Risk neutralization in cardiac operations: Detection and treatment of associated carotid disease

Background. A screening and treatment protocol was implemented to extend th e benefit of prophylactic carotid endarterectomy to patients who had open h eart operations. Methods. Patients aged 65 or older or who at any age had left main coronary disease, transient ischemic attack, or stroke were eligible for preoperati ve carotid duplex screening. Carotid endarterectomies and open heart operat ions were planned as a staged (n = 59) or combined procedure (n = 55) for a ngiographically confirmed carotid stenosis of at least 80%. Results. Duplex scans were obtained in 1,719 of 7,035 open heart surgical p atients over 8 years. The overall stroke rate was 1.5% (108 of 7,035). Seve n of these were strokes of carotid origin (0.1%). There were 129 patients w ith at least 80% stenosis. One hundred fourteen had carotid endarterectomy preceding open heart operation, and none had carotid artery stroke. Twelve patients with at least 80% carotid stenosis by duplex scan had open heart o perations without prophylactic carotid endarterectomies. There were four ca rotid strokes in these 12 patients (p = 0.0001; odds ratio, 20.2). Stroke r isk remained significantly elevated (16.8% p = 0.005) in the 50% to 79% gro up. The changes associated with the reduced risk afforded by this screening and treatment strategy amounted to $346 for each patient in the study. Conclusions. The risk of carotid stroke at the time of cardiac operation ca n be defined by duplex screening. Prophylactic carotid endarterectomy neutr alizes the risk in those with at least 80% stenosis. Consideration for lowe ring the threshold for assessment and treatment of carotid stenoses appears warranted. The economic investment is recouped by the savings in system re sources that would have been depleted through care for carotid stroke and i ts sequelae. (Ann Thorac Surg 1999;68:850-7) (C) 1999 by The Society of Tho racic Surgeons.