Intraoperative Neurophysiologic Monitoring During Cardiac Surgery: an Observational Cohort Study

Overview

Journal Open Heart

Publisher BMJ Publishing Group

Specialty Cardiology & Vascular Diseases

Date 2024 Nov 9

PMID 39521610

Authors

James Brown

Nidhi Iyanna

Sarah Yousef

Derek Serna-Gallegos

Jianhui Zhu

Pyongsoo Yoon

David Kaczorowski

Johannes Bonatti

Danny Chu

Jeffrey Balzer

Kathirvel Subramaniam

Parthasarathy D Thirumala

Ibrahim Sultan

Affiliations

Soon will be listed here.

Abstract

Objective: To evaluate the impact of intraoperative neuromonitoring (IONM) on stroke and operative mortality after coronary and/or valvular operations.

Methods: This was an observational study of coronary and/or valvular heart operations from 2010 to 2021. Baseline characteristics and postoperative outcomes were compared by the use or non-use of IONM, which included both electroencephalography and somatosensory-evoked potentials. Propensity-score matching was employed to assess the association of IONM usage with operative mortality and stroke.

Results: A total of 19 299 patients underwent a cardiac operation, of which 589 (3.1%) had IONM. Patients with IONM were more likely to have had baseline cerebrovascular disease (60% vs 22%). Patients with IONM had increased operative mortality (5.3% vs 2.5%) and stroke (4.9% vs 1.9%). Moreover, stroke and mortality were highly correlated, with 14% of strokes resulting in death, while only 2% of non-strokes resulted in death (p<0.001). The unadjusted Kaplan-Meier survival estimate was significantly lower among the group with IONM (p<0.001, log-rank). After propensity matching, however, there was no difference in operative mortality or stroke across each group: 3.6% vs 5.3% for mortality and 3.7% vs 5.4% for stroke. In the propensity-matched cohort, the Kaplan-Meier survival estimates were not significantly different across each group (p=0.419, log-rank).

Conclusions: Adjusting for baseline risk, there was no significant difference in adverse outcomes across each group. IONM may serve as a biomarker of cerebral ischaemia, and empirical adjustments based on changes may provide benefits for neurologic outcomes in high-risk patients. The efficacy of IONM during cardiac surgery should be prospectively validated.

References

Paras S, Mina A, Crammond D, Visweswaran S, Anetakis K, Balzer J . Cardiovascular-related mortality after intraoperative neurophysiologic monitoring changes during carotid endarterectomy. Clin Neurophysiol. 2022; 139:43-48. DOI: 10.1016/j.clinph.2022.04.005. View

Grant S, Kendall S, Goodwin A, Cooper G, Trivedi U, Page R . Trends and outcomes for cardiac surgery in the United Kingdom from 2002 to 2016. JTCVS Open. 2022; 7:259-269. PMC: 9390523. DOI: 10.1016/j.xjon.2021.02.001. View

Edmonds Jr H, Rodriguez R, Audenaert S, Austin 3rd E, Pollock Jr S, Ganzel B . The role of neuromonitoring in cardiovascular surgery. J Cardiothorac Vasc Anesth. 1996; 10(1):15-23. DOI: 10.1016/s1053-0770(96)80174-1. View

Hogue Jr C, Murphy S, Schechtman K, Davila-Roman V . Risk factors for early or delayed stroke after cardiac surgery. Circulation. 1999; 100(6):642-7. DOI: 10.1161/01.cir.100.6.642. View

Chang R, Reddy R, Sudadi S, Balzer J, Crammond D, Anetakis K . Diagnostic accuracy of various EEG changes during carotid endarterectomy to detect 30-day perioperative stroke: A systematic review. Clin Neurophysiol. 2020; 131(7):1508-1516. DOI: 10.1016/j.clinph.2020.03.037. View

Chen C, Peterson M, Mazer C, Hibino M, Beaudin A, Chu M . Acute Infarcts on Brain MRI Following Aortic Arch Repair With Circulatory Arrest: Insights From the ACE CardioLink-3 Randomized Trial. Stroke. 2022; 54(1):67-77. DOI: 10.1161/STROKEAHA.122.041612. View

