 1993;55:1400–1407.PubMedCrossRefGoogle Scholar
  81. 81.
    Murkin JM, Boyd WD, Ganapathy S, Adams SJ, Peterson RC. Beating heart surgery: why expect less central nervous system morbidity? Ann Thorac Surg. 1999;68:1498–1501.PubMedCrossRefGoogle Scholar
  82. 82.
    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;84:1174–1179.PubMedCrossRefGoogle Scholar
  83. 83.
    Van Dijk D, Jansen EW, Hijman R, et al. Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: a randomized trial. JAMAJ Am Med Assoc. 2002;287:1405–1412.CrossRefGoogle Scholar
  84. 84.
    van Dijk D, Spoor M, Hijman R, et al. Cognitive and cardiac outcomes 5 years after off-pump vs on-pump coronary artery bypass graft surgery. J Am Med Assoc. 2007;297:701–708.CrossRefGoogle Scholar
  85. 85.
    McBride WT, Armstrong MA, McMurray TJ. An investigation of the effects of heparin, low molecular weight heparin, protamine, and fentanyl on the balance of pro- and anti-inflammatory cytokines in in-vitro monocyte cultures. Anaesthesia. 1996;51:634–640.PubMedGoogle Scholar
  86. 86.
    Diephuis JC, Moons KG, Nierich AN, Bruens M, van Dijk D, Kalkman CJ. Jugular bulb desaturation during coronary artery surgery: a comparison of off-pump and on-pump procedures. Br J Anaesth. 2005;94:715–720.PubMedCrossRefGoogle Scholar
  87. 87.
    Croughwell ND, Newman MF, Blumenthal JA, et al. Jugular bulb saturation and cognitive dysfunction after cardiopulmonary bypass. Ann Thorac Surg. 1994;58:1702–1708.PubMedCrossRefGoogle Scholar
  88. 88.
    Takagi H, Kato T, Umemoto T. Off-pump coronary artery bypass sacrifices graft patency. J Thorac Cardiovasc Surg. 2007;133:1394–1395.PubMedGoogle Scholar
  89. 89.
    Al-Ruzzeh S, George S, Bustami M, et al. Effect of off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomised controlled trial. BMJ (Clinical research edBri Med J. 2006;332:1365.CrossRefGoogle Scholar
  90. 90.
    Wijeysundera DN, Beattie WS, Djaiani G, et al. Off-pump coronary artery surgery for reducing mortality and morbidity: meta-analysis of randomized and observational studies. J Am Coll Cardiol. 2005;46:872–882.PubMedCrossRefGoogle Scholar
  91. 91.
    Aldea GS, Soltow LO, Chandler WL, et al. Limitation of thrombin generation, platelet activation, and inflammation by elimination of cardiotomy suction in patients undergoing coronary artery bypass grafting treated with heparin-bonded circuits. J Thorac Cardiovasc Surg. 2002;123:742–755.PubMedCrossRefGoogle Scholar
  92. 92.
    Kincaid EH, Jones TJ, Stump DA, et al. Processing scavenged blood with a cell saver reduces cerebral lipid microembolization. Ann Thorac Surg. 2000;70:1296–1300.PubMedCrossRefGoogle Scholar
  93. 93.
    Whitaker DC, Newman SP, Stygall J, Hope-Wynne C, Harrison MJ, Walesby RK. The effect of leucocyte-depleting arterial line filters on cerebral microemboli and neuropsychological outcome following coronary artery bypass surgery. Eur J Cardiothorac Surg. 2004;25:267–274.PubMedCrossRefGoogle Scholar
  94. 94.
    Challa VR, Lovell MA, Moody DM, Brown WR, Reboussin DM, Markesbery WR. Laser microprobe mass spectrometric study of aluminum and silicon in brain emboli related to cardiac surgery. J Neuropathol Exp Neurol. 1998;57:140–147.PubMedCrossRefGoogle Scholar
  95. 95.
    Rubens FD, Boodhwani M, Mesana T, Wozny D, Wells G, Nathan HJ. The cardiotomy trial: a randomized, double-blind study to assess the effect of processing of shed blood during cardiopulmonary bypass on transfusion and neurocognitive function. Circulation. 2007;116(11 Suppl):I89–97.PubMedGoogle Scholar
  96. 96.
    Djaiani G, Fedorko L, Borger MA, et al. Continuous-flow cell saver reduces cognitive decline in elderly patients after coronary bypass surgery. Circulation. 2007;116:1888–1895.PubMedCrossRefGoogle Scholar
  97. 97.
    Davila-Roman VG, Phillips KJ, Daily BB, Davila RM, Kouchoukos NT, Barzilai B. Intraoperative transesophageal echocardiography and epiaortic ultrasound for assessment of atherosclerosis of the thoracic aorta. J Am Coll Cardiol. 1996;28:942–947.PubMedCrossRefGoogle Scholar
  98. 98.
    Acarturk E, Demir M, Kanadasi M. Aortic atherosclerosis is a marker for significant coronary artery disease. Jpn Heart J. 1999;40:775–781.PubMedCrossRefGoogle Scholar
  99. 99.
    Blackshear JL, Pearce LA, Hart RG, et al. Aortic plaque in atrial fibrillation: prevalence, predictors, and thromboembolic implications. Stroke. 1999;30:834–840.PubMedGoogle Scholar
  100. 100.
    Nohara H, Shida T, Mukohara N, Obo H, Higami T. Ultrasonic plaque density of aortic atheroma and stroke in patients undergoing on-pump coronary bypass surgery. Ann Thorac Cardiovasc Surg. 2004;10:235–240.PubMedGoogle Scholar
  101. 101.
