INVITED COMMENTARY

Abstract

Dacey and associates in the Northern New England Cardiovascular Disease Study Group have provided yet another valuable report on outcomes after coronary artery bypass grafting (CABG) surgery. In this article, they report on their analysis of stroke and its long-term consequences for > 35,000 patients having CABG within the consortium hospitals from 1992 through 2001. Their reported incidence of perioperative stroke, 1.61%, likely represents the fewest number of their patients who actually sustained neurologic injury after surgery, because their criterion for the diagnosis is “a new fixed neurologic defect,” and it does not account for less severe or more diffuse neurologic and cognitive changes. That these patients are the most severely affected is apparent from the nearly 25% hospital mortality observed in the stroke group. What is particularly important new information in this report is the documentation of the profound impact of major stroke on late survival after CABG. The annualized incidence of death is 3.2 times more likely in those who sustained major strokes, and 10-year actuarial survival based on this large patient group is only 27% for patients who suffered stroke compared with 62% in those without stroke. However, it is important to note that the authors also report the following: “The greatest risk of death [in stroke patients] was noted within the first year after surgery. Survival after 1 year approximates that of patients who did not suffer a stroke.” Figure 3 in their article summarizes the pattern of survival from years 2 to 5 and documents the similar survival curves in all of these patients. Stroke patients who are successfully rehabilitated experience favorable survival capacity. There are two other somewhat unique observations made by this study. The authors note that patients whose stroke mechanism they defined as hypoperfusion (ie, bilateral “watershed” strokes) experienced particularly unfavorable long-term outcomes. These patients are believed to have sustained diffuse bilateral cerebral ischemia due to systemic hypoperfusion. As they note in a previous article [1Likosky D.S. Marrin C.A. Caplan L.R. et al.Determination of etiologic mechanisms of strokes secondary to coronary artery bypass graft surgery.Stroke. 2003; 34: 2830-2834Crossref PubMed Scopus (223) Google Scholar], such patients typically have areas of hypodensity between the anterior and middle, as well as middle and posterior cerebral arteries on computed tomography or magnetic resonance imaging studies. They are often comatose and have diffuse, rather than focal, functional impairment. A corollary observation notes that patients who were discharged after surgery to sites other than home or a rehabilitation facility also had very poor long-term survival. We can assume that these “other” sites were chronic care facilities, in which the most functionally impaired poststroke patients received supportive rather than rehabilitative care. As the authors conclude, this study clearly documents that the negative effects of stroke on patient survival extend well beyond the perioperative setting. However, if the stroke patient is a candidate for rehabilitation, long-term survivorship may be favorable. Perioperative Stroke and Long-Term Survival After Coronary Bypass Graft SurgeryThe Annals of Thoracic SurgeryVol. 79Issue 2PreviewStroke is a devastating complication of coronary artery bypass graft (CABG) surgery. In-hospital outcomes have been described, yet the long-term effect of stroke on mortality following CABG surgery has not been well studied. Full-Text PDF