Pumphead Revisited

[ccrawford]

Strange results curve

Strange results curve

Hugo asked whether pumpheadedness was known to get worse over time. In his study, Newman tested post CABG patients 4 times using five tests of cognitive skills: short term recall, repeating a series of numbers, visual retention, pairing digits with symbols, and connecting a series of numbers and letters. The test was given at four different times: one week post surgery, after six weeks, six months later and, five years later. The five year test was controlled or compensated for the effects of advancing age. At one week, 53% were unable to match their pre-surgery scores, at six weeks, 36% showed some impairment, at six months those showing some impairment dropped to 24%. Surprisingly, at five years 42% performed so poorly they were again declared cognitively impaired. The article did not attempt to explain why the increased incidence occured at five years. Nor did the article attempt to refute another study that showed no impairment occurrring. Obviously, if you concur with the study, this is a serious problem worth spending some research dollars on, in order to reduce future incidence. I would agree that most of us are thankful just to be alive, but there are a lot of post surgery patients that are really struggling with some pump induced impairments. Hope this answers your question. Chris

 

[hhardt]

Chris, my memory used to be outstanding. I played chess without a board in college. I could tell what was in which vugraph where several days after many continuous presentations, and so forth. My experience is that it got better the first few months after the operation and then started going down after about 18 months. The greatest frustration is having everyone around me finishing my sentences because I lose part of the thought. I know exactly what I am trying to say, just can't get it out. I am only a little over 2 years now and hoping it turns around
Hugo

 

[Bob]

Pumpheadiness

Pumpheadiness

I am five months out from mitrol repair and still have trouble thinking. Most of the time it is the usual things such as names, dates, etc. Common for a 67 year old. However the disturbing problem is loss of repetative memory. To be specific. I forget to push the igintion key release button on my pickup. Several times I have just sat there trying to get the key out before discovering the release button. It was really embarrasing the day I took the truck back to the dealer for repair. The mechanic just stared at me after he said,"you have to push this". There are other impairments of short term memory like this. My surgery took less than three hours but I dont know the pump time. My recent visit to my cardio guy earned me a good rating on recovery.

This problem would make a great research subject for a doctoral student at a major university.

 

[ccrawford]

Hugo - I'm not qualified to advise you, but the author seemed to find some improvement by 1. doing things that force you to concentrate. 2. Keeping the mind busy by solving problems of one sort or another. In my case, although they did both a valve and a single bypass, I was only in surgery for a little over two hours and don't think I have much pumphead affect. I do have trouble remembering certain names, but this was the case before surgery too. Also my reading speed/concentration may not be quite as fast or good, but on the other hand it might be the books aren't quite as thrilling. Its hard to judge, absent some measurement of cognitive skill. Bob- I agree with you completely. I think the topic warrants a lot more research. I plan to print these responses out and discuss with my cardio just to get his reaction.I'll probably wait until we get a few more comments. Obviously, there are ongoing improvements in the filtering systems being used in heart lung machines, and there are undoubtedly some older machines still in use. Add to that a lot of other variables such as drug mix used, length of surgery, number of blood vessels clamped, condition of blood vessels, etc. and you have a real multivariate problem to solve. There seems to be too many incidences of this to not pursue further research. I'll be curious to see my cardio's response. I appreciate all the replies we have gotten so far. Chris

 

[Granbonny]

Bob..Hugo

Bob..Hugo

You both are a little older than me. I'm age 63..Bet you both can remember your 1st grade teacher's name..Your first pair of roller skates. where we had to use the key to tighten our skates over the shoes..Every room in your house that you lived in when you were growing up, ect..A neighbor came by and asked me today..when I was doing yard work..where had I been lately. Had to think a minute and tell them I was on a trip to Alabama last week for Father's Day.. That comes with age. Memory is still good..but like Nancy said on another thread I did..I think they froze me during open-heart surgery. Bonnie

 

[hensylee]

Hey Bonnie, I remember all that and I'm 70.

