Postperfusion syndrome

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Postperfusion syndrome, also known as pumphead, is a controversial condition that describes a constellation of neurocognitive impairments attributed to cardiopulmonary bypass (CPB) during cardiac surgery.

Deficits due to postperfusion are thought to include memory impairment, stilted speech, depression, confusion, and diminished hand-eye coordination. Patients are also thought to experience altered sex drive, lessened inhibitions and other personality changes.[1]

Contents

[edit] Evidence for postperfusion syndrome

A study by Newman et. al. at Duke University Medical Center published in the New England Journal of Medicine (NEJM), showed an increased incidence of cognitive decline after coronary artery bypass surgery (CABG); both immediately (53 percent at discharge from hospital) and over time (36 percent six weeks , 24 percent at six months, and 42 percent at five years) [2]. This study shows a strong association of neurocognitive decline with CABG, but as level II-3 evidence-based medicine (due to the lack of a control group) cannot be used to demonstrate causation.

Subsequent studies have compared "on-pump" CABG with off-pump coronary artery bypass (OPCAB) - essentially establishing controls to compare of the incidence of neurocognitive decline in CABG with and without the use of CPB. A small study (60 patients total, 30 in each treatment arm) by Zamvar et. al. demonstrated neurocognitive impairment at both 1 week and 10 weeks postoperatively [3]. However, a larger study (281 patients total) by Van Dijk et. al. showed CABG surgery without cardiopulmonary bypass improved cognitive outcomes 3 months after the procedure, but the effects were limited and became negligible at 12 months [4]. Furthermore, the Van Dijk study showed no difference between the on-pump and off-pump groups in quality of life, stroke rate, or all-cause mortality at 3 and 12 months. More recently OPCAB has been proposed to be beneficial in patients at high-risk of neurological injury; a study by Jenson et. al published in Circulation found no significant difference in the incidence of cognitive dysfunction 3 months after either OPCAB or off-pump CABG [5].

Given the above evidence, post-perfusion syndrome has high incidence post CPB in the setting of CABG surgery, but is transient with no permanent neurological impairments. Controlled "on-pump" versus "off-pump" cardiac surgery has only been studied in the setting of CABG and is not necessarily generalizable to other types of cardiac surgery. Recent advancements in transcatheter and percutaneous valve replacement may soon allow comparison of other types of cardiac surgery with and without CPB.

[edit] Proposed mechanism of injury

Physicians speculate causation by tiny debris and air bubbles (microemboli) that enter the brain via cardiopulmonary bypass. Surgeons attempt to minimize time spent on bypass to decrease postoperative deficits; studies have shown increased bypass time is associated with increased incidence and severity of postperfusion syndrome[citation needed] and mortality.[citation needed]

[edit] Confusion in other surgeries

People who undergo non-cardiac surgery frequently develop in-hospital confusion and delirium with persistant neurocognitive deficits[citation needed]. Also, this study may be attributing the normal cognitive decline in the patient population to bypass surgery; the incidence is decreasing after surgery, but has a large increase after 5 years - this increase over time can be explained by the underlying risk of developing neurocognitive decline in the CABG patient population (the average age of patients in this study is 60.6)[citation needed].

[edit] Postperfusion in the press

Postperfusion syndrome has attracted some public notoriety following the coronary bypasses of former U.S. President Bill Clinton and Vice-President Dick Cheney. The National Enquirer published an article [6] speculating Clinton experienced permenant debilitating brain damage; using the NEJM article[2] discussed above to provide credibility to the claim.

[edit] References

  1. ^ Stutz, Bruce (July 2003). Pumphead. Scientific American Magazine. Retrieved on 2006-11-08.
  2. ^ a b Newman M, Kirchner J, Phillips-Bute B, Gaver V, Grocott H, Jones R, Mark D, Reves J, Blumenthal J (2001). "Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery.". N Engl J Med 344 (6): 395-402. PMID 11172175.
  3. ^ Zamvar V, Williams D, Hall J, Payne N, Cann C, Young K, Karthikeyan S, Dunne J (2002). "Assessment of neurocognitive impairment after off-pump and on-pump techniques for coronary artery bypass graft surgery: prospective randomised controlled trial.". BMJ 325 (7375): 1268. PMID 12458242.
  4. ^ Van Dijk D, Jansen E, Hijman R, Nierich A, Diephuis J, Moons K, Lahpor J, Borst C, Keizer A, Nathoe H, Grobbee D, De Jaegere P, Kalkman C (2002). "Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: a randomized trial.". JAMA 287 (11): 1405-12. PMID 11903027.
  5. ^ a b Jensen B, Hughes P, Rasmussen L, Pedersen P, Steinbrüchel D (2006). "Cognitive outcomes in elderly high-risk patients after off-pump versus conventional coronary artery bypass grafting: a randomized trial.". Circulation 113 (24): 2790-5. PMID 16769915.
  6. ^ Brenna, Tony and Peter Davidson (October 2004). Clinton's Secret Health Crisis. Retrieved on 2006-11-08.

[edit] See also

[edit] External links

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