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Considerations for Reduction of Risk of Perioperative Stroke in Adult Patients Undergoing Cardiac and Thoracic Aortic Operations: A Scientific Statement From the American Heart Association

By Currents Editor posted 10-01-2020 11:41

  

Circulation (08/26/20) doi: 10.1161/CIR.0000000000000885
Gaudino, Mario; Benesch, Curtis; Bakaeen, Faisal; et al.
https://www.ahajournals.org/doi/10.1161/CIR.0000000000000885

  

A scientific statement from the American Heart Association (AHA) recommends specific preoperative, intraoperative, and postoperative steps to reduce the risk of perioperative stroke in adult patients undergoing cardiac and proximal thoracic aortic operations and improve the outcomes of patients who experience a perioperative stroke. The statement notes that perioperative stroke is associated with 5- to 10-fold higher risk of in-hospital mortality, increased cost, longer hospital stays, and greater risk of cognitive decline 1 year following surgery. According to the AHA, measures for the intraoperative prevention of stroke include use of intraoperative neuromonitoring; use of epiaortic scanning; maintaining a mean arterial pressure of 60 mm Hg - 65 mm Hg during cardiopulmonary bypass; use of a transfusion trigger between 7.5 g/dL and 8 g/dL; minimizing hemodilution; using active perfusion techniques in aortic surgeries with longer circulatory arrest time; considering, at the time of surgery, left atrial appendage ligation or atrial fibrillation ablation; and in the presence of thrombus, considering surgical thrombectomy or delay of surgery with anticoagulation. Measures for early stroke diagnosis include performing a complete postoperative neurologic exam as soon as the clinical situation allows, considering use of a fast-track anesthesia protocol in patients at high risk for a stroke, having a Stroke Team in place and alert immediately in case of clinical suspicion of a stroke, and obtaining a head CT and CT angiography of the head and neck. Finally, AHA recommends several steps for rapid treatment in the event of perioperative stroke, including transferring the patient to an intensive care setting; optimizing cerebral oxygenation and perfusion; considering thrombolysis and thrombectomy; and conducting screenings that include speech, swallow and depression evaluations in addition to deep vein thrombolysis prophylaxis and evaluation for rehabilitation.

 
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