Research progress on silent cerebral infarction after cardiac surgery through cardiopulmonary bypass_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LIU Yu , ZHANG Hongwei , YANG Peng , HUANG Yao , LU Chen ,  HU Jia

Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P.R.China;

Corresponding author：

HU Jia, Email: humanjia@msn.com

Keywords：

Silent cerebral infarction; cardiopulmonary bypass; embolus; review

DOI：

10.7507/1007-4848.202004098

Video：

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In the absence of symptoms, silent cerebral infarction can be discovered incidentally during an imaging or neuropathological examination. After cardiovascular surgery with cardiopulmonary bypass, the morbidity is high, and it may contribute to neurocognitive dysfunction, symptomatic cerebral infarction and increased risk of death. The embolus caused by various operations intraoperatively are closely associated with this progress. However, controversies over the prevention still persist. As a result, an overall summary of silent cerebral infarction after cardiovascular surgery with cardiopulmonary bypass will be presented in this review.

Citation： LIU Yu, ZHANG Hongwei, YANG Peng, HUANG Yao, LU Chen, HU Jia. Research progress on silent cerebral infarction after cardiac surgery through cardiopulmonary bypass. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2021, 28(6): 735-739. doi: 10.7507/1007-4848.202004098 Copy

1.	Sacco RL, Kasner SE, Broderick JP, et al. An updated definition of stroke for the 21st century: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 2013, 44(7): 2064-2089.
2.	Sun X, Lindsay J, Monsein LH, et al. Silent brain injury after cardiac surgery: A review: Cognitive dysfunction and magnetic resonance imaging diffusion-weighted imaging findings. J Am Coll Cardiol, 2012, 60(9): 791-797.
3.	Fanning JP, Wesley AJ, Wong AA, et al. Emerging spectra of silent brain infarction. Stroke, 2014, 45(11): 3461-3471.
4.	Smith EE, Saposnik G, Biessels GJ, et al. Prevention of stroke in patients with silent cerebrovascular disease: A scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 2017, 48(2): e44-e71.
5.	Grabert S, Lange R, Bleiziffer S. Incidence and causes of silent and symptomatic stroke following surgical and transcatheter aortic valve replacement: A comprehensive review. Interact Cardiovasc Thorac Surg, 2016, 23(3): 469-476.
6.	Messé SR, Acker MA, Kasner SE, et al. Stroke after aortic valve surgery: Results from a prospective cohort. Circulation, 2014, 129(22): 2253-2261.
7.	Hassell ME, Nijveldt R, Roos YB, et al. Silent cerebral infarcts associated with cardiac disease and procedures. Nat Rev Cardiol, 2013, 10(12): 696-706.
8.	Fisher CM. Lacunes: Small, deep cerebral infarcts. Neurology, 1965, 15: 774-784.
9.	Vedel AG, Holmgaard F, Rasmussen LS, et al. High-target versus low-target blood pressure management during cardiopulmonary bypass to prevent cerebral injury in cardiac surgery patients: A randomized controlled trial. Circulation, 2018, 137(17): 1770-1780.
