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S. Otomo et al. / Interactive CardioVascular and Thoracic Surgery
[2] Veliz-Reissmülar G, Torres HA, van der Linden J, Lindblom D, Jönhagen ME. Pre-operative mild cognitive dysfunction predicts risk for post-operative delirium after cardiac surgery. Aging Clin Exp Res 2007;19:172–7. [3] Bucerius J, Gummert JF, Borger MA, Walther T, Doll N, Falk V et al. Predictors of delirium after cardiac surgery delirium: effect of beatingheart (off-pump) surgery. J Thorac Cardiovasc Surg 2004;127:57–64. [4] Bokeriia LA, Golukhova EZ, Polunina AG. Postoperative delirium in cardiac operations: microembolic load is an important factor. Ann Thorac Surg 2009;88:349–50. [5] Siepe M, Pfeiffer T, Gieringer A, Zemann S, Benk C, Schlensak C et al. Increased systemic perfusion pressure during cardiopulmonary bypass is associated with less early postoperative cognitive dysfunction and delirium. Eur J Cardiothorac Surg 2011;40:200–7. [6] Hála M. Pathophysiology of postoperative delirium: systemic inflammation as a response to surgical trauma causes diffuse microcirculatory impairment. Med Hypotheses 2007;68:194–6. [7] Rudolph JL, Babikian VL, Birjinink V, Crittenden MD, Treanor PR, Pochay VE et al. Atherosclerosis is associated with delirium after coronary artery bypass graft surgery. J Am Geriatr Soc 2005;53:462–6. [8] Goto T, Baba T, Honma K, Shibata Y, Arai Y, Uozumi H et al. Magnetic resonance imaging findings and postoperative neurologic dysfunction in elderly patients undergoing coronary artery bypass grafting. Ann Thorac Surg 2001;72:137–42. [9] Goto T, Baba T, Matsuyama K, Honma K, Ura M, Koshiji T. Aortic atherosclerosis and postoperative neurological dysfunction in elderly coronary surgical patients. Ann Thorac Surg 2003;75:1912–8. [10] Heiserman JE, Drayer BP, Keller PJ, Fram EK. Intracranial vascular stenosis and occlusion: evaluation with three-dimensional time-of-flight MR angiography. Radiology 1992;185:667–73. [11] Masaryk TJ, Lewin JS, Laub G. Magnetic resonance angiography. In: Stark DD, Bradley WG (eds). Magnetic Resonance Imaging, 2nd edn. St Louis: Mosby Year Book, 1992, 299–334. [12] Fazekas F, Chawluk JB, Alavi A, Hurtig HI, Zimmerman RA. MR signal abnormalities at 1.5 T in Alzheimer’s dementia and normal aging. AJR 1987; 149:351–6. [13] Hasegawa K, Inoue K, Moriya K. An investigation of dementia rating scale for the elderly. Seishin Igaku (Tokyo) 1974;16:965–69. [14] Trzepacz PT. The delirium rating scale. Its use in consultation-liaison research. Psychosomatics 1999;40:193–204. [15] Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington, DC: American Psychiatric Association, 2000. [16] Koster S, Hensens AG, Schuurmans MJ, van der Palen J. Consequences of delirium after cardiac operations. Ann Thorac Surg 2012;93:705–11. [17] Kazmierski J, Kowman M, Banach M, Fendler W, Okonski P, Banys A et al. IPDACS Study. Incidence and predictors of delirium after cardiac surgery: results from the IPDACS study. J Psychosom Res 2010;69: 179–85. [18] Martin BJ, Buth KJ, Arora RC, Baskett RJ. Delirium: a cause for concern beyond the immediate postoperative period. Ann Thorac Surg 2012;93: 1114–20. [19] Vermeer SE, Prins ND, Heijer T, Hofman A, Koudstaal PJ, Breteler MMB. Silent brain infarcts and the risk of dementia and cognitive decline. N Engl J Med 2003;348:1215–22. [20] Greene NH, Attix DK, Weldone C, Smith PJ, McDonagh DL, Monk TG. Measures of executive function and depression identify patients at risk for postoperative delirium. Anesthesiology 2009;110:788–95. [21] Carey CL, Kramer JH, Josephson SA, Mungas D, Reed BR, Schuff N et al. Subcortical lacunes are associated with executive dysfunction in cognitively normal elderly. Stroke 2008;39:397–402. [22] Barbut D, Hinton RB, Szatrowski TP, Hartman GS, Bruefach M, Williams-Russo P et al. Cerebral emboli detected during bypass surgery are associated with clamp removal. Stroke 1994;25:2398–402. [23] Borger MA, Peniston CM, Weisei RD, Vasiliou M, Green REA, Feindel CM. Neuropsychologic impairment after coronary bypass surgery: effect of gaseous microemboli during perfusionist interventions. J Thorac Cardiovasc Surg 2001;121:743–9. [24] Irimia P, Martinez-Vila E, Martinez-Cuesta A, Zulueta J. Delirium due to brain microembolism: diagnostic value of diffusion-weighted MRI. J Neuroimaging 2007;17:175–7. [25] Caplan LR, Hennerici M. Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol 1998;55:1475–82.
