Invited Commentary

Abstract

Mesenteric ischemia after cardiac surgical procedures is a catastrophic event. Despite the expedient execution of appropriate therapeutic measures immediately after the diagnosis has been established, mortality remains exceedingly high. Surviving patients usually face a prolonged period of recovery under extended stays in the intensive care unit. Whereas the patient’s comorbidity, which may contribute considerably to the cause of mesenteric ischemia, is not subject to intervention, clinical experience suggests that the time delay between the onset of mesenteric ischemia and its diagnosis is a crucial factor for the patient’s prognosis and that it may be shortened by improved means of detection. In the past, various studies have identified several of risk factors for mesenteric ischemia; however, their significance is mostly academic because their predictive value is too low to hasten the process of diagnosis. More recently, elevated levels of procalcitonin (PCT) have been associated with various forms of mesenteric ischemia. It is the great merit of this excellent report by Klingele and colleagues [1Klingele M. Bomberg H. Poppleton A. et al.Elevated procalcitonin in patients after cardiac surgery: a hint to nonocclusive mesenteric ischemia.Ann Thorac Surg. 2015; 99: 1306-1313Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar] that they investigated the correlation between postoperatively elevated PCT levels and the occurrence of nonocclusive mesenteric ischemia (NOMI) in an observational cohort study with a comprehensive statistical approach. The authors found for the postoperative PCT level in receiver operating characteristic analyses an area under the curve of 0.94, which is much better than what we deal with when we apply the current risk scores to our patient population. Even after adjustment for a multitude of risk factors such as age, gender, EuroSCORE 2, pulmonary hypertension, chronic obstructive pulmonary disease, previous stroke, insulin-dependent diabetes, duration of operation, and six additional risk factors, the risk of developing NOMI remained 28-fold higher in patients with a postoperative PCT level above 6.6 ng/mL. Although Klingele and colleagues focused on NOMI in their study, corroborating evidence from other studies indicates that the findings just mentioned could perhaps apply to obstructive mesenteric ischemia just as well, which requires further investigation. However, the ultimate test remains to be taken. Further studies need to clarify whether early detection of NOMI by elevated PCT levels is actually early enough to improve outcome and lower mortality. Without this confirmation of clinical significance, highly elevated PCT levels after cardiac operations may end up being just another marker. In the mean time, as long as these confirmative studies are missing, clinicians are encouraged to consider an elevated PCT level as a strong indicator of NOMI, which may, in conjunction with other specific clinical findings, justify appropriate therapeutic measures in selected cases. Elevated Procalcitonin in Patients After Cardiac Surgery: A Hint to Nonocclusive Mesenteric IschemiaThe Annals of Thoracic SurgeryVol. 99Issue 4PreviewNonocclusive mesenteric ischemia (NOMI) can occur after cardiac surgery, commonly in conjunction with use of cardiopulmonary bypass. Some evidence suggests that serum procalcitonin (PCT) levels are increased in patients with mesenteric ischemia; however, an association between PCT and NOMI has not yet been studied. The current study investigates whether elevated serum PCT levels are found in patients exhibiting NOMI. Full-Text PDF