10.	De Vaal MH, Gee MW, Stock UA, et al. Computational evaluation of aortic occlusion and the proposal of a novel, improved occluder: Constrained endo-aortic balloon occlusion. Int J Numer Method Biomed Eng, 2016, 32(12).
11.	Babin-Ebell J, Gimpel-Henning K, Sievers HH, et al. Influence of clamp duration and pressure on endothelial damage in aortic cross-clamping. Interact Cardiovasc Thorac Surg, 2010, 10(2): 168-171.
12.	Kovács KR, Czuriga D, Bereczki D, et al. Silent brain infarction—A review of recent observations. Int J Stroke, 2013, 8(5): 334-347.
13.	Taylor RL, Borger MA, Weisel RD, et al. Cerebral microemboli during cardiopulmonary bypass: Increased emboli during perfusionist interventions. Ann Thorac Surg, 1999, 68(1): 89-93.
14.	Borger MA, Peniston CM, Weisel RD, et al. Neuropsychologic impairment after coronary bypass surgery: Effect of gaseous microemboli during perfusionist interventions. J Thorac Cardiovasc Surg, 2001, 121(4): 743-749.
15.	Uysal S, Reich DL. Neurocognitive outcomes of cardiac surgery. J Cardiothorac Vasc Anesth, 2013, 27(5): 958-971.
16.	Park-Hansen J, Holme SJV, Irmukhamedov A, et al. Adding left atrial appendage closure to open heart surgery provides protection from ischemic brain injury six years after surgery independently of atrial fibrillation history: The LAACS randomized study. J Cardiothorac Surg, 2018, 13(1): 53.
17.	中华医学会神经病学分会中华医学会神经病学分会脑血管病学组. 中国无症状脑梗死诊治共识. 中华神经科杂志, 2018, 51(9): 692-698.
18.	Berger M, Terrando N, Smith SK, et al. Neurocognitive function after cardiac surgery: From phenotypes to mechanisms. Anesthesiology, 2018, 129(4): 829-851.
19.	Banbury MK, Kouchoukos NT, Allen KB, et al. Emboli capture using the Embol-X intraaortic filter in cardiac surgery: A multicentered randomized trial of 1, 289 patients. Ann Thorac Surg, 2003, 76(2): 508-515.
20.	Shani L, Cohen O, Beckerman Z, et al. Novel emboli protection cannula during cardiac surgery: First animal study. Asian Cardiovasc Thorac Ann, 2014, 22(1): 25-30.
21.	Bolotin G, Huber CH, Shani L, et al. Novel emboli protection system during cardiac surgery: A multi-center, randomized, clinical trial. Ann Thorac Surg, 2014, 98(5): 1627-1633.
22.	Mack MJ, Acker MA, Gelijns AC, et al. Effect of cerebral embolic protection devices on CNS infarction in surgical aortic valve replacement: A randomized clinical trial. JAMA, 2017, 318(6): 536-547.
23.	Crestanello JA. "Not in my brain": The use of embolic protection devices to prevent brain embolization during cardiovascular procedures. J Thorac Cardiovasc Surg, 2018, 156(6): e205-e206.205-206.
24.	Caplan LR, Hennerici M. Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol, 1998, 55(11): 1475-1482.
25.	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(5): 1302-1311.
26.	Siepe M, Pfeiffer T, Gieringer A, et al. Increased systemic perfusion pressure during cardiopulmonary bypass is associated with less early postoperative cognitive dysfunction and delirium. Eur J Cardiothorac Surg, 2011, 40(1): 200-207.
27.	鲍春荣, 梅举, 丁芳宝, 等. 应用中低温停循环联合单侧脑灌注行急诊弓部替换手术的早中期结果. 中国胸心血管外科临床杂志, 2019, 26(8): 1-5.
