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Serious cognitive impairment from bypass operation, Scientific American

Around one-fourth of those who undergo this operation experience sufficient brain damage so as to be noticed by the clinician note.
 
In July of 2003 Scientific American did an article on the dark side of bypass operations, namely the serious cognitive impairment.  From Scientific American article on the web at http://www.sciamdigital.com/index.cfm?fa=Products.ViewIssuePreview&ARTICLEID_CHAR=99AA36E1-B743-630F-D182CB50B0D72C7E

Pumphead; July 2003; Scientific American Magazine; by Bruce Stutz; 6 Page(s)

The last thing I remembered was the cold room with a stainless-steel ceiling. I was about to undergo open-heart surgery, an experience shared by about 500,000 people in the U.S. every year. After the anesthesia took effect, surgeons made an incision in my groin to reach my femoral vein and artery. Through the vein they threaded a tube called a cannula into the right atrium, an upper chamber inside my heart. This tube, and another attached to the artery, was connected to a cardiopulmonarybypass pump, also known as a pump oxygenator or a heart-lung machine. A dose of heparin kept my blood from clotting as it traversed the machine's innards. As the venous blood passed through the oxygenator, it was cooled to prevent tissue damage. My body temperature lowered to 25 degrees Celsius (77 degrees Fahrenheit)-deep hypothermia. Surgeons inserted an inflatable clamp into my aorta to seal it off. Two liters of cold potassium solution stopped my heart, and for the next two hours the machine took over. An eight-inch incision below my right breast allowed the doctors to pass cameras and instruments between my ribs and then to repair my congenitally defective heart valve.

 

I left the hospital a week later. The incision healed quickly and painlessly. In a couple weeks I was out and about on slow but successively longer walks. Within a month I was back in the gym. Mentally, however, I felt a bit hazy, a little disconnected and sometimes even lost. I soon learned that the physician's warning, "You may be a little depressed for a time afterward," would not do justice to the long, dumbfounding struggle against what seemed to be the sudden onset, at 51 years of age, of attention-deficit disorder or incipient senility. Adrift in a clueless no-man's-land, I felt my moods range from querulous to despondent. I couldn't muster the concentration to deal with the problem. I just wanted to be able to think. Think anything. I didn't know it at the time, but I was suffering from what surgeons among themselves call ôpumphead,ö an all-tooapt appellative that refers to the dimwitted state in which patients seem to linger after being hooked up to a heart-lung machine for open-heart or, in my case, valve surgery. Other symptoms include patchy recall, social difficulties and personality changes. Pumphead was long suspected from anecdotal and journal reports of patients tested soon after their operations. But only recently did a fiveyear study of bypass patients indicate that after an initial recovery of mental capabilities in the first few months, the condition often worsens later and persists for years. Could the familiar heart-lung machine-which annually provides life-giving oxygen to blood during 900,000 coronary-bypass operations around the world-be at fault?

From the original July 03 article by Bruce Stutz pgs. 77-81.  Highlights:

 

About 500,000 operations per year in U.S. (probably about half are cigarette smokers).

The operation is done with a heart-lung machine, administering of herparin to prevent blood clotting, and deep hypothermia (body temperature of 77 degrees).   @ liters of cold potassium solution is used to stop the heart.  The machine for two hours circulates the blood.  Typical effects are quarrelsomeness, depression, patchy recall, despondency, inability to focus on complex matters, and a reduction in sex drive.   Surgeons have labeled such patients “pumpheads”.  This condition after moderate recovery in the first month, “often worsens later and persists for years.”   One problem “in addition to bubbles, clotted shards of blood cells, particles of corroded tubing and arterial plaque—all collectively called emboli—can make their way through the pump and cannulae and back into the body… and they can block blood flow in a manner akin to a mini stroke, starving or even killing nearby tissue.” (80-81).  “Microemboli—one thenth the size of the detectable ones and numbering 200 to 300 an hour—may still escape discovery and potentially damage body or brain tissue.  Newman and others believe that these types of anomalies during surgery, could cause cognitive problems in patients.”  (JK is skeptical of this because before the process of filtration and other methods, the effects of emboli would have been markedly worse. The literature doesn’t support this.)  A five-year study of 52 bypass patients at the University of Wurzburg in Germany, published last fall in Neurology, found no global decline” in cognitive abilities comparable with the baseline (pre-serurgy) test performance of subjects (81).”   This conflicts with the of Newman who tested 261 patients the week before hospitalization, during the week after the operation, after wix weeks, and again siz months later.  “After the surgery, 53 percent of the subjects were unable to match their earlier cognitive performance.”  Six weeks late, 36 percent, and 24 percent at the six-month interval (80).  [No mention of a control group, which ideally should consist of patients who went into treatment for a condition requiring little medication such as the setting of a femur.  JK also wonders about the effect of medications.]  “Off pump surgery now accounts for anywhere from 20 to 80 percent of heart surgies, depending on the surgeon and the hospital” (81).  Using Doppler ultrasound for 40 patients receiving off-pump surgery, there were onl 27 emboli, compared with an average of 1,766 during on-pump operations (81).  Any cognitive benefits, however, were unclear—confirmed by other studies.  “Too many other factors that occur during and immediately after heart surgery could also be participants in cognitive decline:  inflammation, hypoxia (insufficient oxygen delivery to tissues), lowered blood pressure, irregular heart rhythms, or body temperature that is too warm or too cold.    

