STRATEGY FOR THE REDUCTION OF STROKE INCIDENCE IN CARDIAC SURGICAL PATIENTS

Atherosclerosis of the ascending aorta (AAA) and severe carotid artery disease are risk factors for stroke in cardiac surgical patients. Twe lve hundred of a consecutive series of 1,334 patients 50 years of age or older having a cardiac operation were screened for the presence of AAA by intraoperative ultrasonographic scanning and for the presence o f carotid artery occlusive disease (791 of 798 patients greater-than-o r-equal-to 65 years of age and younger symptomatic patients) by caroti d duplex scanning. Coronary artery disease was present in 88% of the p atients. Patients with moderate or severe AAA (n = 231; 19.3% of the t otal) were treated by ascending aortic replacement (n = 27) or by modi fied, less extensive techniques (n = 168) to avoid the atherosclerotic areas. Thirty-three patients had combined carotid endarterectomy and cardiac operation. Thirty-day mortality and stroke rates for the 1,200 patients were 4.0% and 1.6%, respectively. The stroke rate was low (1 .1%) among the 969 patients with no or mild AAA. It was zero among 27 patients with moderate or severe AAA who had ascending aortic replacem ent and among the 33 patients who had carotid endarterectomy. The stro ke rates were higher for 111 patients with moderate or severe ascendin g aortic disease who had only minor interventions (6.3%) and for 16 pa tients with severe carotid artery disease who did not have carotid end arterectomy (18.7%). Screening for AAA and carotid artery disease and aggressive surgical treatment of moderate or severe AAA and severe or symptomatic carotid artery disease appears to reduce the frequency of stroke in older cardiac surgical patients.