28.	Matte GS, del Nido PJ. History and use of del Nido cardioplegia solution at Boston Children's Hospital. J Extra Corpor Technol, 2012, 44(3): 98-103.
29.	Ramanathan R, Parrish DW, Armour TK, et al. Use of del Nido cardioplegia in adult cardiac surgery. Thorac Cardiovasc Surg, 2015, 63(7): 624-627.
30.	Guajardo Salinas GE, Nutt R, Rodriguez-Araujo G. Del Nido cardioplegia in low risk adults undergoing first time coronary artery bypass surgery. Perfusion, 2017, 32(1): 68-73.
31.	O'Donnell C, Wang H, Tran P, et al. Utilization of Del Nido cardioplegia in adult coronary artery bypass grafting — A retrospective analysis. Circ J, 2019, 83(2): 342-346.
32.	Govindapillai A, Hua R, Rose R, et al. Protecting the aged heart during cardiac surgery: Use of del Nido cardioplegia provides superior functional recovery in isolated hearts. J Thorac Cardiovasc Surg, 2013, 146(4): 940-948.
33.	Ad N, Holmes SD, Massimiano PS, et al. The use of del Nido cardioplegia in adult cardiac surgery: A prospective randomized trial. J Thorac Cardiovasc Surg, 2018, 155(3): 1011-1018.
34.	Kavala AA, Turkyilmaz S. Comparison of del Nido cardioplegia with blood cardioplegia in coronary artery bypass grafting combined with mitral valve replacement. Braz J Cardiovasc Surg, 2018, 33(5): 496-504.
35.	Timek T, Willekes C, Hulme O, et al. Propensity matched analysis of del Nido cardioplegia in adult coronary artery bypass grafting: Initial experience with 100 consecutive patients. Ann Thorac Surg, 2016, 101(6): 2237-2241.
36.	吕晓钗, 叶建熙, 刘燕. Del Nido心肌保护液在成人心脏瓣膜手术中应用的病例对照研究. 中国胸心血管外科临床杂志, 2018, 25(9): 781-785.
37.	Mukdad L, Toppen W, Sanaiha Y, et al. Incidence of cerebral microemboli in single-dose vs. multidose cardioplegia in adult cardiac surgery. J Extra Corpor Technol, 2018, 50(3): 143-148.
38.	Valooran GJ, Nair SK, Chandrasekharan K, et al. del Nido cardioplegia in adult cardiac surgery — Scopes and concerns. Perfusion, 2016, 31(1): 6-14.
39.	Saqqur M, Tsivgoulis G, Nicoli F, et al. The role of sonolysis and sonothrombolysis in acute ischemic stroke: A systematic review and meta-analysis of randomized controlled trials and case-control studies. J Neuroimaging, 2014, 24(3): 209-220.
40.	Školoudík D, Hurtíková E, Brát R, et al. Sonolysis in prevention of brain infarction during cardiac surgery (SONORESCUE): Randomized, controlled trial. Medicine (Baltimore), 2016, 95(20): e3615.
41.	韩劲松. 左心耳干预在心房颤动外科治疗中的研究进展. 中国胸心血管外科临床杂志, 2015, 22(1): 75-79.
42.	Patel D, Gillinov MA, Natale A. Atrial fibrillation after cardiac surgery: Where are we now? Indian Pacing Electrophysiol J, 2008, 8(4): 281-291.
43.	Yao X, Gersh BJ, Holmes DR, et al. Association of surgical left atrial appendage occlusion with subsequent stroke and mortality among patients undergoing cardiac surgery. JAMA, 2018, 319(20): 2116-2126.
44.	Atti V, Anantha-Narayanan M, Turagam MK, et al. Surgical left atrial appendage occlusion during cardiac surgery: A systematic review and meta-analysis. World J Cardiol, 2018, 10(11): 242-249.

