Postperfusion syndrome: Difference between revisions
m sp (7): et. al.→et al. |
m Robot-assisted disambiguation (you can help!): Mortality |
||
| Line 5: | Line 5: | ||
A study by Newman et al. at [[Duke University Medical Center]] published in the ''[[New England Journal of Medicine]]'' (NEJM), showed an increased incidence of cognitive decline after [[coronary artery bypass surgery]] (CABG); both immediately (53 percent at discharge from [[hospital]]) and over time (36 percent six weeks , 24 percent at six months, and 42 percent at five years).<ref name="Newman">{{cite journal | author = Newman M, Kirchner J, Phillips-Bute B, Gaver V, Grocott H, Jones R, Mark D, Reves J, Blumenthal J | title = Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. | journal = N Engl J Med | volume = 344 | issue = 6 | pages = 395-402 | year = 2001 | id = PMID 11172175}}</ref> This study shows a strong association of neurocognitive decline with CABG, but as [[Evidence-based medicine#Qualification of evidence|level II-3]] (due to the lack of a [[control group]]) cannot be used to demonstrate causation. |
A study by Newman et al. at [[Duke University Medical Center]] published in the ''[[New England Journal of Medicine]]'' (NEJM), showed an increased incidence of cognitive decline after [[coronary artery bypass surgery]] (CABG); both immediately (53 percent at discharge from [[hospital]]) and over time (36 percent six weeks , 24 percent at six months, and 42 percent at five years).<ref name="Newman">{{cite journal | author = Newman M, Kirchner J, Phillips-Bute B, Gaver V, Grocott H, Jones R, Mark D, Reves J, Blumenthal J | title = Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. | journal = N Engl J Med | volume = 344 | issue = 6 | pages = 395-402 | year = 2001 | id = PMID 11172175}}</ref> This study shows a strong association of neurocognitive decline with CABG, but as [[Evidence-based medicine#Qualification of evidence|level II-3]] (due to the lack of a [[control group]]) cannot be used to demonstrate causation. |
||
Subsequent studies have compared "on-pump" CABG with [[off-pump coronary artery bypass]] (OPCAB) - essentially establishing controls to compare of the incidence of neurocognitive decline in CABG with and without the use of CPB. A small study (60 patients total, 30 in each treatment arm) by Zamvar et al. demonstrated neurocognitive impairment at both 1 week and 10 weeks postoperatively.<ref name="Zamvar">{{cite journal | author = Zamvar V, Williams D, Hall J, Payne N, Cann C, Young K, Karthikeyan S, Dunne J | title = Assessment of neurocognitive impairment after off-pump and on-pump techniques for coronary artery bypass graft surgery: prospective randomised controlled trial. | journal = BMJ | volume = 325 | issue = 7375 | pages = 1268 | year = 2002 | id = PMID 12458242}}</ref> However, a larger study (281 patients total) by Van Dijk et al. showed CABG surgery without cardiopulmonary bypass improved cognitive outcomes 3 months after the procedure, but the effects were limited and became negligible at 12 months.<ref name="VanDijk">{{cite journal | author = Van Dijk D, Jansen E, Hijman R, Nierich A, Diephuis J, Moons K, Lahpor J, Borst C, Keizer A, Nathoe H, Grobbee D, De Jaegere P, Kalkman C | title = Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: a randomized trial. | journal = JAMA | volume = 287 | issue = 11 | pages = 1405-12 | year = 2002 | id = PMID 11903027}}</ref> Furthermore, the Van Dijk study showed no difference between the on-pump and off-pump groups in quality of life, [[stroke]] rate, or all-cause [[mortality]] at 3 and 12 months. More recently OPCAB has been proposed to be beneficial in patients at high-risk of neurological injury; a study by Jenson et. al published in Circulation found no significant difference in the incidence of cognitive dysfunction 3 months after either OPCAB or off-pump CABG.<ref name="Jenson">{{cite journal | author = Jensen B, Hughes P, Rasmussen L, Pedersen P, Steinbrüchel D | title = Cognitive outcomes in elderly high-risk patients after off-pump versus conventional coronary artery bypass grafting: a randomized trial. | journal = Circulation | volume = 113 | issue = 24 | pages = 2790-5 | year = 2006 | id = PMID 16769915}}</ref> |
Subsequent studies have compared "on-pump" CABG with [[off-pump coronary artery bypass]] (OPCAB) - essentially establishing controls to compare of the incidence of neurocognitive decline in CABG with and without the use of CPB. A small study (60 patients total, 30 in each treatment arm) by Zamvar et al. demonstrated neurocognitive impairment at both 1 week and 10 weeks postoperatively.<ref name="Zamvar">{{cite journal | author = Zamvar V, Williams D, Hall J, Payne N, Cann C, Young K, Karthikeyan S, Dunne J | title = Assessment of neurocognitive impairment after off-pump and on-pump techniques for coronary artery bypass graft surgery: prospective randomised controlled trial. | journal = BMJ | volume = 325 | issue = 7375 | pages = 1268 | year = 2002 | id = PMID 12458242}}</ref> However, a larger study (281 patients total) by Van Dijk et al. showed CABG surgery without cardiopulmonary bypass improved cognitive outcomes 3 months after the procedure, but the effects were limited and became negligible at 12 months.