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Jan 9, 2009 07:00 PM | 25
Every year, about half a million Americans undergo open-heart surgery. Roughly 60 percent of them experience some degree of mental decline after the surgery, a phenomenon that surgeons call "pumphead." A new study in this month's Annals of Thoracic Surgery sheds light on possible causes of the mysterious condition, which in some patients is temporary but in others may last a lifetime.
"It has been well-documented that there is an issue of cognitive decline in the period of time [a few months] immediately after surgery," says lead study author James Slater, a cardiothoracic surgeon at Atlantic Health System in Morristown, N.J. Slater says the amount of cognitive decline varies; some patients have a tough time concentrating, others have trouble with memory and learning. Slater recalls, for instance, a onetime crossword whiz who, post-surgery, could no longer do The New York Times Sunday crossword puzzle. (Read about Bruce Stutz's experience with "pumphead" in the June 2003 issue of Scientific American.)
Once believed to be a passing phase, researchers have found that pumphead may linger indefinitely – or return years after an operation and persist. A 2001 study published in The New England Journal of Medicine found that 42 percent of patients suffered cognitive decline five years after receiving open-heart surgery (For some, the cognitive problems had continued or returned, while others were experiencing them for the first time).
The exact causes of pumphead are still up for debate, but Slater's research suggests it is at least partly due to problems with oxygen reaching the brain during surgery. In conventional open-heart surgery (most often performed to clear blocked vessels supplying blood to the heart), a patient is hooked up to a heart-lung machine for the duration of the three-or-so-hour procedure. The heart-lung machine takes over the job of the heart (which is stopped during the surgery), pumping oxygen-rich blood through the body. But the machine is not as efficient as the real heart when it comes to delivering a healthy supply of oxygen-rich blood to the brain, Slater says. And as his study shows, the resulting oxygen deprivation appears to be a major factor in pumphead.
Slater's team followed 240 patients that underwent open-heart surgery from 2004 to 2006. All of the patients were hooked up to cerebral oximonitor sensors that track the amount of oxygenated blood reaching the brain. The researchers found that patients whose oxygen levels fell below a certain threshold (calculated using a mathematical formula) had double the chance of suffering at least some cognitive decline. The study only followed up patients for three months after their operations, so it is not clear whether oxygen deprivation is related to cognitive decline years after the procedure.
Mark Newman, chair of anesthesiology at Duke University School of Medicine in Durham, N.C., says that another possible cause of pumphead is that fatty deposits that normally adhere to the walls of blood vessels may become dislodged and travel to the brain (and cause clots) when doctors clamp the vessels to hook patients up to a heart-lung machine. In addition, he says, "Some people are genetically more susceptible to pumphead than others. That could be related to immune response." Surgery can cause a big outpouring of immune system cytokines and white blood cells whose job is normally to fight foreign invaders such as viruses and bacteria but may get confused and mistakenly attack healthy tissue, Newman says.
The good news, Slater says, is that there already exists a technology that might help doctors avert the problem: a monitor (the same one used in his study) that tracks the amount of oxygen-rich blood reaching the brain during surgery, informing doctors when they should take steps to prevent brain damage—giving a patient meds to increase blood pressure and boost oxygen in the brain, for example. The device is already being used in some 700 U.S. hospitals.
(Update, posted 1/12/09: A commenter asked a good question, whether Slater had any financial interest in the oximeter he used in the study. The answer, Slater tells us, is no: "I have no financial interest in the company or the product," he wrote in an email. "The research was done funded with our own research funds. Absolutely no conflict of interest to declare.")
Image credit ©iStockphoto.com/miralex
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25 Comments
Add CommentSo, that's what happened to me.
Reply | Report Abuse | Link to thisSince I am at the moment considering a valve operation recommended by two different doctors, this is of great interest. Is this phenomenon widely known by heart surgeons?
Reply | Report Abuse | Link to thisVery interesting article. I have also experienced reduced brain acuity or functioning since my open heart surgery 9 months ago. It's not debilitating, but I have noticed a distinct loss of memory - particularly short-term memory. Something else I'd be very interested in learning more about is the emotional effects of open heart surgery. Since emotions are triggered in the brain, I wonder if the studies mentioned discuss this as well?
