Atheroemboles et chirurgie cardiaque: importance de la mise au point préopératoire

OBJECTIVE: Atheroembolization is a recognized complication of cardiac surgical procedures, and has been implicated in postoperative stroke, renal failure, multiorgan failure, and death. Preoperative identification of patients at risk for developing atheroemboli is essential. The aim of this study was to determine preoperative risk factors for atheroemboli and to assess the postoperative course of the patients who developed atheroembolic syndrome. METHODS: A retrospective record review was conducted. From 1/1990 to 12/1994, 5.486 patients underwent coronary artery bypass grafting (CABG), valve operations, or other cardiac surgical procedures at the Massachusetts General Hospital. Among this population, 107 patients (1.9%) developed atheroembolic syndrome. There were compared to a concurrent population of 925 patients operated during the same period. RESULTS: Patients who developed atheroemboli were older, with an increased incidence (p < 0.01) of hypertension, cerebrovascular disease, and aortoiliac disease. Many had a complicated course after catheterization, with renal insufficiency (35%) and evidence of peripheral emboli (12%). Average Intensive Care Unit stay, hospital stay, and hospital cost of these patients were 16.8 days, 48.4 days and 88,000 respectively, compared to 1.5 days, 9.6 days and 23,000 for the concurrent population. Of these 107 patients only two were discharged home, the others either died (48 patients, or 25% of all cardiac surgical deaths during this period), or rehabilitation or chronic hospital facilities. Twenty-seven autopsies were performed and invariably showed a diffusely diseased aorta, with calcification, mural thrombus, and ulceration. CONCLUSIONS: Atheroembolization during cardiac surgical procedures has profound medical and economic consequences. Because of the diffuse nature of aortic disease, measures approaching the disease as a local process are likely to be unsuccessful. Appropriate evaluation would ideally identify patients with extensive aortic atheromatous disease, prior to rather than during surgery.