Cerebral microemboli in mini-sternotomy compared to mini- thoracotomy for aortic valve replacement: a cross sectional cohort study

Background Recently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation. Methods Trans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke’s Cognitive Examination Revised Test before and 30 days after surgical procedure. Results A total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8 ± 14.4 vs.72 ± 5.84, p = 0.003), heavier (85.2 ± 12.4 vs.72.5 ± 12.9, p = 0.002) and had higher body surface area (1.98 ± 0.167 vs. 1.83 ± 0.178, p = 0.006). Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158 ± 24 vs. 134 ± 30 min, p < 0.001, respectively). There were no differences between groups in microembolic load, length of ICU or total hospital stay. Total microembolic signals count was correlated with cardiopulmonary bypass duration (5.64, 95%CI 0.677–10.60, p = 0.027). Addenbrooke’s Cognitive Examination Revised Test score decreased equivalently in both groups (p = 0.630) (MS: 85.2 ± 9.6 vs. 82.9 ± 11.4, p = 0.012; MT: 85.2 ± 9.6 vs. 81.3 ± 8.8, p = 0.001). Conclusion There is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline. Trial registry number clinicaltrials.gov, NCT02697786 14.

Cerebral Microemboli in Mini-Sternotomy Compared to Mini-Thoracotomy for Aortic Valve Replacement: A Cross Sectional Cohort Study

Background: Recently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation.Methods: Trans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke’s Cognitive Examination Revised Test before and 30 days after surgical procedure.Results: A total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8±14.4 vs.72±5.84, p=0.003), heavier (85.2 ± 12.4 vs.72.5 ± 12.9, p= 0.002) and had higher body surface area (1.98 ±0.167 vs. 1.83±0.178, p=0.006).Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158 ±24 vs. 134±30 min, p<0.001, respectively). There were no differences between groups in microembolic load, length of ICU or total hospital stay. Total microembolic signals count was correlated with cardiopulmonary bypass duration (5.64, 95%CI 0.677–10.60, p=0.027). Addenbrooke’s Cognitive Examination Revised Test score decreased equivalently in both groups (p=0.630) (MS: 85.2±9.6 vs. 82.9±11.4, p=0.012; MT: 85.2±9.6 vs. 81.3±8.8, p=0.001). Conclusion: There is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline.

Internal Jugular Microembolic Signal Detection in a Patient with Cerebral Sinus Thrombosis Complicated by Pulmonary Embolism

A 40-year-old woman with prior history of headaches, left-sided weakness, and diplopia was diagnosed with right sigmoid and transverse sinus thrombosis; increased intracranial pressure and associated cerebral venous infarction that underwent 12 months anticoagulation and then stopped. She has been off anticoagulation for about a year then started not “feeling right,” and was diagnosed with pneumonia and pulmonary embolism. During her course of hospitalization, she presented with progressive headache, possible left-sided weakness, associated blurry vision, nausea, and vomiting. Magnetic resonance venogram (MRV) shows lack of flow-related signals within the left half of the distal superior sagittal sinus, left transverse sinus, and nonocclusive thrombus in the left sigmoid sinus. Mechanical sinus thrombectomy attempted without significant difference in clot burden. A transcranial Doppler (TCD) emboli monitoring exam was ordered and was performed on the bilateral internal jugular for 15 min each. Microembolic signals detected: 52 emboli per hour right internal jugular vein (IJV), and 32 emboli per hour left IJV. She was discharged on methazolamide, furosemide, topiramate, and lifelong warfarin. No major events have been reported since discharge from 2008 to 2016.