Reply | Report Abuse | Link to thisI had 5 bypasses 3 1/2 years ago and I'm nowhere near back to "normal".
Reply | Report Abuse | Link to thisI hadn't heard about Pumphead until this article, but it does explain my sub-par memory.
I underwent a bypass ten years ago and have experienced no decline in short term memory or other cognitive impairment. The procedure, which was new at the time, was the "beating heart" or "off-pump" not requiring use of the heart-lung machine. It worked for me.
Reply | Report Abuse | Link to thisI had a triple bypass in 1989 at age 44, which entailed time on a heart-lung machine. I have never noticed any symptoms of "pumphead," although I learned of it soon after the surgery. My mind is as keen as it always was, I have no trouble with short-term memory, and I am very good at crosswords. Perhaps I am more irritable, although after 20 years it's hard to tell, especially as I've always been cranky!
Reply | Report Abuse | Link to thisA heart attack and the ensuing surgery were difficult enough to deal with; I'm certainly glad to have escaped with my faculties intact! I sympathize with any sufferers of "pumphead," however-I would hate to experience it!
This phenomenon has been widely discussed in the medical community for 10 years or more. Many surgeons have been doing off-pump bypass surgery. My surgeon did an off-pump procedure for my bypass, still, I haven't been the same since and it's been ten years. I think my problem is related to the anesthesia.
Reply | Report Abuse | Link to thisWhat is this miracle oximeter that Dr Slater speaks of so highly. Does he have an interest in promoting it's use?
Reply | Report Abuse | Link to thisJames Davis mentioned Ginkgo Biloba and Gotu Kola. I would recommend to anybody that they look into these herbs. Both can enhance cognitive functioning, even in normal people, relatively safely. It's good to ask your doctor about them first, as Ginkgo may not mix well with blood thinners and Gotu Kola can be sedating and may interfere with some medications. For the most part, however, they are pretty safe to use, even in the long-term.
Reply | Report Abuse | Link to thisThank you for the article. My daughter has an IQ in the mid 180's. My son, who had open heart surgery at 6 1/2, and a slight stroke afterward, only has an IQ in the mid 160's. I have always wondered if the surgery (and stroke) resulted in the difference in intelligence.
Reply | Report Abuse | Link to thisI had a quad bypass 7 years ago and was put on a heart-lung machine. Although I can't say that my mental acuity per se declined, I did sink into serious depression for years afterward which also entailed some memory problems as I became more forgetful. This is the first I've ever heard of "pumphead". My therapist for my depression asked on several occasions if I had suffered any brain damage. Guess I'm overdue to query my cardiologist about this stuff, eh?
Reply | Report Abuse | Link to thisThis is quite interesting. My husband recently had valve surgery and totally flipped out for approximately four weeks. He had every test in the book and no one could come up with any conclusive answer as to why this happened. With the help of medication he improved and is now being weaned off of it.
Reply | Report Abuse | Link to thisThis is quite interesting. My husband had valve surgery and totally flipped out for approximately four weeks. He had every test in the book and no one could come up with a conclusive answer as to why this happened. He is fine now with the help of medication which he is currantly being weaned off of.
Reply | Report Abuse | Link to thisI had triple-bypass surgery ten years ago using the heart-lung machine. I never felt that I was quite the same afterwards. I described my condition to others as not feeling as sharp as before and feeling that my thinking was fuzzy. I was a philosophy professor at the time (now retired) and think that I still did very well in my profession, but never really performed up to my previous level. No one else noticed any difference. I'm happy that things have improved for patients now.
Reply | Report Abuse | Link to thisIn September of 2008 I had open heart surgery to repair my aorta. 3 of the things I am still experiencing are dull constant headaches, difficulty concentrating, memory lapses and of all things a runny nose. Surgeon put me on Plavix which has helped with the headaches but the rest of it I am still experiencing. I was on the pump a long time and they also cooled me to 59 degrees and completely stopped everything so maybe that is my issue. I do know that I also get cold very easily. I don't know about anyone else but if these are my only side affects....I am just glad to be alive.
