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| AATS/NHLBI: Cardiothoracic Surgery Exploring Collaborative Clinical Research Opportunities |
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Title and Author Translating Strategies to Protect the BrainTimothy J. Gardner Abstract Despite advances in surgical, anesthetic and medical management, neurological injury in cardiac surgery continues to account for substantial morbidity and increased mortality. Older age, pre-existing cerebrovascular disease, generalized atherosclerosis and impaired cardiac function increase the risk of neurological complications. Efforts to reduce the occurrence of brain injury have focused on risk assessment of individual patients undergoing surgery, with subsequent perioperative management strategies directed at dealing with patient-specific risk factors and conditions. In addition, procedural and technical refinements, with particular attention to modifiable aspects of cardiopulmonary bypass and hemodynamic management during and after surgery, have been implemented. The increase in the percentage of older, high-risk patients undergoing cardiac surgery, along with a greater use of procedures with increased inherent risk of brain injury, including open valve procedures, VAD implants and catheter-implanted valve replacements, will place more patients at risk of neurological complications, in spite of current protective strategies. There continues to be a lack of clear understanding of the pathophysiology of ischemic brain injury. In addition, there are no reliable biomarkers of acute neurological damage. The lack of specific methods to prevent secondary ischemic damage and to promote recovery of the brain is highlighted by failure of discovery to-date of any effective neuroprotective agents or drugs. This absence of basic scientific understanding of the nature and responsiveness of ischemic brain damage underscores the importance of continued support for basic research studies to better characterize the patterns of brain injury manifested by patients with stroke and encephalopathy after cardiac surgery. Current strategies to protect the brain in cardiac surgery should be enhanced and studied as opportunities to avoid or mitigate neurological injury. More precise identification of individual patients� risks, including the use of preoperative brain imaging, should be pursued. Enhanced perioperative patient management strategies that include reduction in exposure to embolic injury, improved hemodynamic management to insure adequate cerebral perfusion, sufficient oxygen availability especially for elderly individuals, and further refinements in extracorporeal circulatory support, should be supported. Techniques to diagnose and characterize neurological injury immediately after surgery and early in the postoperative period should be explored, along with options for rapid intervention in patients with on-going brain ischemia. Key Research Gap Requiring NHLBI Leadership The role of neuroprotective agents and novel management strategies in an older, high risk population of patients undergoing cardiac surgery. Key Citations 1: McKhann GM et al. Stroke & Encephalopathy after Cardiac Surg. Stroke 2006;37:562-71.2: Charlesworth DC et al. Development and validation of a prediction model for strokes after coronary artery bypass grafting. Ann Thorac Surg 2003;76:436-43. 3: Tarakji KG et al. Temporal onset, risk factors, outcomes of stroke after CABG. JAMA 2011;305:381-90. |
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Copyright © 2012 American Association for Thoracic Surgery
All rights reserved. IMPORTANT REMINDER: The preceding information is intended only to provide
general guidance and not as a definitive basis for diagnosis or treatment in any particular case.
It is very important that you consult a doctor about any specific medical problem or question.
All rights reserved. IMPORTANT REMINDER: The preceding information is intended only to provide
general guidance and not as a definitive basis for diagnosis or treatment in any particular case.
It is very important that you consult a doctor about any specific medical problem or question.