Post-operative cognitive dysfunction

[Capizzi]

I wanted to ask the forum about resources and perspectives they have used to cope with long-term post-surgical cognitive changes. I would like to learn what has helped others remain positive and hopeful. I thought I would also share things that have helped me over the last two years. I will separate my initial post because of its length.

The 'What you can expect after surgery' pamphlet stated that the patient might experience short-term memory loss, which as it turns out does not mean ‘short-term/temporary loss of memory’ but ‘possible permanent damage to short-term memory’. I was told my cognitive problems would dissipate with time, but later was told, maybe not. Newman showed that after five years long-term cognitive decline was experienced by 42% of cardiac patients http://www.ncbi.nlm.nih.gov/pubmed/11172175.
An article by Wang is a good jumping off point for people to discuss risks and preventive steps with their surgeon or cardiologist, Postoperative Cognitive Dysfunction: Current Developments in Mechanism and Prevention http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4206478

There are at least three things going on at the same time, which make it difficult to deconstruct and understand cognitive change:
1. The brain injury
2. The surgical insult, manipulation of the heart in particular
3. Adaptation to a 'new' heart, specifically cerebral blood pressure regulation

 

[Capizzi]

Several cognitive issues were immediately obvious to me post-surgery. The crippling anxiety was gone, leaving me with eerie silence in my head. I had a strange abundance of oxygen. And I could neither feel nor hear my heart beating. It turns out that people who hear their hearts are different from those that do not. It turns out there is a not too often mentioned role of the heart in cognition.
http://www.bbc.com/future/story/20141205-the-man-with-two-hearts

The post-surgical referral process takes persistence:
One month after surgery I asked my primary medical provider for a neuropsychological test (4 hrs); she performed a Mini-mental status exam (MMSE) (10 min). Cardiac rehab started at almost two months, where I realized I could not remember any instructions. I went back to work two months post-surgery. My cognitive/emotional stress became more of a problem as I recovered from the surgery, and my provider recommended antidepressants. I serially tried four of the standard medications, the side-effects to each being intolerable. I was referred to a psychiatrist who suggested that a brain injury may be the issue. She ordered the neuropsychological test and referred me to a neurologic physiatrist (9 months post-surgery). He ordered a CAT scan to ensure I had not had a major stroke. He recommended exercise, Tai Chi, light social interaction, dietary supplements and probiotics, acupuncture, afternoon naps, and meditation. He referred me to an ophthalmologist because I was having difficulty processing visual information. He referred me to a speech therapist who usually works with people who have had strokes (12 months post-surgery), and the speech therapist helped me distinguish what cognitive abilities I had lost. She helped me to stop comparing myself to who I had been before, and helped me let go of that person. Physical therapy stressed tests showed that my blood pressure increased to 250/157 with light elliptical machine exercise; seated bicycling was ok. It took me about a year to get the referrals I needed.

What is short-term memory loss mean?
I strain to compile information in a way that helps make sense of the world. Short-term or working memory is the compiler, and if the compiler is too small, context is easily lost. My most vivid post-surgery memory was looking at a tree, which looked to me almost two-dimensional, as if it were a drawing by a child on a white background.

Reading is difficult. When I look at text, I see only letters. I have lost whole word recognition and struggle with acronyms. I have trouble following speech when proper nouns are not repeatedly used; pronouns are hard.

I carry ear-plugs and sunglasses because of sensitivity to light and noise. I try to avoid busy highway driving. I become exhausted by mental strain. I find I can loosen that knot with humor, naps and meditation. Dopamine triggers vasodilation and reduces vascular inflammation.

Diet:
Although they appear to help with the stress and fatigue, the foods to avoid (alcohol, caffeine, salty foods, sweets/refined sugars) accelerate neurological decline. The link below has reasonable dietary advice for people with TBIs but does not replace a dietician.
http://www.brainline.org/content/20...brain-nutritional-tips-to-speed-recovery.html
Dietary supplements are not all good or equivalent, but I have found the following helps manage stress and inflammation:
Probiotics
Tinctures of hawthorne and lemon balm
Curcumin/Tumeric
Unsweetened electrolyte drinks



