LITERATURE REVIEWLinda Shore-Lesserson, MD

Section Editor

CORONARY ARTERY SURGERYPaul S. Myles, Guest Reviewer

Karagoz HY, Sonmez B, Bakkaloglu B, et al: Cor-onary artery bypass grafting in the conscious patientwithout endotracheal general anesthesia. Ann ThoracSurg 70:91-96, 2000

Off-pump beating heart surgery is becoming popular in many cen-ters. This group from Turkey describes their initial experience of 5patients who underwent coronary artery bypass graft surgery withoutgeneral anesthesia, using high thoracic epidural block. The periopera-tive course of the patients was uneventful, and there was no perioper-ative morbidity or mortality. No patient was converted to generalanesthesia or required cardiopulmonary bypass. Coronary angiogramsrevealed patent anastomoses in all patients. The mean length of hospitalstay was 2.2� 0.4 days. All patients returned to their usual activitiesof daily life within the 1st postoperative month.

Implication: This small case series lends support to performingcoronary bypass graft surgery under regional block in selected cir-cumstances.

Royse AG, Royse CF, Ajani AE, et al: Reducedneuropsychological dysfunction using epiaortic echo-cardiography and the exclusive Y graft. Ann ThoracSurg 69:1431-8, 2000

The presence of ascending aortic atheroma is considered to be a riskfactor for stroke after cardiac surgery and cardiopulmonary bypass.This group investigated the effect of epiaortic screening for atheromaand use of exclusive Y-graft revascularization on the incidence ofneuropsychologic dysfunction after coronary artery bypass graft sur-gery. A control group was studied in which atheroma was assessed bymanual palpation and, if present, was avoided during aortic cannula-tion. This group had conventional proximal aortocoronary grafts.Transcranial Doppler imaging of the right middle cerebral artery wasused to detect cerebral microemboli. Late neuropsychologic dysfunc-tion at 57� 2 days postoperatively in the control group was 38% andin the epioaortic screening–Y graft group was 3.8% (p� 0.012).Microemboli detected by transcranial Doppler imaging during periodsof aortic manipulation were more numerous for patients with latedysfunction (5.2 [3.0]v 0.5 [0.2]; p � 0.018). No clinical strokesoccurred in either group.

Implications: The combined techniques of epiaortic screening andY-graft for coronary artery bypass graft surgery resulted in a lowincidence of late neuropsychologic dysfunction. This is an importantfinding and needs to be confirmed with a large randomized trial.

OUTCOMES MEDICINEPaul S. Myles and Linda Shore-Lesserson

Rodgers A, Walker N, Schug S, et al: Reduction ofpostoperative mortality and morbidity with epidural

or spinal anaesthesia: Results from overview of ran-domised trials. BMJ 321:1493-1497, 2000

Numerous studies have investigated the effects of neuraxial block-ade with epidural or spinal anesthesia. None has had sufficient powerto detect a meaningful difference in major morbidity or mortality. Thissystematic review comprised 141 trials including 9559 patients. Overallmortality was reduced by 30% in patients allocated to neuraxial block-ade (103 of 4871 deathsv 144 of 4688 deaths; odds ratio� 0.70; 95%confidence interval, 0.54 to 0.90;p � 0.006). Neuraxial blockadereduced the risk of deep vein thrombosis by 44%, pulmonary embolismby 55%, and pneumonia by 39% (allp � 0.001). Sensitivity analyses,available via the journal’s website, revealed consistent effects in dif-ferent surgical subgroups, in combination epidural and general anes-thesia, and at different time periods.

Implication: This systematic review suggests that neuraxial block-ade reduces postoperative mortality and major morbidity and supportsmore widespread use of neuraxial blockade.

Bellomo R, Chapman M, Finfer S, et al: Low-dosedopamine in patients with early renal dysfunction: Aplacebo-controlled randomised trial. Australian andNew Zealand Intensive Care Society (ANZICS) Clin-ical Trials Groups. Lancet 356:2139-2143, 2000

Low-dose dopamine is commonly given to patients at risk of renalfailure during and after major surgery. Administration of low-dosedopamine has theoretic and known risks (eg, central venous cannula-tion, arrhythmias, increased myocardial oxygen consumption, splanch-nic ischemia). This study randomly allocated 328 critical care patientsto either low-dose dopamine (2�g/kg/min) or placebo while in theintensive care unit. There were no differences between groups in thepeak serum creatinine concentration (245� 144�mol/L v 249� 147�mol/L; p � 0.93), the number of patients requiring renal replacementtherapy (p� 0.55), or the duration of intensive care unit stay (p�0.67).

Implication: There is no evidence to support the routine use oflow-dose dopamine in critically ill patients.

Newman MF, Kirchner JL, Phillips-Bute B, et al:Longitudinal assessment of neurocognitive functionafter coronary artery bypass surgery. N Engl J Med344:395-402, 2001

In 261 patients undergoing coronary artery bypass graft surgery,cognitive tests were performed at multiple time points during theperioperative period and were followed for 5 years postoperatively.Four domains of cognitive function were studied, and a compositescore was derived. Cognitive dysfunction was present in 53% ofpatients at hospital discharge, 36% at 6 weeks postoperatively, 24% at6 months postoperatively, and 42% at 5 years. Significant univariateand multivariate predictors of neurobehavioral deficits at 5 years in-cluded older age, lower education level, and cognitive dysfunction athospital discharge.

531Journal of Cardiothoracic and Vascular Anesthesia, Vol 15, No 4 (August), 2001: pp 531-532