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Background: Stroke occurs in 1% to 7% of heart surgery. Aortic arch atherosclerosis is a risk factor for intraoperative stroke, and endarterectomy has been proposed to prevent stroke during heart surgery in patients with arch atheromas., Methods and Results: Intraoperative transesophageal echocardiography was performed in 3404 patients undergoing heart surgery between 1990 and 1996. Use of transesophageal echocardiography was unselected and based on equipment availability. Aortic arch atheromas (>/=5 mm, or mobile) were seen in 268 (8%) patients. They were evaluated for intraoperative stroke (confirmed by a neurologist and cerebral infarction on computed tomography or magnetic resonance imaging). Arch endarterectomy was performed in 43 patients as an adjunct to their cardiac procedure in an attempt to prevent intraoperative stroke. The intraoperative stroke rate in all 268 patients with atheromas was high (15.3%). On univariate analysis, age, previous stroke, and arch endarterectomy were significantly associated with intraoperative stroke. On multivariate analysis, age (odds ratio 3.9, P =.01) and arch endarterectomy (odds ratio 3.6, P =.001) were independently predictive of intraoperative stroke. Mortality rate in all 268 patients was high (14.9%). These patients with atheromas also had a long recovery room, intensive care unit, and total hospital length of stay (48 days)., Conclusions: Patients with protruding aortic arch atheromas are at high risk for intraoperative stroke, significant and multiple morbidity, prolonged hospital stay, and death resulting from heart surgery. Aortic arch endarterectomy is strongly associated with intraoperative stroke; its use should be carefully considered in light of these results.

Background and Purpose: Cerebral injury after cardiac surgery is now recognized as a serious and costly healthcare problem mandating immediate attention. To effect solution, those subgroups of patients at greatest risk must be identified, thereby allowing efficient implementation of new clinical strategies. No such subgroup has been identified; however, patients undergoing intracardiac surgery are thought to be at high risk, but comprehensive data regarding specific risk, impact on cost, and discharge disposition are not available., Methods: We prospectively studied 273 patients enrolled from 24 diverse US medical centers, who were undergoing intracardiac and coronary artery surgery. Patient data were collected using standardized methods and included clinical, historical, specialized testing, neurological outcome and autopsy data, and measures of resource utilization. Adverse outcomes were defined a priori and determined after database closure by a blinded independent panel. Stepwise logistic regression models were developed to estimate the relative risks associated with clinical history and intraoperative and postoperative events., Results: Adverse cerebral outcomes occurred in 16% of patients (43/273), being nearly equally divided between type I outcomes (8.4%; 5 cerebral deaths, 16 nonfatal strokes, and 2 new TIAs) and type II outcomes (7.3%; 17 new intellectual deterioration persisting at hospital discharge and 3 newly diagnosed seizures). Associated resource utilization was significantly increased--prolonging median intensive care unit stay from 3 days (no adverse cerebral outcome) to 8 days (type I; P<0.001) and from 3 to 6 days (type II; P<0.001), and increasing hospitalization by 50% (type II, P=0.04) to 100% (type I, P<0.001). Furthermore, specialized care after hospital discharge was frequently necessary in those with type I outcomes, in that only 31% returned home compared with 85% of patients without cerebral complications (P<0.001). Significant risk factors for type I outcomes related primarily to embolic phenomena, including proximal aortic atherosclerosis, intracardiac thrombus, and intermittent clamping of the aorta during surgery. For type II outcomes, risk factors again included proximal aortic atherosclerosis, as well as a preoperative history of endocarditis, alcohol abuse, perioperative dysrhythmia or poorly controlled hypertension, and the development of a low-output state after cardiopulmonary bypass., Conclusions: These prospective multicenter findings demonstrate that patients undergoing intracardiac surgery combined with coronary revascularization are at formidable risk, in that 1 in 6 will develop cerebral complications that are frequently costly and devastating. Thus, new strategies for perioperative management--including technical and pharmacological interventions--are now mandated for this subgroup of cardiac surgery patients.

It has been shown that transesophageal echocardiography (TEE) is useful in evaluating atheromatous disease of the aortic arch and that such disease is a risk factor for stroke in medical patients. Data obtained by traditional methods of evaluating the aortic arch prior to cardiac surgery, namely, chest x-ray (CXR) and cardiac catheterization (CATH), were compared with that detected by TEE. Images of the descending thoracic aorta and aortic arch seen on intraoperative TEE in 258 cardiac surgical patients were graded as I = normal, II = intimal thickening or plaques < 5 mm thick or with a mobile component (severe disease). The aortic knob seen on CXR in 209 of these patients was graded as normal, < 1/2 or > or = > 1/2 ring of calcification. Calcification in the aortic root (graded as 0, 1+, 2+) and irregularities in the aortic lumen seen at CATH in 33 patients were also examined. Data were analyzed with respect to age, gender, type of surgery, and stroke. Increasing age correlated strongly with increasing severity of aortic arch and descending thoracic aortic disease seen by TEE. Severe disease was not present in patients under age 50 but was present in about 20% of those over age 70. Atheromatous disease was found by TEE in 55% of patients with a normal CXR and 91% of those with heavily calcified aortic knobs. Ischemic strokes occurred in seven patients. Severe arch disease correlated significantly with stroke (P < .01). Other variables did not correlate with stroke.(ABSTRACT TRUNCATED AT 250 WORDS)