Brain injury resources:
Brain injuries are all different but the best literature I can find in terms of treatment relates to post-concussion syndrome (PCS). Where rest and cognitive adaptation used to be advised, it is recognized that deconditioning may lead to symptoms of depression. The second link below (Leddy et al) "Concussion is associated with metabolic and physiological changes in the brain and in other organ systems (for example, autonomic function of the heart and altered cerebral autoregulation, sleep, and circadian rhythms). We propose that PCS results from ongoing central and systemic physiologic regulatory dysfunction after traumatic brain injury (TBI) and we further propose that this physiologic dysfunction may be reduced or alleviated by individualized controlled sub-symptom threshold aerobic exercise rehabilitation"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784364/
http://www.ncbi.nlm.nih.gov/pubmed/17917170

Michael Ellis wrote a good summary article in Brain Injury "Physiological, vesticulo-ocular and cervicogenic post-concussion disorders: An evidence-based classification system with directions for treatment" 2015. It emphasizes the importance of sub-threshold aerobic exercise treatment to improve cerebral blood flow. The article discusses associated vision problems, but Brainline has an easier to read article:
http://www.brainline.org/content/2011/03/vision-and-rehabilitation-after-brain-trauma-part-1-.html
or at the Neuro-Optometric Rehabilitation Assoc (NORA): https://nora.cc/
(under Patients)

Support of brain injured:
TBI Consumer Report: Coping with Post-TBI Emotional Distress
http://www.brainline.org/content/20...ping-post-tbi-emotional-distress_pageall.html
Cognitive rehabilitation article at the Brain Injury Resource Center
http://www.headinjury.com/rehabcognitive.html
Traumatic Brain Injury Survival Guide
http://www.tbiguide.com/
Mild cognitive impairment: Tips for living well with memory/cognitive impairment
http://alzonline.phhp.ufl.edu/en/reading/mciarticle.pdf
Spiritual Care handbook on PTSD/TBI, US Navy. The stages through which patients move as they heal are articulated in the handbook
http://www.militaryconnection.com/assets/pdf/Spiritual Care PTSD Handbook.pdf

 

[Capizzi]

Several cognitive issues were immediately obvious to me post-surgery. My mitral valve related crippling anxiety was gone, leaving me in an eerie and uncomfortable silence. I had a strange abundance of oxygen, which may be poorly regulated blood pressure. And I could neither feel nor hear my heart beating. It turns out that people who hear their hearts are different from those that do not. It turns out there is a not too often mentioned role of the heart in cognition.
http://www.bbc.com/future/story/2014...ith-two-hearts

The post-surgical referral process takes persistence:
One month after surgery I asked my primary medical provider for a neuropsychological test (4 hrs); she performed a Mini-mental status exam (MMSE) (10 min). Cardiac rehab started at almost two months, where I realized I could not remember any instructions (the cardiac nurses just nodded to each other and said pumphead ). I went back to work two months post-surgery. My cognitive/emotional stress became more of a problem as I recovered from the surgery, and my provider recommended antidepressants. I serially tried four of the standard medications, the side-effects to each being intolerable. I was referred to a psychiatrist who suggested that a brain injury may be the issue. She ordered the neuropsychological test and referred me to a neurologic physiatrist (9 months post-surgery). He ordered a CAT scan to ensure I had not had a major stroke. He recommended exercise, Tai Chi, light social interaction, dietary supplements and probiotics, acupuncture, afternoon naps, and meditation. He referred me to an ophthalmologist because I was having difficulty processing visual information. He referred me to a speech therapist who usually works with people who have had strokes (12 months post-surgery), and the speech therapist helped me distinguish which cognitive abilities I had lost. She helped me to stop comparing myself to who I had been before, and helped me let go of that person. Physical therapy stress tests showed that my blood pressure increased to 250/157 with light elliptical machine exercise; seated bicycling was ok. It took me about a year to get the referrals I needed.

What does short-term memory loss mean?
I strain to compile information in a way that helps make sense of the world. Short-term or working memory is the compiler, and if the compiler is too small, context is easily lost. My most vivid post-surgery memory was looking at a tree, which looked to me almost two-dimensional, as if it were a drawing by a child on a white background.

The impact of losing context is profound and alienating. I will be driving and suddenly not know were I am, and I am one of those people who has never been lost in their life. During the first year I could not retain a mental image of a room I was in, which feels like being lost in a small room. There are spiritual consequences addressed in the Navy Spiritual Care Handbook on PTSD/TBI.

Reading is difficult. When I look at text, I see only letters. I have lost whole word recognition and struggle with acronyms. I have trouble following speech when proper nouns are not repeatedly used; pronouns are hard.