eComment. Risk factors for delirium after cardiac and peripheral vascular surgery Author: Marios E. Daskalopoulos Vascular Unit, Thriasseio General Hospital, Athens, Greece doi: 10.1093/icvts/ivt348 © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Postoperative delirium (PD) is one of the most common complications after adult cardiac and peripheral vascular surgery, with age and prior neurological dysfunction and psychiatric pathology being among the most prominent risk/predisposing factors [1, 2]. What the current study [3] has to offer to the issue is the knowledge that magnetic resonance imaging (MRI) depicting brain ischaemic lesions preoperatively can be utilized for the neurocognitive and psychiatric prognosis of the operated patients. The advances in the related technology may also lead to the development of radiological scores for ischaemic lesions in the brain, aorta or peripheral vessels that would allow the prediction of the postoperative neuropsychiatric outcome with precision. Conflict of interest: none declared References [1] Tagarakis GI. Neurolological disorders and neuroprotection after heart surgery. Recent Pat CNS Drug Discov 2008;3:226–9. [2] Boehner H, Hummel TC, Habel U, Miller C, Reinbott S, Yang Q et al. Predicting delirium after vascular surgery: a model based on pre- and intraoperative data. Ann Surg 2003;238:149–56. [3] Otomo S, Maekawa K, Goto T, Baba T, Yoshitake A. Pre-existing cerebral infarcts as a risk factor for delirium after coronary artery bypass graft surgery. Interact CardioVasc Thorac Surg 2013;17:799–805.
eComment. Negative effect of delirium beyond the immediate postoperative period Author: Jamil Hajj-Chahine Department of Cardio-thoracic Surgery, University Hospital of Poitiers, Poitiers, France doi: 10.1093/icvts/ivt360 © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. In this interesting publication, Otomo et al. [1] highlights the relationship between pre-existing silent cerebral infarcts assessed by magnetic resonance imaging and postoperative delirium. They clearly demonstrated that pre-existing multiple cerebral infarctions are an independent predictor of postoperative delirium after cardiac surgery. Postoperative delirium is an acute confusional state with fluctuating consciousness and is very common after cardiac surgery. This transit mental syndrome is associated with many negative short-term consequences such as prolonged hospital stay, readmission to the hospital, poorer cognitive and functional recovery yielding an increase in economic and social costs [2-3]. Although delirium may resolve during hospital stay, it may have long-term functional and cognitive consequences, up to two years after the index hospitalization. Recently, Saczynski et al. [4] demonstrated in a prospective study of 225 patients undergoing cardiac surgery that postoperative delirium was a significant risk factor for a decline in cognitive function followed by a prolonged period of impairment up to one year after the cardiac procedure. The authors of the above-mentioned study concluded that postoperative delirium should be added to the list of risk factors of prolonged impairment after cardiac surgery, which include de novo atrial fibrillation, pre-existing cerebral disease, a low level of education and a history of major depression. Of note, Martin et al. [5] found that development of delirium after coronary artery bypass grafting increased the risk of stroke up to five years after the surgery. We fully agree with Otomo et al. that delirium is a marker of impaired cerebral microcirculation and that patients developing delirium have a more vulnerable central nervous system. Postoperative delirium negatively affects early and long-term outcomes. Every efforts to prevent, early detect and rapidly treat delirium are of utmost importance. Postoperative delirium should not be considered as only an inconvenient complication of cardiac surgery. Conflict of interest: none declared
S. Otomo et al. / Interactive CardioVascular and Thoracic Surgery
