Reduced neurological injury during CABG in patients with mobile aortic atheromas: A five-year follow-up study

Background. Mobile atheromas of the thoracic aorta have been identified as a major cause of stroke after coronary artery bypass grafting (CABG). This prospective study was undertaken to identify mobile atheromas and to determ ine the incidence of immediate postoperative embolic events after suitable surgical modifications. Late clinical events attributable to embolization w ere also studied. Methods. Between January 1993 and July 1997, 3,660 patients scheduled for C ABG underwent intraoperative transesophageal echocardiography to identify a ortic atheromatous disease. The disease was graded as follows: grade I, pla ques extending less than 5 mm into the aortic lumen; grade II, plaques exte nding more than 5 mm into the aortic lumen; and grade III, plaques with a m obile element. Only patients with grade III atheromas were included in the study. Various surgical modifications were done depending on the location o f the lesion, eg, aortic arch atherectomy, CABG combined with transmyocardi al laser revascularization, off-pump CABG by median sternotomy, and minimal ly invasive direct coronary artery bypass. Measured outcomes were death, st roke, and other vascular events, both early (within 1 week) and late (1 to 5 years) after operation. Results. Of the 3,660 patients, 104 (2.84%) had mobile atheromas. The perio perative stroke rate was 0.96%, and the incidence of other vascular events was 1.92% at 1 week. There was no embolic event in the group of 88 patients who underwent off-pump CABG. Of the study group, 98.07% are in regular fol low-up. At 5 years, 1 patient had had a nonfatal stroke, and 2 patients had died of causes unrelated to atheromatous disease. Conclusions. The stroke rate was very low in patients with mobile aortic at heromas who underwent CABG after modification in surgical technique, especi ally off-pump CABG. A follow-up of 5 years showed that patients with mobile atheromas have a very low incidence of spontaneous embolization. (Ann Thor ac Surg 2000;70:1558-64) (C) 2000 by The Society of Thoracic Surgeons.