I carry ear-plugs and sunglasses because of sensitivity to light and noise. I try to avoid busy highway driving and complex social situations. The mental strain is exhausting. I find I can loosen that knot with humor, naps and meditation. Dopamine triggers vasodilation and reduces vascular inflammation.

 

[Capizzi]

A number of people have asked for this information, so I thought I'd post it. I keep meeting people who treat their cardiac depression and/or brain injuries with alcohol, which is traumatic for their families. Then I realize how heavily I am dosing myself with caffeine. How are people dealing with the fatigue?

Diet:
Although they appear to help with the stress and fatigue, the foods to avoid (alcohol, caffeine, salty foods, sweets/refined sugars) accelerate neurological decline. The link below has reasonable dietary advice for people with TBIs but does not replace a dietician.
http://www.brainline.org/content/201...-recovery.html
Dietary supplements are not all good or equivalent, but I have found the following helps manage stress and inflammation:
Probiotics
Tinctures of hawthorne and lemon balm
Curcumin/Tumeric
Unsweetened electrolyte drinks

Brain injury resources:
Brain injuries are all different but the best literature I can find in terms of treatment relates to post-concussion syndrome (PCS). Where rest and cognitive adaptation used to be advised, it is recognized that deconditioning may lead to symptoms of depression. The second link below (Leddy et al) "Concussion is associated with metabolic and physiological changes in the brain and in other organ systems (for example, autonomic function of the heart and altered cerebral autoregulation, sleep, and circadian rhythms). We propose that PCS results from ongoing central and systemic physiologic regulatory dysfunction after traumatic brain injury (TBI) and we further propose that this physiologic dysfunction may be reduced or alleviated by individualized controlled sub-symptom threshold aerobic exercise rehabilitation"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784364/
http://www.ncbi.nlm.nih.gov/pubmed/17917170
Depression, anxiety, and cardiac morbidity outcomes after coronary artery bypass surgery: a contemporary and practical review http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3418911

Michael Ellis wrote a good summary article in Brain Injury "Physiological, vesticulo-ocular and cervicogenic post-concussion disorders: An evidence-based classification system with directions for treatment" 2015. It emphasizes the importance of sub-threshold aerobic exercise treatment to improve cerebral blood flow. The article discusses associated vision problems, but Brainline has an easier to read article:
http://www.brainline.org/content/201...a-part-1-.html
or at the Neuro-Optometric Rehabilitation Assoc (NORA): https://nora.cc/(under Patients)

Support of brain injured:
TBI Consumer Report: Coping with Post-TBI Emotional Distress
http://www.brainline.org/content/200...s_pageall.html
Cognitive rehabilitation article at the Brain Injury Resource Center
http://www.headinjury.com/rehabcognitive.html
Traumatic Brain Injury Survival Guide
http://www.tbiguide.com/
Mild cognitive impairment: Tips for living well with memory/cognitive impairment
http://alzonline.phhp.ufl.edu/en/reading/mciarticle.pdf
Spiritual Care handbook on PTSD/TBI, US Navy. The stages through which patients move as they heal are articulated in the handbook
http://www.militaryconnection.com/as...20Handbook.pdf

 

[pellicle]

Hi

I wanted to ask the forum about resources and perspectives they have used to cope with long-term post-surgical cognitive changes.

Resources I have not looked for, but I have no doubt that something goes on. What follows is my own feelings and reflections upon changes, it is not backed up by science or significant research, although by some reading.

I felt a strange change on my 2nd surgery (when I was 28) but that seemed to not be entirely negative.

I found myself more 'detail oriented' and more organised. I was in the midst of my Information Technology degree (and by midst I mean exactly at the end of the second of 3.5 years study).

In my first semester directly following the surgery I had some difficulty, which I'd put down to the nature of the subject ("Language and Language analysis - syntax parsers). There were some annotations to the text book (like about half the sentences had mistakes) which I did not know to apply to the text before about 3/4 way through the subject. In my second semester (of that year) I managed to do well in C++ programming getting 98% on the exam.

I went on to have a successful career in IT over some decade or two.

However its not to say that I did not experience strangenesses - almost like a kind of autism. I found things either comprehendable or not ... I'd either instantly get it or I'd have difficulty. Not always with complex things either.