I believe they are now trying to keep patients to a minimum on heart/lung machines to avoid the pumphead syndrome. They have been doing studies on how to avoid this ever since they came up with the pumphead syndrome - one day they will figure it out. I, personally, don't think it's as big a deal as some may think. It's been 3 yrs for me and I don't think I have lost more than the average 70 year old.

 

[Bill Hall]

I always enjoy the pumphead discussion. Like everyone else I forget short term and am getting slower with age. However, I am still playing chess in tournaments and my rating is the highest yet. I was 4 1/2 hours on the pump and I never noticed any real effects. So, I entered the chess World Open in Philly on July 4 weekend and going for the $10k prize. I will be back to brag if I do well.

 

[hensylee]

And we're all going to root for you.

But - will we be able to live with you if you win?!!! lol

 

[ccrawford]

A liitle bit more

A liitle bit more

I did a google search for "post surgery pump head" and found a few sites with some additional information. The Yale New Haven Hospital markets an off-pump CABG to top executives in order to minimize the risk of pumphead (I'm sure the surgery fee is higher)
About 15 to 20% of CABG's are now done off-pump to minimize pumphead. (Can't do a valve off-pump) The Univ. of Hawai study by Dr. Jeffrey Lee appears to pin down the source of pump head. They used a dopler ultra sound method of measuring micro-emboli on 60 patients in the study and found that the vast majority of micro-emboli were generated when the pump was turned on, not when blood vessels were clamped, unclamped, pierced, etc. If this is valid, then it looks like the research needs to focus on the pump mechanism itself and/or its filters. I ran this topic past my cardio, and he readily agrees that this is an area of research that is ripe. FYI - Chris

 

[Granbonny]

Bill Hall

Bill Hall

I saw someone else had chess under thier user id for their interest. Will see if I can find it again. Seems like it was a newbie Bonnie

 

[Marty]

Sharp pumpheads

Sharp pumpheads

Lets be encouraged by Henry Kissinger, Larry King, and Alexander Haig who all had OHS years ago and Bob Graham who is only two or three months post op. You can be a pumphead and still be sharp.

 

[Granbonny]

Regis Philben sp?

Regis Philben sp?

Live with Regis at 9 a.m. Did he not have open-heart surgery? Seems like I read that somewhere? He does a live show at 9 a.m... and age around 67? Wish I had his energy.. Bonnie

 

[Marty]

Another pumphead

Another pumphead

Just remembered...Arnold Schwartzenegger has had two OHS. We should all look and feel as good as he does.

 

[showhost]

Time on Bypass??

Time on Bypass??

Anybody know diff between "Bypass Time" and "cross-clamp" time? Mine was 202 mins and 156 mins repectively. Not sure what that means.

Thanks

 

[Marty]

Cross Clamp, Pump time

Cross Clamp, Pump time

Good question. I'm going to check with my surgeon and get back to you.

 

[hensylee]

Letterman, too.

 

[Marty]

Bypass time, Crossclamp time

Bypass time, Crossclamp time

OK I think I've got it. First comes the bypass where they take the vein blood going back to the heart and send it to the pump oxygenator by putting a tube in the big vein going to the right atrium or directly in the atrium and draining that blood to the machine. Then at the other end of the machine a tube goes in the aorta with oxygenated blood. The heart and lungs are bypassed. At the end of the operation this is all taken down and when this is completed the time is recorded as pump time.
However between the beginning and end of pump time the aorta is crossclamped to cut off blood to the heart via the coronaries and the heart is stopped and cooled. The surgeon can now operate in a motionless bloodless environment. When he/she is through, the clamps are taken off, the heart is warmed up and restarted. This the end of crossclamp time and duly recorded. A little longer and the pump is taken off. End of pump time. So pump time wraps around clamp time. Nothing to it!

