상계백병원 흉부외과 허재학

 3.1 % stroke in 2108 patients in a prospective study --- Roach GW 1996  Stroke 2.8% in 2000 patients studied prospectively, with an incidence in patients > 75 years (8.9%), years (3.6%) and < 60 years old(0.9 %) --- Tuman KJ 1999

79% significant decrease in cognitive performance postoperatively --- Shaw PJ % at discharge, 36 % at 6 wks, 24 % at 6 mo --- Newman MF % cognitive impairment in pump CABG, no impairment in OPCAB --- Diegeler A 2000 Reduced retinal and cerebral microembolization with OPCAB --- Ascione R 2005

Hammon JW. 2008, Cohn LH ed. Cardiac Surgery in the Adult

 The main risk factor for postoperative stroke --- van der Linden 2001, Hogue 1999, Roach 1996, Blauth 1995  < 2 % stroke in patients with limited or no atheroma  40 % in patients with grade IV or V atheroma --- advanced therapy in cardiac surgery, Barbut 1997  The incidence of atherosclerosis in CABG patients ; 38 ~ 53 % ---Barbut 1996, Bolotin 2005

 Preop CT / MRI  Digital palpation  Epiaortic ultrasonography  TEE

 group I clean aorta  group II remote, stable aortic plaque  group III remote, vulnerable plaque/ulcer  group IV lesions near cannulation site  group V dangerous/impossible cannulation or clamping 박계현, 2009 관상동맥외과 연구회 학술 심포지움

n=77 n= 100 n=45 n=26 n=36

preop. CT vs EAU preop. CT vs TEE Berman P. Heart Surg Forum 7, 2004:E245-E249 - sensitivity 87 %, specificity 82 % Tenenbaum A. Radiology, Vol 208,

The SonoSite ultrasound device displayed alone and with monitor stand Epiaortic Ultrasonography

Kronzon I. et al. Circulation 2006;114:63-75

Suvarna et al. J Cardiothorac and Vasc Anes. 2007:

Bolotin G et al. Chest 2005;127:60-65 reduction in neurologic complications (Ozatik MA 1999, Royse AG 2000)

Risk FactorsOdds Ratio of Stroke95% Confidence Intervalp Value On-CPB CABG vs. OPCABG (matched pairs = 1915, n = 3830) 1.9(1.16, 3.02)<0.01 Extensive aortic manipulation vs. no aortic manipulation (matched pairs = 451, n = 902) 3.1(0.97, 9.62)0.06 Extensive aortic manipulation vs. moderate aortic manipulation (matched pairs = 1720, n = 3440) 1.5(0.92, 2.36)0.10 Moderate aortic manipulation vs. no aortic manipulation (matched pairs = 470, n = 940)1.8(0.51, 6.10)0.37 Kapetanakis EI et al. Ann Thorac Surg 2004;78:

Barbut, D. et al. Stroke 1996;27:87-90 Scatterplot shows value of aortic atheroma in predicting number of emboli

Barbut D. et al.; Ann Thorac Surg 1997;63:

Barbut, D. et al. Stroke 1996;27:87-90 aortic cross clamp release accounted for 42% (TEE) and 41% (TCD) of the total number of emboli

Taylor R. L. et al.; Ann Thorac Surg 1999;68:89-93

Banbury M. K. et al.; Ann Thorac Surg 2003;76:

Borger M. A. et al.; J Thorac Cardiovasc Surg 1999;118: Cannulation using a long cannula ; significant decrease in peak forward flow velocity and turbulence in the aortic arch during CPB Grossi EA. Et al. Ann Thorac Surg 1995;59:

Cook D. J. et al.; J Thorac Cardiovasc Surg 2003;125:

Cook D. J. et al.; Ann Thorac Surg 2002;74:

usual de-airing maneuvers - incomplete to eliminate retained air CO2 flooding to replace the air in the thoracic cavity

 CO2 dissolves in blood and tissue >25 times faster than air  50 % heavier than air  --- but, residual air in pericardial cavity 20 – 80 %, delivered in common manner (Martens S 2001, Persson M 2003)

Svenarud, P 2004

Svenarud, P. et al. Circulation 2004;109: median number of microemboli after release of aortic cross-clamp p < 0.01

Svenarud, P. et al. Circulation 2004;109: total numbers of microemboli present in different areas shown by TEE p < 0.01

Hogue, CW et al. Anesth Analg 2006;103:21-37

Jones T. J. et al.; Ann Thorac Surg 2002;74:

Rodriguez R. A. et al.; Eur J Cardiothorac Surg 2006;29: r = 0.524, p <

Schoenburg M.; J Thorac Cardiovasc Surg 2003;126:

canine brain tissue with cardiotomy suction (Brooker RF 1998) Brain with fat emboli(Moody DM 1995)

Kincaid E. H. et al.; Ann Thorac Surg 2000;70: ± 3 vs 24 ± 5, p = 0.02 Closed bars represent arterial filter group; open bars represent cell saver group

Taylor R. L. et al.; Ann Thorac Surg 1999;68:89-93

 Avoid the atherosclerotic emboli ; preop. CT, EAU  Control the air entry site and remove residual air from the heart strictly  Insufflate the CO2 gas to replace the air ; inside wound cavity, gas diffuser  Eliminate the air in the venous cannula  Wash the blood aspirated from the surgical wound ; the continuous auto transfusion cell saver system  Specialized cannula or filtration device  Cannulate in distal arch using a long cannula