**9. Discussion**

200 Aortic Valve Surgery

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

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

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.

> **Stroke Hospital stay**

**Replacement + CBPG** 16 2 39 8 23 5 63.5 **1 Ao valve replacement** 12 3 23.3 12 21 6 58.2 **Multiple v replacement.** 18 1 68 4 17.7 5 60.5 **Ao root repl. (Bentall)** 16 0 16 5 24.8 5 33.1 **Ao root repl. (David)** 14.5 0 14.5 0 14.5 0 14.5 **2nd AO v replacement** 14 1 41 3 30 2 26.5 **Endoscopic v. repl.** 9 0 9 0 9 0 9

Table 5. Average hospitalization time measured in days in the most common NCs.

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

**RFs AHT DM DL COPD CHF CRI Prior** 

**STROKE** 85.7% 14.2% 42.8% 28.6% 85.7% 14.2% 42.8% **ACS** 53.1% 34.3% 31.2% 6.2% 46.9% 15.6% 12.5% **Encephal.** 73.9% 21.7% 39.1% - 65.2% 21.7% 17.4%

**STROKE** 42.8% 14.2% 14.2% 14.2% 28.6% - - **ACS** 28.1% 6.25% 6.25% - 21.9% 3.1% - **Encephal.** 43.5% 4.3% - 4.3% 34.8% - - 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)

**Smokers Drinkers PAD AT AF AMI** -

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

**ACS Hospital stay** 

**Encephalopathy Hospital** 

**stay** 

**stroke**

(National Hospital for Paraplegics in Toledo).

**Type of surgery Hospital stay** 

ACS = Acute confusional state

use a walker at home.

hypoxi-ischemic encephalopathy and multiple causes.

**without NCs** 

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; Hallow et al, 1999).

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 over females (Hallow et al, 1999).

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 8.3%. (Table 4.)

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 (Bucerius et al, 2004).

 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 infarctions in cardiac surgery.

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 replacement. Table 4.

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

Neurological Complications in Aortic Valve Surgery and Rehabilitation Treatment Used 203

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similar to other work associated with the incidence of endocarditis (Arauz-Gongora et al, 1998).

The average times for aortic clamping and CPB were 101 and 125.2 minutes respectively. This is somewhat higher in some of the surgeries with more NCs such as in 2nd valve replacement, followed by multiple valve replacement and aortic arch replacement (Bentall). Table 4.

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. These results are similar to other publications. However, in our work the appearance of a neurological complication did not significantly increase mortality (Redmond et al, 1996). There are groups with no mortality although the number of patients is lower (n=118) (Mutarelli EG et al, 1993).

The length of hospital stay increases dramatically when there are NCs, as evidenced in other works. Table 5.

The data provided in connection with rehabilitation techniques carried out fall far short because many patients were referred to another hospital area in Madrid or another province of Spain and continued the rehabilitation in places near their original home.

This study is limited mainly in that it is a retrospective study and this prevents us from knowing the exact time of the onset of the NC and therefore we cannot draw valid conclusions regarding the type of NC, the rehabilitation treatment carried out and the prognosis.