 

[DickV]

Related Article in NEJM

The New England Journal of Medicine -- February 8, 2001 -- Vol. 344, No. 6

Longitudinal Assessment of Neurocognitive Function after Coronary-Artery Bypass Surgery
Mark F. Newman, Jerry L. Kirchner, Barbara Phillips-Bute, Vincent Gaver, Hilary Grocott, Robert H. Jones, Daniel B. Mark, Joseph G. Reves, James A. Blumenthal, for the Neurological Outcome Research Group and the Cardiothoracic Anesthesiology Research Endeavors Investigators

Abstract
Background. Cognitive decline complicates early recovery after coronary-artery bypass grafting (CABG) and may be evident in as many as three quarters of patients at the time of discharge from the hospital and a third of patients after six months. We sought to determine the course of cognitive change during the five years after CABG and the effect of perioperative decline on long-term cognitive function.
Methods. In 261 patients who underwent CABG, neurocognitive tests were performed preoperatively (at base line), before discharge, and six weeks, six months, and five years after CABG surgery. Decline in postoperative function was defined as a drop of 1 SD or more in the scores on tests of any one of four domains of cognitive function. (A reduction of 1 SD represents a decline in function of approximately 20 percent.) Overall neurocognitive status was assessed with a composite cognitive index score representing the sum of the scores for the individual domains. Factors predicting long-term cognitive decline were determined by multivariable logistic and linear regression.
Results. Among the patients studied, the incidence of cognitive decline was 53 percent at discharge, 36 percent at six weeks, 24 percent at six months, and 42 percent at five years. We investigated predictors of cognitive decline at five years and found that cognitive function at discharge was a significant predictor of long-term function (P<0.001).
Conclusions. These results confirm the relatively high prevalence and persistence of cognitive decline after CABG and suggest a pattern of early improvement followed by a later decline that is predicted by the presence of early postoperative cognitive decline. Interventions to prevent or reduce short- and long-term cognitive decline after cardiac surgery are warranted. (N Engl J Med 2001;344:395-402.)
Source Information
From the Department of Anesthesiology (M.F.N., J.L.K., B.P.-B., V.G., H.G., J.G.R.), the Department of Surgery (R.H.J.), the Division of Cardiology (D.B.M.), and the Department of Psychiatry and Behavioral Science (J.A.B.), Duke University Medical Center, Durham, N.C. Address reprint requests to Dr. Newman at the Division of Cardiothoracic Anesthesia, Box 3094, Duke University Medical Center, Durham, NC 27710, or at [email protected].
The members of the study groups are listed in the Appendix.
Appendix
The members of the Neurologic Outcome Research Group and the Cardiothoracic Anesthesiology Research Endeavors Investigators of the Duke Heart Center were as follows: Director: M. Newman; Codirector: J. Blumenthal; Anesthesiology: F. Clements, N. de Bruijn, K. Grichnik, H. Grocott, S. Hill, A. Hilton, J. Mathew, J. Reves, D. Schwinn, M. Stafford Smith, A. Grigore, M. Gamoso, G. Mackensen, R. Panten, T. Stanley, L. Ti, J. Kirchner, A. Butler, V. Gaver, W. Cohen, B. Funk, M. Tirronen, W. White, and B. Phillips-Bute; Behavioral Medicine: J. Blumenthal, M. Babyak, and P. Khatri; Neurology: C. Graffagnino, D. Laskowitz, A. Saunders, and W. Strittmatter; Surgery: R. Anderson, T. D'Amico, R. Davis, D. Glower, R. Harpole, J. Jaggers, R. Jones, K. Landolfo, C. Milano, P. Smith, and W. Wolfe; Cardiology: D. Mark, E. Peterson, M. Sketch, and R. Califf.

 

[ccrawford]

Thanks

Thanks

Thank You DickV - For those of you with short memories (no pun intended) the above post is the detailed article that was quoted in the very first of many posts in this thread. Chris