Chair and Department of Clinical Neuropsychology Cardiosurgery Clinic Nicolaus Copernicus University Collegium Medicum in Bydgoszcz, Poland Postoperative cognive dysfunctions after cardiac operations Alina Borkowska, Wojciech Pawliszak, Krzysztof Szwed, Lech Anisimowicz

1965 r. - S Tufo – first statistical eveluation of the prevalence of stroke after cardiac operation (6%) 1970 r. – T. Aberg – first information of psychiatric and psychological complications after cardiac operations with on-pump procedure – the prevalence of neuropsychiatric consequences of these operations about 80% Cardiac operations and CNS

microembolisation hypoxia hypoperfussion hypotermy inflammatory reactions, brain edema oxydative stress blood pressure changes brain blood flow disturbances anaesthesia microembolisation hypoxia hypoperfussion hypotermy inflammatory reactions, brain edema oxydative stress blood pressure changes brain blood flow disturbances anaesthesia Possible reasons of neuropsychiatrics complications after cardiac operations (Newman i wsp., 2001; 2006 Dong-Liang-Mu i wsp., 2013; Sirvinskas i wsp., 2014) Impairment of cells metabolism impairment of neurons structure and functions Abnormalities of brain structures synchronization Impairment of cells metabolism impairment of neurons structure and functions Abnormalities of brain structures synchronization

Neuropsychiatric complications after coronary aftery bypass grafting CABG) Brain impairment visible in neuroimagin and neuropathology evaluation Coma Stroke Amnesia (TIA) Postoperative cognitive dysfunctions (POCD)

Early and late neuropsychiatric disturbances may have occurs in more than half (30-80%) patients after cardiosurgery interventions There is still a problem with a diagnosis and treatment of postoperative cognitive dysfunctions (POCD) Type of cardiac operations are important to the CNS functioning  Operations with pump circulations are associated with higher risk of CNS impairment Neuropsychiatric complications after cardiosurgery interventions

POCD are associated with :  Worsening of patient quality of life  Prolonged time of hospitalization  Higer risk of psychosocial functioning dificulties  Higher risk of depression and persistent cognitive decline  Higher costs of medical care (Phillips-Bute et al. 2006; Stroobant et al. 2010; Ito et al, 2012). Postoperative cognitive dysfunctions

On pump and off pump procedure Higher risk of CNS impairmentLower risk of CNS impairment

„no touch” vs „traditional” OPCABG „Traditional” and „no touch” off pump coronary artery bypass grafting OPCABG

Depression and POCD and cortisol level after OPCABG Higher cortisol level in the first morning after operations associated with:  Higher early POCD development (7 days)  Higher depression rate after postoperative period Dong-Liang Mu i wsp., 2013

The results p = 0,047

POCD after „traditional” vs. „no touch” OPCABG Szwed i wsp. World Journal of Biol Psychiatry 2013

The Syntax score was recently developed as a comprehensive, angiographic tool grading the complexity of coronary artery disease. SYNTAX score (aorta stiffness measurement)

SYNTAX score may be an indirect indicator of the degree of atherosclerosis in vascular zones that are particularly important in the etiology of POCD (i.e. cerebral arteries and ascending aorta). SYNTAX score

Evaluation at the time of admission (7±2 days preoperatively) and discharge (7 days postoperatively) Neuropsychological Evaluation TESTCOGNITIVE FUNCTION Stroop Test - part Aspeed of processing Stroop Test - part Bexecutive functioning Digit Span Test – forward auditory attention short term retention Digit Span Test – backwardverbal working memory Controlled Oral Word Associacion verbal fluency POCD – a decline from preoperative performance of more than 20% on two or more tests

The results Test SYNTAX ≤ 22 (n=58) SYNTAX ≥ 23 (n=46) Pre surgery results Post surgery results p Pre surgery results Post surgery results p ST-A [s] 28,0 (25,0-34,0) 30,0 (26,0 – 36,0) 0,004 29,0 (24,0 – 32,0) 33,0 (26,0 – 38,0) 0,000…7 ST-B [s] 75,0 (63,0 – 87,0) 70,0 (62,0 – 88,0) 0,813 75,0 (64,0 – 90,0) 79,5 (67,0 – 97,0) 0,011 DST 1 [n] 5,0 (4,0 – 6,0) 5,0 (4,0 – 6,0) 0,375 4,5 (4,0 – 5,0) 4,0 (3,0 – 5,0) 0,018 DST 2 [n] 4,0 (4,0-5,0) 4,0 (3,0 – 5,0) 0,271 4,0 (3,0 – 5,0) 4,0 (3,0 – 4,0) 0,039 FAS [n] 25,0 (19,0 – 33,0) 25,5 (19,0 – 33,0) 0,334 23,0 (19,0 – 34,0) 24,0 (19,0 – 34,0) 0,268

Conclusions No touch CABG operations are more safe for CNS compared to the traditional ones  Lower level of cognitive functions impairment  Less dysfunctional areas Syntax score is an useful measurement of POCD predictions To prevent of POCD important are:  Monitoring of adverse events during the operation  Proper diagnosis and treatment of POCD

Alina Borkowska Maciej Bieliński Krzysztof Szwed Martyna Gębska Marta Tomaszewska Gosia Piskunowicz Joanna Ulfig Iwona Miklasz Lech Anisimowicz Wojtek Pawliszak Alina Borkowska Maciej Bieliński Krzysztof Szwed Martyna Gębska Marta Tomaszewska Gosia Piskunowicz Joanna Ulfig Iwona Miklasz Lech Anisimowicz Wojtek Pawliszak