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Adverse Effect of Manipulation of the Ascending Aorta on Stroke after Off-Pump Coronary Artery Bypass Surgery
Takeshi Kinoshita, Tohru Asai, Tomoaki Suzuki.
Shiga University of Medical Science, Otsu, Japan.

OBJECTIVE: We retrospectively examined the adverse effect of manipulation of the ascending aorta on stroke after off-pump CABG.
METHODS: Of 1006 consecutive patients underwent isolated CABG between January 2002 and August 2012, we studied 1000 patients who underwent off-pump CABG without conversion to cardiopulmonary bypass during surgery. We excluded the remaining 6 patients who required emergent PCPS support at other hospitals for cardiac arrest caused by AMI and were then transferred to our hospital, where they underwent emergent CABG with PCPS support. Stroke was defined as a postoperative central neurological deficit lasting >24 hours confirmed by MR scan that resulted in irreversible body impairment. Vein-to-aorta anastomosis was performed using partial clamping or an anastomotic device after assessing the severity and location of atherosclerosis of the ascending aorta using CT scan and epiaortic ultrasonography. Propensity score was created to quantify the likelihood that manipulation of the aorta would be performed in a given patient using a multivariate logistic regression based on the following even
variables with a significant level of < 0.05 in bivariate analyses: age, female gender, body mass index, smoking, hyperlipidemia, chronic kidney disease, previous myocardial infarction, and preoperative intra-aortic balloon pumping (C statistics, 0.74; Hosmer-Lemeshow goodness of fit chi square, 5.92, p=0.657).
RESULTS: The incidence of stroke was 1.1% of all patients (11/1000), 2.0% of patients who did receive the manipulation of the ascending aorta (8/414), and 0.5% of patients who did not (3/586). The risk factors statistically significant in a multivariate logistic regression model were manipulation of the ascending aorta (odds ratio, 2.22; 95% CI, 1.55 to 5.55; p=0.001), history of stroke (odds ratio, 3.59; 95% CI, 1.75 to 7.12; p=0.001), and estimated glomerular filtration rate <60 mL/min/1.73 m2 (odds ratio, 4.76; 95% CI, 2.15 to 7.31; p=0.001). Propensity score-adjusted odds ratio (95% CI) of manipulation of the ascending aorta for the association with postoperative stroke was 2.73 (1.44 to 5.82).
CONCLUSIONS: Manipulation of the ascending aorta needs to be avoided to further reduce the risk of stroke after off-pump CABG.


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