**8. Results**

#### **8.1 Descriptive analysis**

Of the 452 patients, 261 (57.7%) were men and 191 (42.3%) women. The overall average age was 66 years. The types of surgery carried out were divided into: aortic valve replacement + coronary artery bypass grafting (n=71, 15.7%; biological 57.7% and mechanical 42.3%), aortic valve replacement (n=227; biological 50.2%, mechanical 44.5%), aortic valve replacement and another valve (n=72, 15,9%; biological 9.7%, mechanical 90.3%), aortic valve replacement with insertion of tube due to aortic root aneurysm (Bentall's technique) (n=58; 12.8%) (Modified inclusion (David) technique) (n=10, 2,2%), aortic valve replacement (n=12; 2.6% 16.6% biological, 83.4% mechanical), by endoscopy (n=2; 0.4% 100% mechanical). 4% had a history of previous coronary artery bypass grafting. 94.7% of the surgery was scheduled, 2.65% was priority and 2.65% was urgent.

Of the 452 patients, 62.8% (284 patients) had hypertension, 20.8% (94 patients) DM, 48.4% (219 patients) DL, 7.5% (34 patients) COPD, 58.2% (263 patients) CHF with NYCA dyspnea classifications: I - 5.4%, II – 41.6%, III - 45% and IV – 7.8%. CRI was present in 8.4% (38 patients). 37.6% were smokers and 4.4% drinkers. 29.6% had calcified valves, and of these 57.4% were Ao, 18% were mitral, 2.2% were tricuspid, 0.7% were pulmonary and 23.1% had more than one. 4.2% had PAD. 21.2% had a history of chronic atrial fibrillation and 1.5% had had AMI within 3 months prior to the valvular surgery.

The average aortic clamping time was 101 minutes and the CPB was 125.2 minutes. On average 2 packed red cell transfusions were performed per patient.

There were 22 cases of Ao valve replacement for endocarditis due to multiple causes, including Arthrographis Kalrae Fungi, Streptococcus viridans (2 cases), Streptococcus bovis, Streptococcus mitis, Coxiella burnetii (Q fever), Enterococcus faecalis (3 cases), lactococcus, actinomyces odontolyticus, Granulicatella, pseudomonas aeruginosa, staphylococcus epidermidis, S. pneumoniae, 2 cases reported as Gram strains and two other cases as undetermined.


Table 2. Drugs used by patients with operation on the Ao valve

198 Aortic Valve Surgery






Of the 452 patients, 261 (57.7%) were men and 191 (42.3%) women. The overall average age was 66 years. The types of surgery carried out were divided into: aortic valve replacement + coronary artery bypass grafting (n=71, 15.7%; biological 57.7% and mechanical 42.3%), aortic valve replacement (n=227; biological 50.2%, mechanical 44.5%), aortic valve replacement and another valve (n=72, 15,9%; biological 9.7%, mechanical 90.3%), aortic valve replacement with insertion of tube due to aortic root aneurysm (Bentall's technique) (n=58; 12.8%) (Modified inclusion (David) technique) (n=10, 2,2%), aortic valve replacement (n=12; 2.6% 16.6% biological, 83.4% mechanical), by endoscopy (n=2; 0.4% 100% mechanical). 4% had a history of previous coronary artery bypass grafting. 94.7% of the surgery was

Of the 452 patients, 62.8% (284 patients) had hypertension, 20.8% (94 patients) DM, 48.4% (219 patients) DL, 7.5% (34 patients) COPD, 58.2% (263 patients) CHF with NYCA dyspnea classifications: I - 5.4%, II – 41.6%, III - 45% and IV – 7.8%. CRI was present in 8.4% (38 patients). 37.6% were smokers and 4.4% drinkers. 29.6% had calcified valves, and of these 57.4% were Ao, 18% were mitral, 2.2% were tricuspid, 0.7% were pulmonary and 23.1% had more than one. 4.2% had PAD. 21.2% had a history of chronic atrial fibrillation and 1.5% had