Reply | Report Abuse | Link to thisOkay so I have a question? My dad had triple bypass a month ago and is still in a vegetable like state ( I say like because the Doctors don't think he is- but he is in a comma non responsive and still on a ventilator)- is this something that happens frequently? He has brain activity but that is about it? Any ideas?
Reply | Report Abuse | Link to thisIsn't open <a href="http://www.ecommunity.com/cardiovascular/">heart surgery</a> more common now than ever before. My dad have it about 10 years ago i wish an oximeter with around then.
Reply | Report Abuse | Link to thisSince off-pump cardiac surgery has been introduced, there have been a number of clinical studies performed that have virtually eliminated the HL machine as the major factor contributing to post operative cognitive decline. The factor most often linked was clamping or manipulation of the aorta, which is a must in most procedures requiring cardiac surgery. Many programs use non invasive cerebral oxymetry, simply monitoring of the deep brain's oxygen levels. There have been a few studies which have linked the device with being able to identify potentially significant cerebral events during cardiac surgery. Interestingly, level of oxygen is only one component of those studies. Level of anesthesia and hemoglobin (red blood cells) were also highly contributable to poor outcomes. As a practitioner, rarely does one see anything on the monitor which would suspect that the patient may have an untoward event, unless on those factors is not addressed. That is largely due to the fact that the clamping and manipulation of the aorta results in an embolization to the brain and goes largely undetected until the post operative recovery when it is seen on CT scans. Patients, unfortunately, do not have the luxury of having a CT scan post operatively despite suspucious cognitive decline as it is often attributed to the stress of the surgery. Only if the patient demonstrates a significant sign, such as arm weakness or slurred speach, is the clinician likely to perform any tests.
Reply | Report Abuse | Link to thisIt is unfortunate that Scientific American would publish such a one sided article without providing a more balanced perspective. We must constantly strive to provide the best care possible, but there are many variables that can affect outcomes. It is extremely myopic to look at the pump as the source of all of the post bypass sequelae.
Reply | Report Abuse | Link to thisThis group of patients is at higher risk of post-pump brain injury since the lipid and cholesterol deposits are not only in the heart. The complex nature of the disease increases the chances that debris might go to the brain during manipulation, clamping, and infusing fluids into the aorta and the heart itself. Air emboli are another increased risk and can have potentially long term effects. Research has shown some level of decreased brain function is inevitable in older patients over any time frame...whether they have open heart surgery, or not. We have lower mortality today with more co-morbid conditions, but there is always room for improvement and small details can yield important benefits.
Well pumper I had my open heart surgery in 2009 at the age of 23, and I am still suffering cognitive issues. We can't blame it on old age. We can't blame it on disease since I had the surgery to correct a large atrial septal defect, which is a birth defect. I can't think of anything else that could have caused what I have been dealing with since being on the heart-lung bypass machine for 4 hours. My personality has changed into someone who gets irritated at the drop of a hat or worse, just doesn't care about anyone or anything. I used to be able to read a novel faster than anyone I knew. Now I have to reread passages I just read because I forget what it said, or my brain didn't fully comprehend it. Again, I was 23 now I'm 26. Can't blame age. I recently got put on Adderall because I can't concentrate or pay attention. I blazed through undergrad with 3.5 GPA and never needed anything to help study, let alone just pay attention to someone or something. And let us not forget the depression. I don't know if I'm a "pumphead" but I do know that I went into the hospital and came out completely different.