    Sharony R, Grossi EA, Saunders PC, et al. Propensity case-matched analysis of off-pump coronary artery bypass grafting in patients with atheromatous aortic disease. J Thorac Cardiovasc Surg. 2004;127:406–413.PubMedCrossRefGoogle Scholar
  102. 102.
    Sharony R, Bizekis CS, Kanchuger M, et al. Off-pump coronary artery bypass grafting reduces mortality and stroke in patients with atheromatous aortas: a case control study. Circulation. 2003;108(Suppl 1):II15–20.PubMedGoogle Scholar
  103. 103.
    Ribakove GH, Katz ES, Galloway AC, et al. Surgical implications of transesophageal echocardiography to grade the atheromatous aortic arch. Ann Thorac Surg. 1992;53:758–761.PubMedCrossRefGoogle Scholar
  104. 104.
    Barbut D, Lo YW, Hartman GS, et al. Aortic atheroma is related to outcome but not numbers of emboli during coronary bypass. Ann Thorac Surg. 1997;64:454–459.PubMedCrossRefGoogle Scholar
  105. 105.
    Choudhary SK, Bhan A, Sharma R, et al. Aortic ­atherosclerosis and perioperative stroke in patients undergoing coronary artery bypass: role of intra-operative transesophageal echocardiography. Int J Cardiol. 1997;61:31–38.PubMedCrossRefGoogle Scholar
  106. 106.
    Vogt PR, Hauser M, Schwarz U, et al. Complete thromboendarterectomy of the calcified ascending aorta and aortic arch. Ann Thorac Surg. 1999;67:457–461.PubMedCrossRefGoogle Scholar
  107. 107.
    Grossi EA, Bizekis CS, Sharony R, et al. Routine intraoperative transesophageal echocardiography identifies patients with atheromatous aortas: impact on “off-pump” coronary artery bypass and perioperative stroke. J Am Soc Echocardiogr. 2003;16:751–755.PubMedCrossRefGoogle Scholar
  108. 108.
    Bolotin G, Domany Y, de Perini L, et al. Use of ­intraoperative epiaortic ultrasonography to delineate aortic atheroma. Chest. 2005;127:60–65.PubMedCrossRefGoogle Scholar
  109. 109.
    Hogue CW Jr, Murphy SF, Schechtman KB, Davila-Roman VG. Risk factors for early or delayed stroke after cardiac surgery. Circulation. 1999;100:642–647.PubMedGoogle Scholar
  110. 110.
    Davila-Roman VG, Kouchoukos NT, Schechtman KB, Barzilai B. Atherosclerosis of the ascending aorta is a predictor of renal dysfunction after cardiac operations. J Thorac Cardiovasc Surg. 1999;117:111–116.PubMedCrossRefGoogle Scholar
  111. 111.
    Hangler HB, Nagele G, Danzmayr M, et al. Modification of surgical technique for ascending aortic atherosclerosis: impact on stroke reduction in coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;126:391–400.PubMedCrossRefGoogle Scholar
  112. 112.
    Kouchoukos NT, Wareing TH, Daily BB, Murphy SF. Management of the severely atherosclerotic aorta during cardiac operations. J Card Surg. 1994;9:490–494.PubMedCrossRefGoogle Scholar
  113. 113.
    Bonatti J, Nagele G, Hangler H, et al. Extraanatomical coronary artery bypass grafts on the beating heart for management of the severely atherosclerotic ascending aorta. Heart Surg Forum. 2002;5(Suppl 4):S272–281.PubMedGoogle Scholar
  114. 114.
    Royse C, Royse A, Blake D, Grigg L. Assessment of thoracic aortic atheroma by echocardiography: a new classification and estimation of risk of dislodging atheroma during three surgical techniques. Ann Thorac Cardiovasc Surg. 1998;4:72–77.PubMedGoogle Scholar
  115. 115.
    Trehan N, Mishra M, Kasliwal RR, Mishra A. Surgical strategies in patients at high risk for stroke undergoing coronary artery bypass grafting. Ann Thorac Surg. 2000;70:1037–1045.PubMedCrossRefGoogle Scholar
  116. 116.
    Trehan N, Mishra M, Dhole S, Mishra A, Karlekar A, Kohli VM. Significantly reduced incidence of stroke during coronary artery bypass grafting using transesophageal echocardiography. Eur J Cardiothorac Surg. 1997;11:234–242.PubMedCrossRefGoogle Scholar
  117. 117.
    Nicolosi AC, Aggarwal A, Almassi GH, Olinger GN. Intraoperative epiaortic ultrasound during cardiac surgery. J Card Surg. 1996;11:49–55.PubMedCrossRefGoogle Scholar
  118. 118.
    Djaiani G, Fedorko L, Borger M, et al. Mild to moderate atheromatous disease of the thoracic aorta and new ischemic brain lesions after conventional coronary artery bypass graft surgery. Stroke. 2004;35:e356–358.PubMedCrossRefGoogle Scholar
  119. 119.
    Kumral E, Balkir K, Uzuner N, Evyapan D, Nalbantgil S. Microembolic signal detection in patients with symptomatic and asymptomatic lone atrial fibrillation. Cerebrovasc Dis. 2001;12:192–196.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Fellery de Lange
  • G. Burkhard Mackensen
  • Madhav Swaminathan
    • 1
  1. 1.Department of AnesthesiologyDuke University Medical CenterDurhamUSA

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