The average aortic clamping time was 101 minutes and the CPB was 125.2 minutes. On

There were 22 cases of Ao valve replacement for endocarditis due to multiple causes, including Arthrographis Kalrae Fungi, Streptococcus viridans (2 cases), Streptococcus bovis, Streptococcus mitis, Coxiella burnetii (Q fever), Enterococcus faecalis (3 cases), lactococcus,

prosthesis). It requires reimplanting the coronary arteries in the graft.

mechanical prostheses and the anticoagulant treatment they need.

neurologic level having muscle grade of 3 or more. **E:** normal.

standardized test (5 on the upper limb and 5 on the lower limb)

scheduled, 2.65% was priority and 2.65% was urgent.

had AMI within 3 months prior to the valvular surgery.

average 2 packed red cell transfusions were performed per patient.

therapeutic purposes.

**8. Results** 

**8.1 Descriptive analysis** 


Table 3. Percentages of NCs (neurological complications): TIA (transient ischemic attack), SCI Spinal Cord Injury, PN (peripheral neuropathy), CIP (critical illness polyneuropathy), ACS (confusional syndrome)

Table 3 shows the percentages of different NCs in Ao valve surgery. The rate of strokes was 1.5%, corresponding to 7 cases. Of these 7 cases, 2 came from the 71 patients who underwent valve replacement + CABG AO (2.8%), 3 were from the 227 patients that underwent single Ao valve replacement surgery (1.3%), one case was from the 72 patients who underwent multiple valve replacement (1.4%) and finally there was one case from the 12 patients who underwent a 2nd Ao valve replacement (8.3%). Table 4 shows the three most common NCs that have been seen in this study according to the different surgical techniques and the average times for CPB and Ao clamping measured in minutes.

Of the 23 cases of encephalopathy, 17.4% had a metabolic cause, in 56.5% the cause was hypoxic-ischemic and 26% had various causes. Of the strokes, 57.1% were right hemisphere and 42.9% were on the left. There was only one case in which the stroke was haemorrhagic. Of the ischemia (6 cases - 85.7%), 4 were of cardioembolic origin (66.6%), 2 border territory (33.3%) (Man in the Barrel Syndrome) and one was lacunar (16.6%).


Table 4. Most common NC percentages according to the different techniques used. Ao (aorta), vv (valve), repl (replacement), n: total number of patients, ACS (acute confusional syndrome). T. CPB (cardiopulmonary bypass time measured in minutes), T. Clamp (aortic clamping time measured in minutes). CBPG (coronary artery bypass grafting)

There are only 2 cases described of spinal cord injury. One was a side effect of Ao valve replacement surgery and the other came after surgery for aortic arch replacement using the Bentall technique. The two cases were side effects to a spinal cord ischemia. One was a ASIA

Neurological Complications in Aortic Valve Surgery and Rehabilitation Treatment Used 201

NCs are still a common cause of morbidity and mortality in postoperative patients who have undergone aortic valve surgery. Although much has been achieved, there are still many issues to resolve. The research is complex because of the many variables to be considered. Recent neuropsychological studies have shown that over 50% of patients undergoing cardiac surgery suffer brain injury, as evidenced by a CT scan or MRI (Mc Khan et al., 1997;

As regards the sex of the patients, the percentages are fairly balanced (57.7% men and 42.3% women), which is a difference compared to other studies where the male sex clearly prevails

Our study evaluates the type of technique used in aortic valve surgery, focusing on the paradigm that with strokes as a neurological complication fewer complications have arisen than in other studies (Zabala, 2005). These averages in Ao valve replacement surgery + coronary artery bypass grafting were 2.8% compared to 3.3%, and in patients undergoing single Ao valve replacement they came to 1.3% compared to 3.3%. In the patients who underwent multiple valve replacement the percentage was 1.4% as opposed to 6.7%, and finally out of the patients that underwent a 2nd Ao valve replacement the percentage was