<ref name="VanDijk">{{cite journal | author = Van Dijk D, Jansen E, Hijman R, Nierich A, Diephuis J, Moons K, Lahpor J, Borst C, Keizer A, Nathoe H, Grobbee D, De Jaegere P, Kalkman C | title = Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: a randomized trial. | journal = JAMA | volume = 287 | issue = 11 | pages = 1405-12 | year = 2002 | id = PMID 11903027}}</ref> Furthermore, the Van Dijk study showed no difference between the on-pump and off-pump groups in quality of life, [[stroke]] rate, or all-cause [[death|mortality]] at 3 and 12 months. More recently OPCAB has been proposed to be beneficial in patients at high-risk of neurological injury; a study by Jenson et. al published in Circulation found no significant difference in the incidence of cognitive dysfunction 3 months after either OPCAB or off-pump CABG.<ref name="Jenson">{{cite journal | author = Jensen B, Hughes P, Rasmussen L, Pedersen P, Steinbrüchel D | title = Cognitive outcomes in elderly high-risk patients after off-pump versus conventional coronary artery bypass grafting: a randomized trial. | journal = Circulation | volume = 113 | issue = 24 | pages = 2790-5 | year = 2006 | id = PMID 16769915}}</ref> |
||
Given the above evidence, there is high incidence of neurocognitive deficit post bypass surgery, but the deficits are transient with no permanent neurological impairment. Controlled "on-pump" versus "off-pump" cardiac surgery has only been studied in the setting of CABG and is not necessarily generalizable to other types of cardiac surgery. Recent advancements in [[transcatheter]] and [[percutaneous]] [[valve replacement]] may soon allow comparison of other types of cardiac surgery with and without CPB. |
Given the above evidence, there is high incidence of neurocognitive deficit post bypass surgery, but the deficits are transient with no permanent neurological impairment. Controlled "on-pump" versus "off-pump" cardiac surgery has only been studied in the setting of CABG and is not necessarily generalizable to other types of cardiac surgery. Recent advancements in [[transcatheter]] and [[percutaneous]] [[valve replacement]] may soon allow comparison of other types of cardiac surgery with and without CPB. |
||
Revision as of 00:21, 23 May 2007
Postperfusion syndrome, also known as pumphead, is a controversial condition that describes a constellation of neurocognitive impairments attributed to cardiopulmonary bypass (CPB) during cardiac surgery. Symptoms of postperfusion syndrome are thought to include memory impairment, stilted speech, depression, confusion, and diminished hand-eye coordination. Patients are also thought to experience altered sex drive, lessened inhibitions and other personality changes.[1] Studies have shown a high incidence of neurocognitive deficit soon after surgery, but the deficits are transient with no permanent neurological impairment.
Evidence for postperfusion syndrome
A study by Newman et al. at Duke University Medical Center published in the New England Journal of Medicine (NEJM), showed an increased incidence of cognitive decline after coronary artery bypass surgery (CABG); both immediately (53 percent at discharge from hospital) and over time (36 percent six weeks , 24 percent at six months, and 42 percent at five years).[2] This study shows a strong association of neurocognitive decline with CABG, but as level II-3 (due to the lack of a control group) cannot be used to demonstrate causation.
Subsequent studies have compared "on-pump" CABG with off-pump coronary artery bypass (OPCAB) - essentially establishing controls to compare of the incidence of neurocognitive decline in CABG with and without the use of CPB. A small study (60 patients total, 30 in each treatment arm) by Zamvar et al. demonstrated neurocognitive impairment at both 1 week and 10 weeks postoperatively.[3] However, a larger study (281 patients total) by Van Dijk et al. showed CABG surgery without cardiopulmonary bypass improved cognitive outcomes 3 months after the procedure, but the effects were limited and became negligible at 12 months.[4] Furthermore, the Van Dijk study showed no difference between the on-pump and off-pump groups in quality of life, stroke rate, or all-cause mortality at 3 and 12 months. More recently OPCAB has been proposed to be beneficial in patients at high-risk of neurological injury; a study by Jenson et. al published in Circulation found no significant difference in the incidence of cognitive dysfunction 3 months after either OPCAB or off-pump CABG.[5]
Given the above evidence, there is high incidence of neurocognitive deficit post bypass surgery, but the deficits are transient with no permanent neurological impairment. Controlled "on-pump" versus "off-pump" cardiac surgery has only been studied in the setting of CABG and is not necessarily generalizable to other types of cardiac surgery. Recent advancements in transcatheter and percutaneous valve replacement may soon allow comparison of other types of cardiac surgery with and without CPB.