Reply | Report Abuse | Link to thisStem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike "differentiated" cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
Reply | Report Abuse | Link to thisMedical researchers and scientists believe that stem cell therapy will, in the near future, advance medicine dramatically and change the course of disease treatment. This is because stem cells have the ability to grow into any kind of cell and, if transplanted into the body, will relocate to the damaged tissue, replacing it.For more information please visit http://www.neurosurgeonindia.org/
Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike "differentiated" cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
Reply | Report Abuse | Link to thisMedical researchers and scientists believe that stem cell therapy will, in the near future, advance medicine dramatically and change the course of disease treatment. This is because stem cells have the ability to grow into any kind of cell and, if transplanted into the body, will relocate to the damaged tissue, replacing it.For more information please visit http://www.neurosurgeonindia.org/
Open heart surgery is any surgery where the chest is opened and surgery is done on the heart muscle, valves, arteries, or other parts of the heart (such as the aorta). I had my surgery last year and I am doing great now. I don’t think so that open-heart surgery can make you dimmer…
Reply | Report Abuse | Link to thisDavid Summers, a 37 year old MS patient from Murfreesboro, Tennessee was a score of 8.0 on the Expanded Disability Status Scale (EDSS) when he had the Combination Liberation Therapy and Stem Cell Transplantation at CCSVI Clinic in March of 2012. Having been diagnosed in 1996 he had been in a wheelchair for the past decade without any sensation below the waist or use of his legs.
Reply | Report Abuse | Link to this“It was late 2011 and I didn’t have much future to look forward to” says David. “My MS was getting more progressive and ravaging my body. I was diagnosed as an 8.0 on the EDSS scale; 1 being mild symptoms, 10 being death. There were many new lesions on my optic nerves, in my brain and on my spinal cord. My neurologist just told me: ‘be prepared to deteriorate’. I knew that he was telling me I didn’t have much time left, or at least not much with any quality.” David had previously sought out the liberation therapy in 2010 and had it done in a clinic in Duluth Georgia. “The Interventional Radiologist who did it told me that 50% of all MS patients who have the jugular vein-clearing therapy eventually restenose. I didn’t believe that would happen to me if I could get it done. But I have had MS for 16 years and apparently my veins were pretty twisted up”. Within 90 days, David’s veins had narrowed again, and worse, they were now blocked in even more places than before his procedure.
“I was so happy after my original procedure in 2010. I immediately lost all of the typical symptoms of MS. The cog fog disappeared, my speech came back, the vision in my right eye improved, I was able to regulate my body temperature again, and some of the sensation in my hands came back. But as much as I wanted to believe I felt something, there was nothing below the waist. I kind of knew that I wouldn’t get anything back in my legs. There was just way too much nerve damage now”. But any improvements felt by David lasted for just a few months.
After his relapse, David and his family were frustrated but undaunted. They had seen what opening the jugular veins could do to improve him. Because the veins had closed so quickly after his liberation procedure, they considered another clinic that advocated stent implants to keep the veins open, but upon doing their due diligence, they decided it was just too risky. They kept on searching the many CCSVI information sites that were cropping up on the Internet for something that offered more hope. Finding a suitable treatment, especially where there was no known cure for the disease was also a race against time. David was still suffering new attacks and was definitely deteriorating. Then David’s mother Janice began reading some patient blogs about a Clinic that was offering both the liberation therapy and adult autologous stem cell injections in a series of procedures during a hospital stay. “These patients were reporting a ‘full recovery’ of their neurodegenerative deficits” says Janice, “I hadn’t seen anything like that anywhere else”. She contacted CCSVI Clinic in late 2011 and after a succession of calls with the researchers and surgeons they decided in favor of the combination therapies.
“I went to CCSVI Clinic in India without knowing what to expect” says David, “but I basically had one shot left and this was it. I was becoming pretty disabled, and I couldn’t think very clearly”. David was triaged with a clinic intake of other MS patients and had the liberation therapy on March 27, 2012. They also drew bone marrow from his hip bone in the same procedure. When he woke up from the procedure, he again felt the immediate effect of the widening of the veins. “In case anyone doesn’t believe that the liberation therapy works, I can tell them that this is much more than placebo effect.” The MS symptoms described earlier again disappeared. Four days later he had the first of the stem cell injections from the cultured cells taken from his hip bone during the liberation therapy. The first transplant was injected into the area just below his spine. Over the next 4 days he would receive about 100 million stem cells cultured in specific growth factors for differentiated effect.