The NCs evident in postoperative aortic surgery are in keeping with the big series: 0.4% for coma, 6.6% for ACS, 1.5% for STROKE and 5% for encephalopathy (Murkin, 1993, Harrison, 1995; Filsoufi et al, 2008), although there are others in which the incidence is higher

 Identifying predictors for NCs is important for understanding the pathogenesis of these complications as well as for developing preventive strategies (Mornals K et al, 1998; Tjang YS et al, 2007). According to the results of our study, the most influential risk factors in the development of intraoperative and postoperative NCs in aortic valve surgery are: arterial hypertension, heart failure, smoking, having a previous stroke, dyslipidemia and atrial fibrillation in this order, with lesser importance attached to COPD, diabetes mellitus, CRF, being a heavy drinker and peripheral arterial disease. The CPB and aortic clamping time is seen to be longer in cases where there is a NC but with no clearly significant relationship. As regards strokes, we found that 85.7% were ischemic, as in other studies (Zabala, 2005), but the percentages into which the ischemic strokes are usually divided are not what we found in this study. 4 were of cardioembolic origin (66.6%), 2 border territory (33.3%) (Man in the Barrel Syndrome) and one lacunar (16.6%), whereas in the recorded literature 50% are usually due to atherothrombotic causes, 25% are lacunar (related to a chronic hypertension), 20% cardioembolic, and there remain 5% in which we most often include border zone

The aortic valve surgery that proportionately produces the most NCs is 2nd aortic valve replacement followed by Ao valve replacement + coronary artery bypass grafting, aortic root replacement (Bentall) (17.2%), multiple valve replacement and finally single Ao valve

As for the 22 cases of endocarditis, 50% occurred in single aortic valve replacement, followed by 27.2% in multiple replacement surgery, and 9% in both second valve replacement and aortic arch replacement. Of these 22 cases, 2 of them had a stroke, one an acute confusional syndrome and 3 suffered encephalopathy. 11 of them were operated on a valve and 11 on a prosthetic valve. The bacteria that produced it and the complications are

**9. Discussion** 

Hallow et al, 1999).

8.3%. (Table 4.)

(Bucerius et al, 2004).

infarctions in cardiac surgery.

replacement. Table 4.

over females (Hallow et al, 1999).

A, D6 D7 Spinal Cord Injury Syndrome and the other was an ASIA C, D7-D8 spinal cord injury syndrome. Both patients were taken to a hospital specializing in spinal cord injury (National Hospital for Paraplegics in Toledo).

Overall mortality was 1.7% and in no way associated with cases of stroke, or with patients who suffered acute confusional state. There were, however, two deaths of patients with hypoxi-ischemic encephalopathy and multiple causes.

The average time of hospitalization was 18.7 days. Table 5 specifies the different durations of hospital stay depending on the surgery performed and the most common NCs suffered.


Table 5. Average hospitalization time measured in days in the most common NCs. ACS = Acute confusional state

The most common risk factors associated with NCs are shown in Table 6.

As regards rehabilitation for these patients, 97.3% underwent pulmonary rehabilitation before and after surgery, aiming to prevent respiratory complications. 43.8% of patients had some type of neurological complication and needed kinesitherapy techniques. 3.5% required occupational therapy. 1.75% of patients with NCs underwent electrotherapy techniques. During this period, no patient required any type of orthosis and only one of them needed to use a walker at home.


Table 6. Risk factors for NC in Ao valve surgery in %. RFs (risk factors), AHT (arterial hypertension), DM (Diabetes Mellitus), DL (dyslipidemia), COPD (chronic obstructive pulmonary disease), CHF (heart failure), CRF (chronic renal failure), PAD (peripheral arterial disease), AT (atheromatous plaques in Ao), AF (a history of chronic atrial fibrillation), AMI (history of acute myocardial infarction in the last three months)