Pump head

 

JAMA vol. 287, No. 11, March 20, 2002

 

Cognitive Outcome After Off-Pump and On-Pump Coronary Artery Bypass Graft Surgery, A Randomized Trial

Diederik Van Dijk, MD; Erik W. L. Jansen, MD,PhD; Ron Hijman, PhD; Arno P. Nierich, MD,PhD; Jan C. Diephuis, MD; Karel G. M. Moons, PhD; Jaap R. Lahpor, MD,PhD; Cornelius Borst, MD,PhD; Annemieke M. A. Keizer, MSc; Hendrik M. Nathoe, MD; Diederick E. Grobbee, MD,PhD; Peter P. T. De Jaegere, MD,PhD; Cor J. Kalkman, MD,PhD; for the Octopus Study Group

JAMA. 2002;287:1405-1412.

Context  Coronary artery bypass graft (CABG) surgery is associated with a decline in cognitive function, which has largely been attributed to the use of cardiopulmonary bypass (on-pump procedures). Cardiac stabilizers facilitate CABG surgery without use of cardiopulmonary bypass (off-pump procedures) and should reduce the cognitive decline associated with on-pump procedures.

Objective  To compare the effect of CABG surgery with (on-pump) and without (off-pump) cardiopulmonary bypass on cognitive outcome.

Design and Setting  Randomized controlled trial conducted in the Netherlands of CABG surgery patients enrolled from March 1998 through August 2000, with 3- and 12-month follow-up.

Participants and Intervention  Patients scheduled for their first CABG surgery (mean age, 61 years; n = 281) were randomly assigned to off-pump surgery (n = 142) or on-pump surgery (n = 139).

Main Outcome Measures  Cognitive outcome at 3 and 12 months, which was determined by psychologists (blinded for randomization) who administered 10 neuropsychological tests before and after surgery. Quality of life, stroke rate, and all-cause mortality at 3 and 12 months were secondary outcome measures.

Results  Cognitive outcome could be determined at 3 months in 248 patients. Cognitive decline occurred in 21% in the off-pump group and 29% in the on-pump group (relative risk [RR], 0.65; 95% confidence interval [CI], 0.36-1.16; P = .15). The overall standardized change score (ie, improvement of cognitive performance) was 0.19 in the off-pump vs 0.13 in the on-pump group (P = .03). At 12 months, cognitive decline occurred in 30.8% in the off-pump group and 33.6% in the on-pump group (RR, 0.88; 95% CI, 0.52-1.49; P = .69). The overall standardized change score was 0.19 in the off-pump vs 0.12 in the on-pump group (P = .09). No statistically significant differences were observed between the on-pump and off-pump groups in quality of life, stroke rate, or all-cause mortality at 3 and 12 months.

Conclusion  Patients who received their first CABG surgery without cardiopulmonary bypass had improved cognitive outcomes 3 months after the procedure, but the effects were limited and became negligible at 12 months.


Author Affiliations: Departments of Anaesthesiology (Drs Van Dijk, Diephuis, and Kalkman), Cardiothoracic Surgery (Drs Jansen and Lahpor), Psychiatry (Dr Hijman and Ms Keizer), Cardiology (Drs Borst, Nathoe, and De Jaegere), and the Julius Center for Patient Oriented Research (Drs Moons and Grobbee), University Medical Center Utrecht, Utrecht; and Department of Thoracic Anaesthesiology, Isala Clinics, Weezenlanden Hospital, Zwolle (Dr Nierich), the Netherlands.


 

The Annals of Thoracic Surgery 2008; 85:872-879 at http://ats.ctsnetjournals.org/cgi/content/abstract/85/3/872

Original Articles: Cardiovascular

Cognitive Outcomes Three Years After Coronary Artery Bypass Surgery: Relation to Diffusion-Weighted Magnetic Resonance Imaging

 

Stephan C. Knipp, MD*, Nadine Matatko, PhD, Hans Wilhelm, PhD, Marc Schlamann, MD, Matthias Thielmann, MD, Christian Lösch, MS, Hans C. Diener, MD, PhD, Heinz Jakob, MD, PhD

Department of Thoracic and Cardiovascular Surgery, West German Heart Center, Department of Neurology, Institute of Diagnostic and Interventional Radiology and Neuroradiology, Institute of Medical Informatics, Biometry and Epidemiology, University Clinic of Essen, Essen, Germany

Accepted for publication October 24, 2007.