After my 3rd surgery (where I was 48) I felt more significant degredation and I was eager to pin things on that. I for instance felt my eyes were less able to focus. About 4 months after surgery I went to my optometerist and had a test. They reported that I had had small changes since my previous visit but that such changes were entirely consistent with the age group I was in.

hmmmm I thought ...

I was told my cognitive problems would dissipate with time, but later was told, maybe not. Newman showed that after five years long-term cognitive decline was experienced by 42% of cardiac patients http://www.ncbi.nlm.nih.gov/pubmed/11172175.

Its an interesting study but there are some questions in my mind on reading it.

• the participant age is something between 50 and 70
• the professional roles and other cognitive indicators are not mentioned
• there is no discussion of post-surgery exersize
• there seems to be no comparison to expected cognitive decline based on age and other factors

I wonder if this more or less expresses what we otherwise know? That as you age if you don't use it you loose it.

getting on to your part of:

perspectives they have used to cope with long-term post-surgical cognitive changes.

I genuinely feel that the brain is like the body in some ways of considering it. With exersize and training you can improve your fitness both physically and mentally. There are of course natual bounds (we can't all become top athletes nor become Feinman) but within ourselves we can reach our own potential.

I believe that there may be a natural decline with age, and that decline can be hastened by trauma. The trauma may simply serve as a marker on our mental map of our selves.

However the brain (like the body) has the capacity to reroute and regenerate. So rather than hammering what I have lost, I have tried to build on skills that I have never developed (for instance language, learning new ones). This has helped me to develop and then I believe leaverage off that new development.

Lastly while not panning psych specialists I would issue a caution: you need to help yourself, the psych can guide but (like learning piano) you have to do the work. I have seen instances where people become dependent on the treatments and make no progress, perhaps even regress. Particularly with depression. So make sure that you do not come to "rely" on the professional as a substitute for your own work

My own challenges with relation to depression have been real. We are each different, so what works for me may not work for others.

I suppose that I was lucky to have been deeply challenged with losses after my surgery It kicked me in the arse HARD and I had a genuine look at my shotgun and ending it. I came to the view that if there was anything I could do that did not leave me worse off than being dead that I should do those things. If it worked out that things became intractable, I could always kill myself then. So far I've done many different things, but not yet killed myself. Each time I feel melancholy about things I consider my options and still come up with struggle being a viable alternative.

Life could be worse ... I could have been made a paraplegic in some of the motorbike accidents I've had ... certainly after we reach middle age its all about a degrading of what we have. My opinion is that surgery makes parts of this happen suddenly and gives us a milestone with which to make a reference to (thus apparently clarifying the point of change). The truth is we all decline either mentally or physically with age, part of the aging process is to grasp this and understand it.

One may "grieve" for the loss of youth ... myself I have bouts when I grieve for the many losses. Equally I have times were I give thanks for the many gifts bestowed upon me by those who have gone before me and loved me.

So perhaps its all about expectation management and hard work?

 

[Paleowoman]

Interesting post. I've rarely heard of anyone here having long term cognitive dysfunction post AVR although it does seem possible, one hears about "pump head", that type of thing. I never personally had any sort of cognitive dysfunction post surgically - I was 60 at the time of surgery and I've yet to experience even age related cognitive decline I'm glad to say. At two years post AVR though I continue to get visual disturbances: migraine auras without headache and double vision from time to time - I have read that is one of the side effects of being on the heart lung machine, and I know several others here have reported that too even long term post AVR.

 

[Ron Wyatt]

Yep, that's the world I'm living in now. The first surgery was much more serious, but didn't seem to have much effect on my cognitive function. The second, one month later, was to wash all of the blood out from under the dura. My poor brain just hasn't been the same since. I was told, in the hospital, that it wouldn't be a good idea to drive earlier than nine months post op. At the time I thought this was needlessly conservative. And yet I find myself trying to remember the rules of the road when I'm riding with my wife. I usually remember them just fine, but at times they are just gone. It's not like they are on the tip of my tongue... it's like someone scooped out that little bit of my brain... they're just gone. But that information will come back later... I can't count on it. Maybe nine months is a safer idea. I hope this comes to an end soon... I used to be semi-smart.

 

[newarrior]

I wanted to ask the forum about resources and perspectives they have used to cope with long-term post-surgical cognitive changes. I would like to learn what has helped others remain positive and hopeful. I thought I would also share things that have helped me over the last two years. I will separate my initial post because of its length.

