RESUMO
INTRODUCTION: More than half of reported perioperative strokes following cardiac surgery are identified beyond postoperative day one. The objective of our study was to determine preoperative and intraoperative factors that are associated with stroke following cardiac surgery and to identify factors that may contribute delayed recognition of perioperative stroke. METHODS: Patients undergoing coronary artery bypass surgery or isolated valve surgery from January 2, 2015 to April 28, 2017 at an academic health system were identified from the Society of Thoracic Surgeons Registry. We determined preoperative and intraoperative factors associated with perioperative stroke. Two neurologists performed retrospective chart reviews on perioperative stroke patients to determine the last seen well time and the stroke cause. RESULTS: During the study period, 2795 patients underwent coronary artery bypass surgery or isolated valve surgery (mean age 64 ± 11 years, 71% male, 72% Caucasian, 9% history of stroke), of which 43 (1.5%) had a perioperative stroke; 31 (72%) patients had an embolic mechanism of stroke based on neuroimaging. In multivariable analysis, perioperative strokes were independently associated with increasing age (OR 1.04, 95% 1.01-1.07), history of stroke (OR 2.73, 95% CI 1.47-5.06), and history of thoracic aorta disease (OR 3.36, 95% CI 1.16-9.71). Strokes were identified after postoperative day one in 32 (74%) patients of which 26 (81%) had a preoperative last seen well time. CONCLUSION: Given the high frequency of preoperative last seen well time in perioperative stroke patients who are identified after postoperative day one, delayed stroke recognition may contribute to the bimodal distribution in timing of perioperative stroke. Frequent neurological monitoring within 24 hours after CABG or isolated valve surgery should be considered for all patients undergoing cardiac surgery, particularly elderly patients and those with a history of stroke or thoracic aorta disease, to improve early stroke recognition.
Assuntos
Ponte de Artéria Coronária/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Acidente Vascular Cerebral/diagnóstico , Idoso , Bases de Dados Factuais , Diagnóstico Tardio , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Perioperatório , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Estados UnidosAssuntos
Dissecção Aórtica/diagnóstico por imagem , Valva Aórtica/diagnóstico por imagem , Ecocardiografia Tridimensional/métodos , Ecocardiografia Transesofagiana/métodos , Ecocardiografia/métodos , Idoso , Dissecção Aórtica/cirurgia , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Dor no Peito/diagnóstico por imagem , Feminino , Implante de Prótese de Valva Cardíaca , HumanosRESUMO
It is well known that antithrombin (AT) deficiency results in decreased heparin sensitivity, also known as "heparin resistance." However, non-AT-mediated causes of heparin resistance are generally poorly characterized and less prevalent in the literature. We present 2 case reports of non-AT-mediated heparin resistance during cardiac surgery due to paraproteinemia and hyperfibrinogenemia. These cases highlight the challenges posed by unusual conditions in achieving adequate anticoagulation for cardiopulmonary bypass (CPB). The pros and cons of the treatment selections for these cases are discussed, and the potential complications of large doses of unfractionated heparin are considered.