emphasize the need for large randomized trials to further elu-cidate these complex interactions.
Suzana M. F. Malheiros, MDAyrton R. Massaro, MDEnio Buffolo, MDDepartments of Neurology and Cardiovascular SurgeryUniversidade Federal de Sa˜o PauloSa˜o Paulo, Brazil
1.
Van Dijk D, Jansen EWL, Hijman R, et al. Cognitive outcome after off-pumpandon-pumpcoronaryarterybypassgraftsurgery:arandomizedtrial.
JAMA
.2002;287:1405-1412.
2.
Malheiros SMF, Massaro AR, Gabbai AA, et al. Is the number of microembolicsignals related to neurologic outcome in coronary bypass surgery?
Arq Neurop- siquiatr
. 2001;59:1-5.
3.
Buffolo E, de Andrade CS, Branco JN, et al. Coronary artery bypass graftingwithout cardiopulmonary bypass.
Ann Thorac Surg
. 1996;61:63-66.
4.
Malheiros SMF, Brucki SMD, Gabbai AA, et al. Neurological outcome in coro-naryarterysurgerywithandwithoutcardiopulmonarybypass.
ActaNeurolScand
.1995;92:256-260.
TotheEditor:
DrVanDijkandcolleagues
1
reportedlittledif-ference in the cognitive function of patients 12 months aftereither off-pump or on-pump CABG. This outcome was unex-pectedsinceon-pumpproceduresareassociatedwithaorticcan-nulationandprolongedextracorporealperfusion,bothofwhichmay shower the brain with emboli. One explanation for thisfinding, which the authors did not discuss, might be that pa-tients in need of CABG have a high baseline rate of 12-monthcognitivedeclinewithorwithoutsurgery.Thisisatestablehy-pothesis:controlgroupsofpatientswhoaremanagedwithoutsurgery (eg, with drugs only or with drugs and angioplasty)could be assembled and followed up for a year and subjectedtothesametestsofcognitivefunctionastheinterventiongroupsinthisstudy.ThenwemightbetterlearnifCABGorsomeotheraspect of these patients’ illness is responsible for their cogni-tive decline over time.
Donald Venes, MDPortland, Ore
1.
Van Dijk D, Jansen EWL, Hijman R, et al. Cognitive outcome after off-pumpandon-pumpcoronaryarterybypassgraftsurgery:arandomizedtrial.
JAMA.
2002;287:1405-1412.
To the Editor:
The results of Dr Van Dijk and colleagues
1
donot appear to have resolved the conflicting conclusions drawnfrom the 2 prior randomized trials that have found that off-pump CABG reduced the postoperative cognitive dysfunc-tion.
2,3
One potential limitation of all these studies is the ad-equacy of management of the patient during CPB. Relevantvariableswouldincludemaintaininganappropriatehematocrit,highflowrate,andmeanperfusionpressurewhileonbypass,andhavingabloodfilteronthearteriallimbofthebypasscircuit.Thesedifferences could greatly influence cerebral morbidity.In addition to psychometric evaluation of the cerebral in- jury in patients with CPB procedures, a high incidence of ab-normalities was found on magnetic resonance imaging (MRI)obtainedbeforeandaftertheCPBprocedure.Theischemicle-sions demonstrated by MRI typically are localized at the gray/ white junction and the watershed area suggesting that em-bolic phenomena and hypoperfusion, respectively, are likelythe underlying causes of the cerebral injury. Based on our ex-perience with preoperative and postoperative (3-7 days) MRIimaging, the CPB procedures performed with strict in-line fil-trationandrelativelyhighperfusionratedemonstratednoMRIor neurological evidence of ischemic injury in any of our pa-tients.
4
Suchfindingsfurthersupportthenotionthatthevaria-tion in CPB procedure can influence the neurological out-comeinpatientsundergoinganytypeofsurgeryrequiringCPBprocedure. Therefore, the efficacy of off-pump CABG surgerycannot be adequately assessed without standardized CPB pro-cedure and quality control.
William T. C. Yuh, MD, MSEEChristopher J. Knott-Craig, MDMonala D. Tilak, MDDepartment of Radiological SciencesOklahoma University Health Science CenterOklahoma City
1.
Van Dijk D, Jansen EWL, Hijman R, et al. Cognitive outcome after off-pumpandon-pumpcoronalarterybypassgraftsurgery:arandomizedtrial.
JAMA.
2002;287:1405-1412.
2.
Diegeler A, Hirsch R, Schneider F, et al. Neuromonitoring and neurocognitiveoutcome in off-pump versus conventional coronary bypass operation.
Ann Tho-rac Surg
. 2000;69:1162-1166.
3.
Lloyd CT, Ascione R, Underwood MJ, et al. Serum S-100 protein release andneuropsychologicoutcomeduringcoronaryrevascularizationonthebeatingheart:a prospective randomized study.
J Thorac Cardiovasc Surg.
2000;119:148-154.
4.
SimonsonTM,YuhTCY,HindmanJ,etal.ContrastMRofthebrainafterhigh-perfusion cardiopulmonary bypass.
AJNR Am J Neuroradiol.
1994;15:3-7.
InReply:
WeagreewithDrsFouad-TaraziandFeldschuhthatwhilemoderatehemodilutionmayimproverheologyandmain-tainoxygendelivery,severehemodilutioncombinedwithste-nosis of cerebral arteries may contribute to negative cerebraloutcomes.However,thishypothesisneedstobeformallyevalu-ated. This could be accomplished in a retrospective study in-vestigating the relationship between perioperative hematocritandstroke,inadesigncomparablewiththestudyofWuetal,
1
which assessed the association between hematocrit and mor-tality in patients with myocardial infarction. If a negative im-pact of severe hemodilution during CABG were confirmed, aformal trial of a more aggressive transfusion regimen wouldbe warranted, in which the effect on subtle cognitive declinecould be evaluated.Dr Malheiros and colleagues have a large experience in off-pump surgery and were one of the first groups to describe alargeseriesofoff-pumpprocedures.
2
Theresultsoftheirstud-iesareinaccordancewithours;avoidingCPBdoesnotleadtoa large or easily detectable improvement of cognitive or neu-rologic outcome.
2,3
The shower of microemboli to the brain isonlyoneofthepostulatedmechanismsofcognitivedeclinefol-lowing CABG. A subsample of the patients in our study alsounderwentintraoperativetranscranialDopplerultrasoundex-amination. Like Malheiros et al, we found more emboli in on-pumppatientsthaninoff-pumppatients(unpublishedresults). We agree that the composition rather than the number of theemboliprobablydeterminestheclinicaleffect.Atriallargerwithmorestatisticalpowerthanoursmayhelptoestablishwhether
LETTERS
3078
JAMA,
June 19, 2002
—
Vol 287, No. 23
(Reprinted)
©2002 American Medical Association. All rights reserved.
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