Abstract
BackgroundMyocardial injury after noncardiac surgery frequently occurs and may influence survival. The aims of this study were to examine the association between myocardial injury after noncardiac surgery and patient and procedural factors as well as its impact on postoperative clinical outcome. MethodsA retrospective analysis was conducted from data collected in adults enrolled in a randomized trial in elective major open abdominal surgery. Preoperative patient characteristics, intraoperative hemodynamic changes, and postoperative adverse events were analyzed, and Kaplan-Meier curves were built for postoperative survival probability. After adjustment for baseline patient and procedural characteristics, the effect of myocardial injury after noncardiac surgery on postoperative outcomes was analyzed in a propensity score matched cohort. ResultsAmong 394 patients, myocardial injury after noncardiac surgery was reported in 109 (27.7%) and was associated with a higher cardiovascular risk profile, prolonged surgery (333 ± 111 min vs 295 ± 134 min, P = .010), greater need for transfusions (41.3% vs 19.3%, P < .001), higher incidence of major adverse cardiac events (22.9% vs 6.7%, P < .001), pulmonary complications (31.2% vs 17.9%, P = .004) , acute kidney injury (30.3% vs 18.2%, P = .009), and systemic inflammatory syndrome (28.4% vs 13.0%, P < .001). After propensity score matching, the operative time and the need for blood transfusion remained higher among myocardial injury after noncardiac surgery patients who experienced more frequent major adverse cardiac events and acute kidney injury. In both the entire and matched cohorts, survival up to 30 months after surgery was determined mainly by the presence of cancer. ConclusionThe burden of cardiovascular disease and operative stress surgery is predictive of myocardial injury after noncardiac surgery and, in turn, with a higher incidence of cardiac adverse events, whereas the presence of cancer is associated with poor survival in patients undergoing major open abdominal surgery. Further studies are needed to determine whether myocardial injury after noncardiac surgery can be prevented by better control of the patient’s cardiovascular condition and implementation of less invasive of surgical procedures.
Highlights
Patients with Myocardial injury after noncardiac surgery (MINS) underwent higher-risk procedures based on POSSUM scores, with greater need for blood transfusion (41.3% vs 19.3% in no MINS group, P 1⁄4 .003), prolonged surgical time (333 ±112 min vs 295 ± 134 min, P < .001) (Table II), and higher postoperative weight gain (þ5 kg [2.2e6.9] vs þ4 kg [1.8e6.2], P 1⁄4 .029)
Within 30 months after surgery, the causes of death (N 1⁄4 73) were related to advanced cancer stage (N 1⁄4 35), sepsis (N 1⁄4 21), pneumonia and/or respiratory failure (N 1⁄4 6), ischemic heart failure (N 1⁄4 2), nonischemic heart failure (N 1⁄4 2), gastroduodenal hemorrhage (N 1⁄4 2), status epilepticus (N 1⁄4 1), and unknown causes (N 1⁄4 5). In this single-center study, MINS occurred in 28% of cases after major open abdominal surgery, among patients with cardiovascular diseases and prolonged interventions requiring blood transfusion
Vascular, and urologic surgery, the incidence of MINS has been previously reported between 8% and 35%, with cardiovascular diseases being strongly predictive of MINS.[5]
Summary
Major adverse cardiac events (MACEs) such as cardiac death, myocardial infarction (MI), arrhythmias, and heart failure are leading causes of 30-day mortality and largely contribute to prolonged hospital length of stay and reduced quality of life.1e3 Myocardial injury after noncardiac surgery (MINS) is an emerging pathological entity defined by elevation in plasma levels of cardiac troponin I or T (cTnI/T) in the presence or absence of clinical and electrocardiographic signs of cardiac ischemia.[4]Whereas the incidence of perioperative MI ranges from 3% to 6%, MINS has been reported in up to 35% of surgical patients and conveys an increased risk of death and MACEs.[1,5,6]In contrast to type I MI resulting from the occlusion of a coronary artery due to atheromatous plaque rupture, type II MIs andC. Results: Among 394 patients, myocardial injury after noncardiac surgery was reported in 109 (27.7%) and was associated with a higher cardiovascular risk profile, prolonged surgery (333 ± 111 min vs 295 ± 134 min, P 1⁄4 .010), greater need for transfusions (41.3% vs 19.3%, P < .001), higher incidence of major adverse cardiac events (22.9% vs 6.7%, P < .001), pulmonary complications (31.2% vs 17.9%, P 1⁄4 .004) , acute kidney injury (30.3% vs 18.2%, P 1⁄4 .009), and systemic inflammatory syndrome (28.4% vs 13.0%, P < .001). The operative time and the need for blood transfusion remained higher among myocardial injury after noncardiac surgery patients who experienced more frequent major adverse cardiac events and acute kidney injury In both the entire and matched cohorts, survival up to 30 months after surgery was determined mainly by the presence of cancer. Further studies are needed to determine whether myocardial injury after noncardiac surgery can be prevented by better control of the patient’s cardiovascular condition and implementation of less invasive of surgical procedures
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