* Address correspondence to Dr Knipp, Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University Clinic of Essen, Hufelandstrasse 55, Essen, 45122, Germany (Email: stephan.knipp@uk-essen.de ).

Background: Cognitive decline is well recognized early after coronary artery bypass graft surgery (CABG), but controversy exists regarding the degree and duration of these changes. We investigated the course of cognitive performance during 3 years after surgery and determined whether ischemic brain injury detected by diffusion-weighted magnetic resonance imaging was related to cognitive decline.

Methods: Thirty-nine patients undergoing on-pump CABG completed preoperative neuropsychologic examination and were followed up prospectively at discharge, 3 months, and 3 years after surgery. Cognitive performance was assessed with a battery of 11 standardized psychometric tests assessing 7 cognitive domains. Cognitive outcome was analyzed by determining (1) mean changes in within-patient scores over time (identifying cognitive functions with decline), and (2) the incidence of cognitive deficit for each individual (identifying patients with decline). Objective evidence of acute cerebral ischemia was obtained by diffusion-weighted magnetic resonance imaging. Prospectively collected data were used to identify predictors of cognitive deficits.

Results: From baseline to discharge, cognitive test scores significantly declined in 7 measures. Most tests improved by 3 months. Between 3 months and 3 years, late decline was observed in 2 measures with persistent deterioration in 1 measure (verbal memory) relative to baseline. Postoperative cognitive deficits (drop of 1 SD in scores on 3 tests) were observed in 56% of patients at discharge, 23% at 3 months and 31% at 3 years. On postoperative diffusion-weighted magnetic resonance imaging, there were new ischemic cerebral lesions in 51% of patients. The presence of cognitive deficit at discharge was a significant univariate predictor of late cognitive decline (p = 0.025). A relation between the presence of new diffusion-weighted magnetic resonance imaging detected lesions and cognitive decline, however, was not found.

Conclusions: Longitudinal cognitive performance of patients with CABG showed a two-stage course with early improvement followed by later decline. Long-term cognitive deficit was predicted by early cognitive decline, but not by ischemic brain lesions on magnetic resonance imaging.

 

* Standard Deviation (SD): A statistic used as a measure of the dispersion or variation in a distribution, equal to the square root of the arithmetic mean of the squares of the deviations from the arithmetic mean.   The standard deviation of the list x1, x2, x3...xn is given by the formula:
sigma = sqrt(((x1-(avg(x)))^2 + (x1-(avg(x)))^2 + ... + (xn(avg(x)))^2)/n)

The formula is used when all of the values in the population are known.

 

 

 

 

 

Those who have a financial interest in the outcome manipulate the results, Major study finds that all 37 journal articles positive effects over stated; the average was 32%. Statins cause erectile dysfunction, cognitive imparement, and cancer.  

Lipitor (2011) lifetime sales $131 billion, tops all drugs.  Plavix at $60 billion is second.

 

STATINS CANCER Link

52% short term

 

LA Times, Health section, July 21, 2008  --  excerpts

Vytorin, the combination drug (simvastatin (better known by its commercial name Zocor) and ezetimibe--known as Zetia) prescribed to lower cholesterol, sustained another blow today, when the author of a major clinical trial announced that the medication had failed to drive down hospitalization and death due to heart failure in patients with narrowing of the aortic valve. In the process, researchers in Norway detected a significant blip in cancers in the 1,800 subjects they followed

Today's findings suggested something more ominous: the incidence of cancer -- and of dying of cancer -- was significantly higher in the patients taking Vytorin. Altogether, 67 patients on placebo developed cancer during the trial. Among subjects on Vytorin, 102 developed cancers of various kinds.*  This is the second adverse press—the first being in March 08, when the ENHANCE trial found that Vytorin fared no better than a placebo at reducing plaque buildup on the walls of patients' arteries.* *

Comments by jk

Simvastatin (Zocor) is off patent.  Thus in a scramble for profits a combination drug (on patent) was introduced.  Direct to consumer market cost $155 in 07—mainly TV ads. 

*  The pressing issue is that since the development  of Statins, the very first animal studies in the 60s it has been known that Statins increase the incidents of cancer.  However, nearly all studies done thereafter have not included cancer. 

*  Several studies have failed to find a reduction in the build of plaque, even thought the statins including Zocor, reduce LDL and cholesterol.  Few studies include the principle reason for taking a statin, namely a reduction in the death rate.  Claims for such reduction probably entail a failure to control the contravening variable, aspirin usage.  Given a pile of evidence, including the very mechanism of plaque formation, which involves inflammation process, I must conclude that the use of statins is highly suspect.  Given the harm done including cognitive impairment, weakness, and cancer, if my skepticism is born out, the harm done by statins as a course of treatment will far surpass that of VIOXX which killed over 200,000 people world wide by accelerating atherosclerosis. 

 EXTENDED RELEASE NIACIN IS A SAFER, AND A MORE EFFECTIVE WAY TO LOWER MI RISK!