1. Sacco RL, Kasner SE, Broderick JP, et al. An updated definition of stroke for the 21st century: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 2013, 44(7): 2064-2089.
2. Sun X, Lindsay J, Monsein LH, et al. Silent brain injury after cardiac surgery: A review: Cognitive dysfunction and magnetic resonance imaging diffusion-weighted imaging findings. J Am Coll Cardiol, 2012, 60(9): 791-797.
3. Fanning JP, Wesley AJ, Wong AA, et al. Emerging spectra of silent brain infarction. Stroke, 2014, 45(11): 3461-3471.
4. Smith EE, Saposnik G, Biessels GJ, et al. Prevention of stroke in patients with silent cerebrovascular disease: A scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 2017, 48(2): e44-e71.
5. Grabert S, Lange R, Bleiziffer S. Incidence and causes of silent and symptomatic stroke following surgical and transcatheter aortic valve replacement: A comprehensive review. Interact Cardiovasc Thorac Surg, 2016, 23(3): 469-476.
6. Messé SR, Acker MA, Kasner SE, et al. Stroke after aortic valve surgery: Results from a prospective cohort. Circulation, 2014, 129(22): 2253-2261.
7. Hassell ME, Nijveldt R, Roos YB, et al. Silent cerebral infarcts associated with cardiac disease and procedures. Nat Rev Cardiol, 2013, 10(12): 696-706.
8. Fisher CM. Lacunes: Small, deep cerebral infarcts. Neurology, 1965, 15: 774-784.
9. Vedel AG, Holmgaard F, Rasmussen LS, et al. High-target versus low-target blood pressure management during cardiopulmonary bypass to prevent cerebral injury in cardiac surgery patients: A randomized controlled trial. Circulation, 2018, 137(17): 1770-1780.
10. De Vaal MH, Gee MW, Stock UA, et al. Computational evaluation of aortic occlusion and the proposal of a novel, improved occluder: Constrained endo-aortic balloon occlusion. Int J Numer Method Biomed Eng, 2016, 32(12).
11. Babin-Ebell J, Gimpel-Henning K, Sievers HH, et al. Influence of clamp duration and pressure on endothelial damage in aortic cross-clamping. Interact Cardiovasc Thorac Surg, 2010, 10(2): 168-171.
12. Kovács KR, Czuriga D, Bereczki D, et al. Silent brain infarction—A review of recent observations. Int J Stroke, 2013, 8(5): 334-347.
13. Taylor RL, Borger MA, Weisel RD, et al. Cerebral microemboli during cardiopulmonary bypass: Increased emboli during perfusionist interventions. Ann Thorac Surg, 1999, 68(1): 89-93.
14. Borger MA, Peniston CM, Weisel RD, et al. Neuropsychologic impairment after coronary bypass surgery: Effect of gaseous microemboli during perfusionist interventions. J Thorac Cardiovasc Surg, 2001, 121(4): 743-749.
15. Uysal S, Reich DL. Neurocognitive outcomes of cardiac surgery. J Cardiothorac Vasc Anesth, 2013, 27(5): 958-971.
16. Park-Hansen J, Holme SJV, Irmukhamedov A, et al. Adding left atrial appendage closure to open heart surgery provides protection from ischemic brain injury six years after surgery independently of atrial fibrillation history: The LAACS randomized study. J Cardiothorac Surg, 2018, 13(1): 53.
17. 中华医学会神经病学分会中华医学会神经病学分会脑血管病学组. 中国无症状脑梗死诊治共识. 中华神经科杂志, 2018, 51(9): 692-698.
18. Berger M, Terrando N, Smith SK, et al. Neurocognitive function after cardiac surgery: From phenotypes to mechanisms. Anesthesiology, 2018, 129(4): 829-851.
19. Banbury MK, Kouchoukos NT, Allen KB, et al. Emboli capture using the Embol-X intraaortic filter in cardiac surgery: A multicentered randomized trial of 1, 289 patients. Ann Thorac Surg, 2003, 76(2): 508-515.
20. Shani L, Cohen O, Beckerman Z, et al. Novel emboli protection cannula during cardiac surgery: First animal study. Asian Cardiovasc Thorac Ann, 2014, 22(1): 25-30.
21. Bolotin G, Huber CH, Shani L, et al. Novel emboli protection system during cardiac surgery: A multi-center, randomized, clinical trial. Ann Thorac Surg, 2014, 98(5): 1627-1633.
22. Mack MJ, Acker MA, Gelijns AC, et al. Effect of cerebral embolic protection devices on CNS infarction in surgical aortic valve replacement: A randomized clinical trial. JAMA, 2017, 318(6): 536-547.