[2] Veliz-Reissmülar G, Torres HA, van der Linden J, Lindblom D, Jönhagen ME. Pre-operative mild cognitive dysfunction predicts risk for post-operative delirium after cardiac surgery. Aging Clin Exp Res 2007;19:172–7. [3] Bucerius J, Gummert JF, Borger MA, Walther T, Doll N, Falk V et al. Predictors of delirium after cardiac surgery delirium: effect of beatingheart (off-pump) surgery. J Thorac Cardiovasc Surg 2004;127:57–64. [4] Bokeriia LA, Golukhova EZ, Polunina AG. Postoperative delirium in cardiac operations: microembolic load is an important factor. Ann Thorac Surg 2009;88:349–50. [5] Siepe M, Pfeiffer T, Gieringer A, Zemann S, Benk C, Schlensak C et al. Increased systemic perfusion pressure during cardiopulmonary bypass is associated with less early postoperative cognitive dysfunction and delirium. Eur J Cardiothorac Surg 2011;40:200–7. [6] Hála M. Pathophysiology of postoperative delirium: systemic inflammation as a response to surgical trauma causes diffuse microcirculatory impairment. Med Hypotheses 2007;68:194–6. [7] Rudolph JL, Babikian VL, Birjinink V, Crittenden MD, Treanor PR, Pochay VE et al. Atherosclerosis is associated with delirium after coronary artery bypass graft surgery. J Am Geriatr Soc 2005;53:462–6. [8] Goto T, Baba T, Honma K, Shibata Y, Arai Y, Uozumi H et al. Magnetic resonance imaging findings and postoperative neurologic dysfunction in elderly patients undergoing coronary artery bypass grafting. Ann Thorac Surg 2001;72:137–42. [9] Goto T, Baba T, Matsuyama K, Honma K, Ura M, Koshiji T. Aortic atherosclerosis and postoperative neurological dysfunction in elderly coronary surgical patients. Ann Thorac Surg 2003;75:1912–8. [10] Heiserman JE, Drayer BP, Keller PJ, Fram EK. Intracranial vascular stenosis and occlusion: evaluation with three-dimensional time-of-flight MR angiography. Radiology 1992;185:667–73. [11] Masaryk TJ, Lewin JS, Laub G. Magnetic resonance angiography. In: Stark DD, Bradley WG (eds). Magnetic Resonance Imaging, 2nd edn. St Louis: Mosby Year Book, 1992, 299–334. [12] Fazekas F, Chawluk JB, Alavi A, Hurtig HI, Zimmerman RA. MR signal abnormalities at 1.5 T in Alzheimer’s dementia and normal aging. AJR 1987; 149:351–6. [13] Hasegawa K, Inoue K, Moriya K. An investigation of dementia rating scale for the elderly. Seishin Igaku (Tokyo) 1974;16:965–69. [14] Trzepacz PT. The delirium rating scale. Its use in consultation-liaison research. Psychosomatics 1999;40:193–204. [15] Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington, DC: American Psychiatric Association, 2000. [16] Koster S, Hensens AG, Schuurmans MJ, van der Palen J. Consequences of delirium after cardiac operations. Ann Thorac Surg 2012;93:705–11. [17] Kazmierski J, Kowman M, Banach M, Fendler W, Okonski P, Banys A et al. IPDACS Study. Incidence and predictors of delirium after cardiac surgery: results from the IPDACS study. J Psychosom Res 2010;69: 179–85. [18] Martin BJ, Buth KJ, Arora RC, Baskett RJ. Delirium: a cause for concern beyond the immediate postoperative period. Ann Thorac Surg 2012;93: 1114–20. [19] Vermeer SE, Prins ND, Heijer T, Hofman A, Koudstaal PJ, Breteler MMB. Silent brain infarcts and the risk of dementia and cognitive decline. N Engl J Med 2003;348:1215–22. [20] Greene NH, Attix DK, Weldone C, Smith PJ, McDonagh DL, Monk TG. Measures of executive function and depression identify patients at risk for postoperative delirium. Anesthesiology 2009;110:788–95. [21] Carey CL, Kramer JH, Josephson SA, Mungas D, Reed BR, Schuff N et al. Subcortical lacunes are associated with executive dysfunction in cognitively normal elderly. Stroke 2008;39:397–402. [22] Barbut D, Hinton RB, Szatrowski TP, Hartman GS, Bruefach M, Williams-Russo P et al. Cerebral emboli detected during bypass surgery are associated with clamp removal. Stroke 1994;25:2398–402. [23] Borger MA, Peniston CM, Weisei RD, Vasiliou M, Green REA, Feindel CM. Neuropsychologic impairment after coronary bypass surgery: effect of gaseous microemboli during perfusionist interventions. J Thorac Cardiovasc Surg 2001;121:743–9. [24] Irimia P, Martinez-Vila E, Martinez-Cuesta A, Zulueta J. Delirium due to brain microembolism: diagnostic value of diffusion-weighted MRI. J Neuroimaging 2007;17:175–7. [25] Caplan LR, Hennerici M. Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol 1998;55:1475–82.
