Answers sought in link between heart surgery, cognitive damage

Within 10 days of undergoing triple-bypass surgery, Dr. Nabil El Sanadi seemed ready to get back to work.

“He was worried about everybody else, asking how members of his senior team were doing, asking how the hospital volumes were, and looking toward the future,” said Mark Sprada, vice president and chief nursing officer at Broward Health in Fort Lauderdale, Fla.

No one saw any evidence that El Sanadi, described as having an “infectious laugh” and a “true passion for his work,” might have been suffering from any ill effects, much less depression, after his surgery. No previous behavior hinted at why El Sanadi, 60, shot himself Jan. 23 in the lobby bathroom of his condo building. Some friends cautiously wondered if his death was the result of a complication linked to heart procedures.

While there are no signs that El Sanadi's surgery played a role in his suicide, the fact that those close to him are still in utter disbelief over his death have brought the terms “bypass brain” and “pump head” back into the spotlight. Still, the widespread acknowledgment of cognitive damage and some high-profile cases don't appear to have yielded many efforts to manage it.

President Bill Clinton made uncharacteristic remarks during speeches and interviews on the campaign trail after his 2004 quadruple-bypass surgery that were believed to be the result of a postoperative condition that causes a shortened attention span, difficulties concentrating, short-term memory loss and slowed response.

This kind of impairment was first brought to light in a 2001 study published in the New England Journal of Medicine. Researchers found that 53% of 261 patients tested had at least a 20% decline in cognitive test scores after undergoing coronary artery bypass graft surgery, with 42% still experiencing cognitive decline after five years. The findings did not show causation.

But air bubbles or impurities could enter the bloodstream as it moves through a cardiopulmonary pump during coronary artery bypass grafting procedures. That debris could travel to the brain and cause small strokes. Concern over the complication has led to the development of techniques that allow surgeons to operate while the heart is still beating.

It also has driven some patients to opt for stents or medications.

But in 2009, Johns Hopkins Medicine researchers found that cognitive impairment over a six-year period was no different among patients who had bypass surgery with a heart-lung pump compared with those who had the same procedure without the device, or even those who chose arterial stents instead of surgery.

Sprada said he spent time with El Sanadi each day after his surgery and described his mood and personality as upbeat.

“His demeanor pre-operatively … did not change post-operatively,” Sprada remembered.

“He was always available to any community member who had a concern or who had a family member who needed to go to the hospital,” said Charlotte Mather-Taylor, Broward Health vice president of government relations. “It didn't matter the time of day or night, he was always there for people.”

But another friend told the Sun Sentinel, the Fort Lauderdale newspaper, that El Sanadi was unusually unresponsive in the days before his death. And yet another said he suspected El Sanadi's health issues played a role in his suicide.

“We do see depression as a big part of increasing the mortality in (cardiac) patients, but it's not usually so overt that it (causes) suicide,” said Dr. Annabelle Volgman, a cardiologist at Rush University Medical Center in Chicago.

According to the American College of Cardiology, as many as 20% of people hospitalized with a heart attack report symptoms of depression, and heart disease patients are three times more likely to develop depressive symptoms compared with the general population.

Volgman added that depressed patients usually stop taking medications after surgery or fail to participate in cardiac rehabilitation efforts such as exercise.

Yet the online information regarding coronary artery bypass graft surgeries at Broward Health, where El Sanadi had his procedure, does not warn patients about possible cognitive side effects, and does not ask them to report changes in emotional or mental status after surgery to their cardiologists or primary-care physicians.

The opportunity to find ways to link the two conditions is often missed.

Volgman acknowledged that cardiologists are not trained to measure cognition, although there's been a push for cardiologists to consider that cognitive impairment may affect cardiac patients' health outcomes. And in 2008, the American Heart Association recommended that cardiologists screen patients for depression, believing the two were comorbid.

When seeing patients who complain about cognitive decline, Volgman works with a neurologist, and they communicate on their separate treatments to make sure they align.

“It is something that we (cardiologists) should know, and so the more people we educate about it, the better,” Volgman said, adding that doctors should listen to a patient's complaint “instead of ignoring it.”

In 2013, a Loyola University Medical Center psychiatrist proposed a new subspecialty to diagnose and treat patients who suffer from both depression and heart disease.

Dr. Angelos Halaris told Medscape Medical News at that time that his idea of creating a “psychocardiology” specialty was a “pipe dream.”

“But I wanted to put it out there, because our colleagues in cardiology as well as in psychiatry need to realize there is a very clear association between emotional/psychiatric/psychological conditions and cardiovascular health,” he said.

Nothing came of those ideas.