The 'What you can expect after surgery' pamphlet stated that the patient might experience short-term memory loss, which as it turns out does not mean ‘short-term/temporary loss of memory’ but ‘possible permanent damage to short-term memory’. I was told my cognitive problems would dissipate with time, but later was told, maybe not. Newman showed that after five years long-term cognitive decline was experienced by 42% of cardiac patients Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery - PubMed.
An article by Wang is a good jumping off point for people to discuss risks and preventive steps with their surgeon or cardiologist, Postoperative Cognitive Dysfunction: Current Developments in Mechanism and Prevention Postoperative Cognitive Dysfunction: Current Developments in Mechanism and Prevention

There are at least three things going on at the same time, which make it difficult to deconstruct and understand cognitive change:
1. The brain injury
2. The surgical insult, manipulation of the heart in particular
3. Adaptation to a 'new' heart, specifically cerebral blood pressure regulation

Good god this is horrible and appears to be under reported...Anyone have any recent thoughts ? I'd love to see this reposted to the group

 

[tom in MO]

Good god this is horrible and appears to be under reported...Anyone have any recent thoughts ? I'd love to see this reposted to the group

Newarrior you sure try hard to find the horror stories. You sure don't come off as a warrior.

I had pump head, got better, no big deal.

Poor Capizzi is not even close to being typical. From what I can tell, typically most people have no cognitive difficulties following OHS.

 

[Zoltania]

173 minutes on the bypass machine for me. Zero pump head.

 

[newarrior]

See my comment

 

[newarrior]

I'm not looking for horror stories. I am simply trying to educate myself in regards to the surgical process from pre op all the way to post op.

 

[user 16827]

pump head exists for sure @newarrior

I had short term issues for a while and weirdly i lost my orienteering skills, even wandering around the hospital i got lost a few times.

i had 2 post opp TIA, again this can happen

you don't have an aneurysm ( i don't think ) if you did and depending how far up the arch they repair
they cool your brain to reroute the carotids, this can impact cognitive function.

https://pubmed.ncbi.nlm.nih.gov/12220062/

 

[newarrior]

pump head exists for sure @newarrior

I had short term issues for a while and weirdly i lost my orienteering skills, even wandering around the hospital i got lost a few times.

i had 2 post opp TIA, again this can happen

you don't have an aneurysm ( i don't think ) if you did and depending how far up the arch they repair
they cool your brain to reroute the carotids, this can impact cognitive function.

https://pubmed.ncbi.nlm.nih.gov/12220062/

Thanks man ! Can you explain, "i had 2 post opp TIA" ? Thanks !

 

[user 16827]

my surgery involved an aneurysm repair as well as the AVR.

TIA or mini stroke can happen, my surgeon put it down to debris, my scans showed no bleed or clot.

TIA are a risk , short lived , i was mute for around 12 hours and really confused for a few days
my poor wife was terrified

long term i 99.9% function well

I mention this only because you seem to want to understand what can go wrong, all surgery involve risk.

i would still choose a mechanical valve, 2 TIA, & a hard rehab over death Dave.

Keep researching because the correct answers are out there for you

 

[pellicle]

i would still choose a mechanical valve, 2 TIA, & a hard rehab over death Dave.

Nods agreement

 

[newarrior]

my surgery involved an aneurysm repair as well as the AVR.

TIA or mini stroke can happen, my surgeon put it down to debris, my scans showed no bleed or clot.

TIA are a risk , short lived , i was mute for around 12 hours and really confused for a few days
my poor wife was terrified

long term i 99.9% function well

I mention this only because you seem to want to understand what can go wrong, all surgery involve risk.

i would still choose a mechanical valve, 2 TIA, & a hard rehab over death Dave.

Keep researching because the correct answers are out there for you

Hey man I may be UNinsured for cardiac conditions for life as I live in Asia so I am trying to evaluate my financial risk if I live overseas the rest of my life.. Plus I don't have family or friends I can count on post op/if my health does down so I need to be extra cautious

 

[Unicusp]

Newarrior you sure try hard to find the horror stories. You sure don't come off as a warrior.

I had pump head, got better, no big deal.

Poor Capizzi is not even close to being typical. From what I can tell, typically most people have no cognitive difficulties following OHS.

True. When I asked both of my surgeons about "Pump Head", they looked at me with a very strange look and said it was very very rare. And, nothing for me to worry about. So, I didn't and moved on!