eComment. Risk factors for delirium after cardiac and peripheral vascular surgery Author: Marios E. Daskalopoulos Vascular Unit, Thriasseio General Hospital, Athens, Greece doi: 10.1093/icvts/ivt348 © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Postoperative delirium (PD) is one of the most common complications after adult cardiac and peripheral vascular surgery, with age and prior neurological dysfunction and psychiatric pathology being among the most prominent risk/predisposing factors [1, 2]. What the current study [3] has to offer to the issue is the knowledge that magnetic resonance imaging (MRI) depicting brain ischaemic lesions preoperatively can be utilized for the neurocognitive and psychiatric prognosis of the operated patients. The advances in the related technology may also lead to the development of radiological scores for ischaemic lesions in the brain, aorta or peripheral vessels that would allow the prediction of the postoperative neuropsychiatric outcome with precision. Conflict of interest: none declared References [1] Tagarakis GI. Neurolological disorders and neuroprotection after heart surgery. Recent Pat CNS Drug Discov 2008;3:226–9. [2] Boehner H, Hummel TC, Habel U, Miller C, Reinbott S, Yang Q et al. Predicting delirium after vascular surgery: a model based on pre- and intraoperative data. Ann Surg 2003;238:149–56. [3] Otomo S, Maekawa K, Goto T, Baba T, Yoshitake A. Pre-existing cerebral infarcts as a risk factor for delirium after coronary artery bypass graft surgery. Interact CardioVasc Thorac Surg 2013;17:799–805.
eComment. Negative effect of delirium beyond the immediate postoperative period Author: Jamil Hajj-Chahine Department of Cardio-thoracic Surgery, University Hospital of Poitiers, Poitiers, France doi: 10.1093/icvts/ivt360 © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. In this interesting publication, Otomo et al. [1] highlights the relationship between pre-existing silent cerebral infarcts assessed by magnetic resonance imaging and postoperative delirium. They clearly demonstrated that pre-existing multiple cerebral infarctions are an independent predictor of postoperative delirium after cardiac surgery. Postoperative delirium is an acute confusional state with fluctuating consciousness and is very common after cardiac surgery. This transit mental syndrome is associated with many negative short-term consequences such as prolonged hospital stay, readmission to the hospital, poorer cognitive and functional recovery yielding an increase in economic and social costs [2-3]. Although delirium may resolve during hospital stay, it may have long-term functional and cognitive consequences, up to two years after the index hospitalization. Recently, Saczynski et al. [4] demonstrated in a prospective study of 225 patients undergoing cardiac surgery that postoperative delirium was a significant risk factor for a decline in cognitive function followed by a prolonged period of impairment up to one year after the cardiac procedure. The authors of the above-mentioned study concluded that postoperative delirium should be added to the list of risk factors of prolonged impairment after cardiac surgery, which include de novo atrial fibrillation, pre-existing cerebral disease, a low level of education and a history of major depression. Of note, Martin et al. [5] found that development of delirium after coronary artery bypass grafting increased the risk of stroke up to five years after the surgery. We fully agree with Otomo et al. that delirium is a marker of impaired cerebral microcirculation and that patients developing delirium have a more vulnerable central nervous system. Postoperative delirium negatively affects early and long-term outcomes. Every efforts to prevent, early detect and rapidly treat delirium are of utmost importance. Postoperative delirium should not be considered as only an inconvenient complication of cardiac surgery. Conflict of interest: none declared