He was not quite prepared for what happened next. A few hours after the first transplant, he was taken back into his hospital room and was transferred to the hospital bed. “I’m not completely helpless when it comes to moving from a chair or a bed”, says David, “One of the things I can do for myself is to use my arms to throw my leg into a position to be able to shift the rest of my body weight over to where I’m going. But this time to my amazement, I didn’t have to pick up the dead weight of my leg and throw it. It moved on its own, exactly where my brain told it to go”. Shortly after his first stem cell transplant procedure, some motor function in his lower body had returned. “This was the first time in 10 years I had any sensation or motor function below my waste so it was quite a shock.”
In the next month, most every motor nerve and body function has either returned or is on its way to recovery. “It’s been over a decade since I’ve had any power over my elimination functions. Now it’s all come back. I have total bladder control”. He’s also working out every day, following the physiotherapy routine given him by the clinic. “For years, I haven’t been able to work out without getting sick for a couple of days afterward. Now I have muscles popping out all over the place where I haven’t seen them since my MS became progressive…and I can work out as hard or as much as I want. With my ability to do the hard work my balance is improving each day and I’m able to take steps unassisted. I’m definitely going to be coming all the way back.”
Dr. Av Gupte, the neurosurgeon who has now done over 2000 adult autologous stem cell transplants for various neurologic disease conditions says that the stem cells in David’s body will continue to work their healing process for the next year. “With the incredible progress I’ve seen so far, I won’t need a year”, says David. “It’s only been a little over two months and I have most everything back. I can’t wait to get up each day to check out my improvements. My right hand is completely back to normal without any numbness and the left is on its way. I have good strength in my legs now and I’m working on the balance”.
Other MS patients treated with the combination therapy over the past 18 months have seen similar improvements but none have been as disabled as David. “If I can come back from where I was, most everyone with MS could too. For me, CCSVI Clinic has been my miracle and I can’t say enough about the doctors, researchers and staff who are helping me to recover. For me, MS was my previous diagnosis”.For more information please visit http://www.ccsviclinic.ca/?p=904
Chronic cerebrospinal venous insufficiency (CCSVI), or the pathological restriction of venous vessel discharge from the CNS has been proposed by Zamboni, et al, as having a correlative relationship to Multiple Sclerosis. From a clinical perspective, it has been demonstrated that the narrowed jugular veins in an MS patient, once widened, do affect the presenting symptoms of MS and the overall health of the patient. It has also been noted that these same veins once treated, restenose after a time in the majority of cases. Why the veins restenose is speculative. One insight, developed through practical observation, suggests that there are gaps in the therapy protocol as it is currently practiced. In general, CCSVI therapy has focused on directly treating the venous system and the stenosed veins. Several other factors that would naturally affect vein recovery have received much less consideration. As to treatment for CCSVI, it should be noted that no meaningful aftercare protocol based on evidence has been considered by the main proponents of the ‘liberation’ therapy (neck venoplasty). In fact, in all of the clinics or hospitals examined for this study, patients weren’t required to stay in the clinical setting any longer than a few hours post-procedure in most cases. Even though it has been observed to be therapeutically useful by some of the main early practitioners of the ‘liberation’ therapy, follow-up, supportive care for recovering patients post-operatively has not seriously been considered to be part of the treatment protocol. To date, follow-up care has primarily centered on when vein re-imaging should be done post-venoplasty. The fact is, by that time, most patients have restenosed (or partially restenosed) and the follow-up Doppler testing is simply detecting restenosis and retrograde flow in veins that are very much deteriorated due to scarring left by the initial procedure. This article discusses a variable approach as to a combination of safe and effective interventional therapies that have been observed to result in enduring venous drainage of the CNS to offset the destructive effects of inflammation and neurodegeneration, and to regenerate disease damaged tissue.
Reply | Report Abuse | Link to thisAs stated, it has been observed that a number of presenting symptoms of MS almost completely vanish as soon as the jugulars are widened and the flows equalize in most MS patients. For more information please visit http://www.ccsviclinic.ca/?p=978