23. Crestanello JA. "Not in my brain": The use of embolic protection devices to prevent brain embolization during cardiovascular procedures. J Thorac Cardiovasc Surg, 2018, 156(6): e205-e206.205-206.
24. Caplan LR, Hennerici M. Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol, 1998, 55(11): 1475-1482.
25. 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(5): 1302-1311.
26. Siepe M, Pfeiffer T, Gieringer A, et al. Increased systemic perfusion pressure during cardiopulmonary bypass is associated with less early postoperative cognitive dysfunction and delirium. Eur J Cardiothorac Surg, 2011, 40(1): 200-207.
27. 鲍春荣, 梅举, 丁芳宝, 等. 应用中低温停循环联合单侧脑灌注行急诊弓部替换手术的早中期结果. 中国胸心血管外科临床杂志, 2019, 26(8): 1-5.
28. Matte GS, del Nido PJ. History and use of del Nido cardioplegia solution at Boston Children's Hospital. J Extra Corpor Technol, 2012, 44(3): 98-103.
29. Ramanathan R, Parrish DW, Armour TK, et al. Use of del Nido cardioplegia in adult cardiac surgery. Thorac Cardiovasc Surg, 2015, 63(7): 624-627.
30. Guajardo Salinas GE, Nutt R, Rodriguez-Araujo G. Del Nido cardioplegia in low risk adults undergoing first time coronary artery bypass surgery. Perfusion, 2017, 32(1): 68-73.
31. O'Donnell C, Wang H, Tran P, et al. Utilization of Del Nido cardioplegia in adult coronary artery bypass grafting — A retrospective analysis. Circ J, 2019, 83(2): 342-346.
32. Govindapillai A, Hua R, Rose R, et al. Protecting the aged heart during cardiac surgery: Use of del Nido cardioplegia provides superior functional recovery in isolated hearts. J Thorac Cardiovasc Surg, 2013, 146(4): 940-948.
33. Ad N, Holmes SD, Massimiano PS, et al. The use of del Nido cardioplegia in adult cardiac surgery: A prospective randomized trial. J Thorac Cardiovasc Surg, 2018, 155(3): 1011-1018.
34. Kavala AA, Turkyilmaz S. Comparison of del Nido cardioplegia with blood cardioplegia in coronary artery bypass grafting combined with mitral valve replacement. Braz J Cardiovasc Surg, 2018, 33(5): 496-504.
35. Timek T, Willekes C, Hulme O, et al. Propensity matched analysis of del Nido cardioplegia in adult coronary artery bypass grafting: Initial experience with 100 consecutive patients. Ann Thorac Surg, 2016, 101(6): 2237-2241.
36. 吕晓钗, 叶建熙, 刘燕. Del Nido心肌保护液在成人心脏瓣膜手术中应用的病例对照研究. 中国胸心血管外科临床杂志, 2018, 25(9): 781-785.
37. Mukdad L, Toppen W, Sanaiha Y, et al. Incidence of cerebral microemboli in single-dose vs. multidose cardioplegia in adult cardiac surgery. J Extra Corpor Technol, 2018, 50(3): 143-148.
38. Valooran GJ, Nair SK, Chandrasekharan K, et al. del Nido cardioplegia in adult cardiac surgery — Scopes and concerns. Perfusion, 2016, 31(1): 6-14.
39. Saqqur M, Tsivgoulis G, Nicoli F, et al. The role of sonolysis and sonothrombolysis in acute ischemic stroke: A systematic review and meta-analysis of randomized controlled trials and case-control studies. J Neuroimaging, 2014, 24(3): 209-220.
40. Školoudík D, Hurtíková E, Brát R, et al. Sonolysis in prevention of brain infarction during cardiac surgery (SONORESCUE): Randomized, controlled trial. Medicine (Baltimore), 2016, 95(20): e3615.
41. 韩劲松. 左心耳干预在心房颤动外科治疗中的研究进展. 中国胸心血管外科临床杂志, 2015, 22(1): 75-79.
42. Patel D, Gillinov MA, Natale A. Atrial fibrillation after cardiac surgery: Where are we now? Indian Pacing Electrophysiol J, 2008, 8(4): 281-291.
43. Yao X, Gersh BJ, Holmes DR, et al. Association of surgical left atrial appendage occlusion with subsequent stroke and mortality among patients undergoing cardiac surgery. JAMA, 2018, 319(20): 2116-2126.
44. Atti V, Anantha-Narayanan M, Turagam MK, et al. Surgical left atrial appendage occlusion during cardiac surgery: A systematic review and meta-analysis. World J Cardiol, 2018, 10(11): 242-249.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Research progress on silent cerebral infarction after cardiac surgery through cardiopulmonary bypass

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