Proposed mechanism of injury
Physicians speculate causation by tiny debris and air bubbles (microemboli) that enter the brain via cardiopulmonary bypass. Surgeons attempt to minimize time spent on bypass to decrease postoperative deficits; studies have shown increased bypass time is associated with increased incidence and severity of postperfusion syndrome[citation needed] and mortality.[citation needed]
Neurocognitive deficit as a consequence of vascular disease
A study by McKhann et al.[6] compared the neurocognitive outcome of people with coronary artery disease (CAD) to heart-healthy controls (people with no cardiac risk factors). People with CAD were subdivided into treatment with CABG, OPCAB and non-surgical medical management. The three groups with CAD all performed significantly lower at baseline than the heart-healthy controls. All groups improved by 3 months, and there were minimal intrasubject changes from 3 to 12 months. No consistent difference between the CABG and off-pump patients was observed. The authors concluded patients with long-standing coronary artery disease have some degree of cognitive dysfunction secondary to cerebrovascular disease before surgery; there is no evidence the cognitive test performance of bypass surgery patients differed from similar control groups with coronary artery disease over a 12 month follow-up period. A related study by Selnes et al.[7] concluded patients with coronary artery bypass grafting did not differ from a comparable nonsurgical control group with coronary artery disease 1 or 3 years after baseline examination. This finding suggests that late cognitive decline after coronary artery bypass grafting previously reported by Newman et al.[2] may not be specific to the use of cardiopulmonary bypass, but may also occur in patients with similar risk factors for cardiovascular and cerebrovascular disease.
Postperfusion syndrome in the press
Postperfusion syndrome has attracted some public notoriety following the coronary bypasses of former U.S. President Bill Clinton and Vice-President Dick Cheney. The National Enquirer published an article [8] speculating Clinton experienced permanent debilitating brain damage; using the NEJM article[2] discussed above to provide credibility to the claim.
See also
- Heparin-coated blood oxygenator
- Postoperative cognitive dysfunction
- Post-chemotherapy cognitive impairment (aka "chemo brain")
References
- ^ Stutz, Bruce (2003). "Pumphead". Scientific American Magazine. Retrieved 2006-11-08.
{{cite web}}: Unknown parameter|month=ignored (help) - ^ a b c Newman M, Kirchner J, Phillips-Bute B, Gaver V, Grocott H, Jones R, Mark D, Reves J, Blumenthal J (2001). "Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery". N Engl J Med. 344 (6): 395–402. PMID 11172175.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Zamvar V, Williams D, Hall J, Payne N, Cann C, Young K, Karthikeyan S, Dunne J (2002). "Assessment of neurocognitive impairment after off-pump and on-pump techniques for coronary artery bypass graft surgery: prospective randomised controlled trial". BMJ. 325 (7375): 1268. PMID 12458242.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Van Dijk D, Jansen E, Hijman R, Nierich A, Diephuis J, Moons K, Lahpor J, Borst C, Keizer A, Nathoe H, Grobbee D, De Jaegere P, Kalkman C (2002). "Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: a randomized trial". JAMA. 287 (11): 1405–12. PMID 11903027.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Jensen B, Hughes P, Rasmussen L, Pedersen P, Steinbrüchel D (2006). "Cognitive outcomes in elderly high-risk patients after off-pump versus conventional coronary artery bypass grafting: a randomized trial". Circulation. 113 (24): 2790–5. PMID 16769915.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ McKhann G, Grega M, Borowicz L, Bailey M, Barry S, Zeger S, Baumgartner W, Selnes O (2005). "Is there cognitive decline 1 year after CABG? Comparison with surgical and nonsurgical controls". Neurology. 65 (7): 991–9. PMID 16107605.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Selnes O, Grega M, Borowicz L, Barry S, Zeger S, Baumgartner W, McKhann G (2005). "Cognitive outcomes three years after coronary artery bypass surgery: a comparison of on-pump coronary artery bypass graft surgery and nonsurgical controls". Ann Thorac Surg. 79 (4): 1201–9. PMID 15797050.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Brenna, Tony and Peter Davidson (2004). "Clinton's Secret Health Crisis". Retrieved 2006-11-08.
{{cite web}}: Unknown parameter|month=ignored (help)
Further reading
- PMID 16785349 Can Cognition Survive Heart Surgery? Editorial by MA Samuels accompanying Jenson et al. [1].
- Cardiac Surgery In The Adult Chapter 11D Organ Damage
External links
- Pump Head - Cognitive Impairment After Bypass Surgery and rebuttal Pump Head - Not a Problem After All? Richard N. Fogoros, M.D. articles at about.com
- http://biomed.brown.edu/Courses/BI108/2006-108websites/group01Heparin-coatedOxygenators/pages/Background.htm
- ^ Jensen B, Hughes P, Rasmussen L, Pedersen P, Steinbrüchel D (2006). "Cognitive outcomes in elderly high-risk patients after off-pump versus conventional coronary artery bypass grafting: a randomized trial". Circulation. 113 (24): 2790–5. PMID 16769915.
{{cite journal}}: CS1 maint: multiple names: authors list (link)