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40. Single Cross Clamp Improves Six Month Cognitive Outcome in High Risk Coronary Bypass Patients
John W Hammon, David A Stump, John E Butterworth, Kashemi Rorie, Dwight D Deal, Edward A Kincaid, Neal D Kon; Winston-salem, NC

Objective:
We hypothesized that a strategy that reduced aortic manipulation would reduce the incidence of cognitive deficits in patients undergoing coronary artery bypass grafting compared to the “traditional” approach, and that neurobehavioral outcomes with the “RAM” strategy would approach those obtained with OPCAB.
Methods:
Consenting high risk(>age,diabetes, hypertension) patients scheduled for CABG with CPB were randomly assigned to one of two aortic management protocols: a “traditional” approach in which distal anastamoses were accomplished while the aorta was cross-clamped but proximal anastamoses were sewn while a partial occlusion clamp was applied to the aorta(MAC) vs. a “reduced aortic manipulation” approach in which the aorta was clamped a single time with a reduced pressure clamp(SAC) and the partial occlusion clamp was not used. A contemporaneous group of patients undergoing OPCAB surgery without CPB was also enrolled. Subjects in all 3 groups underwent neurological and neuropsychological testing before and after surgery. After randomization, patients assigned to either approach could be changed to another strategy if the attending surgeon determined that patient safety demanded this change.
The study design anticipated that surgical techniques would evolve over the course of patient enrollment, and anticipated that some patients would have intra-op echocardiographic findings that would demand that the “traditional” approach be abandoned (e.g. severe aortic atherosclerosis) or the reduced manipulation abandoned(severe ischemia,poor LV function). Thus, an unequal distribution of patients was expected.By surgeon decision 30/96 MAC patients switched to SAC and 3/85 SAC patients switched to MAC.
Eligible patients had a battery of Neuropsychological tests pre and at 6 months post-op. A 20% decrement in 2 or more tests was defined as a deficit(NPD)
Results:
MAC:69pts enrolled,age67.3±7.9y,Mortality@6mo3/69(4%)
SAC:112pts enrolled,age63.9±7.5y,Mortality@6mo 0/112(0%)
OPCAB: 75pts enrolled, age60.9±11y,Mortality@6mo1/75(1%)
NEUROBEHAVIORIAL
MAC:48pts Tested,Stroke3/48(6%),NPD@6mo26/48(54%)
SAC:84pts Tested,Stroke4/84(5%),NPD@6mo25/84(30%)*
OPCAB:46pts Tested,Stroke2/46(4%),NPD@6mo16/46(35%)
*p<0.01vsMAC by Chi Square all others NS
Conclusions:
A surgical strategy designed to minimize aortic manipulation can significantly reduce the incidence of cognitive deficits in CABG patients from traditional techniques. In this series the results of the RAM strategy were not significantly different from patients having OPCAB.

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