Salazar J, Wityk R, Grega M, Borowicz L, Doty J, Petrofski J . Stroke after cardiac surgery: short- and long-term outcomes. Ann Thorac Surg. 2001; 72(4):1195-201; discussion 1201-2. DOI: 10.1016/s0003-4975(01)02929-0. View

Florence G, Guerit J, Gueguen B . Electroencephalography (EEG) and somatosensory evoked potentials (SEP) to prevent cerebral ischaemia in the operating room. Neurophysiol Clin. 2004; 34(1):17-32. DOI: 10.1016/j.neucli.2004.01.001. View

Svensson L, Crawford E, Hess K, Coselli J, Raskin S, Shenaq S . Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients. J Thorac Cardiovasc Surg. 1993; 106(1):19-28; discussion 28-31. View

10.

Borger M, Ivanov J, Weisel R, Rao V, Peniston C . Stroke during coronary bypass surgery: principal role of cerebral macroemboli. Eur J Cardiothorac Surg. 2001; 19(5):627-32. DOI: 10.1016/s1010-7940(01)00649-2. View

11.

Zanatta P, Messerotti Benvenuti S, Bosco E, Baldanzi F, Palomba D, Valfre C . Multimodal brain monitoring reduces major neurologic complications in cardiac surgery. J Cardiothorac Vasc Anesth. 2011; 25(6):1076-85. DOI: 10.1053/j.jvca.2011.05.015. View

12.

Bozzani A, Arici V, Ticozzelli G, Pregnolato S, Boschini S, Fellegara R . Intraoperative Cerebral Monitoring During Carotid Surgery: A Narrative Review. Ann Vasc Surg. 2021; 78:36-44. DOI: 10.1016/j.avsg.2021.06.044. View

13.

Fleseriu C, Sultan I, Brown J, Mina A, Frenchman J, Crammond D . Role of Intraoperative Neurophysiological Monitoring in Preventing Stroke After Cardiac Surgery. Ann Thorac Surg. 2023; 116(3):623-629. DOI: 10.1016/j.athoracsur.2023.01.004. View

14.

Tarakji K, Sabik 3rd J, Bhudia S, Batizy L, Blackstone E . Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA. 2011; 305(4):381-90. DOI: 10.1001/jama.2011.37. View

15.

Riepen B, DeAndrade D, Floyd T, Fox A . Postoperative stroke assessment inconsistencies in cardiac surgery: Contributors to higher stroke-related mortality?. J Stroke Cerebrovasc Dis. 2023; 32(5):107057. DOI: 10.1016/j.jstrokecerebrovasdis.2023.107057. View

16.

Selnes O, Gottesman R, Grega M, Baumgartner W, Zeger S, McKhann G . Cognitive and neurologic outcomes after coronary-artery bypass surgery. N Engl J Med. 2012; 366(3):250-7. DOI: 10.1056/NEJMra1100109. View

17.

Harrer M, Waldenberger F, Weiss G, Folkmann S, Gorlitzer M, Moidl R . Aortic arch surgery using bilateral antegrade selective cerebral perfusion in combination with near-infrared spectroscopy. Eur J Cardiothorac Surg. 2010; 38(5):561-7. DOI: 10.1016/j.ejcts.2010.03.016. View

18.

Head S, Borgermann J, Osnabrugge R, Kieser T, Falk V, Taggart D . Coronary artery bypass grafting: Part 2--optimizing outcomes and future prospects. Eur Heart J. 2013; 34(37):2873-86. DOI: 10.1093/eurheartj/eht284. View

19.

Kaiser H, Hight D, Avidan M . A narrative review of electroencephalogram-based monitoring during cardiovascular surgery. Curr Opin Anaesthesiol. 2019; 33(1):92-100. DOI: 10.1097/ACO.0000000000000819. View

20.

McDonagh D, Berger M, Mathew J, Graffagnino C, Milano C, Newman M . Neurological complications of cardiac surgery. Lancet Neurol. 2014; 13(5):490-502. PMC: 5928518. DOI: 10.1016/S1474-4422(14)70004-3. View