Prevention of cardiac events in perioperative period in patients with acute calculous cholecystitis and coronary heart disease

Abstract

The aim — to evaluate the effectiveness of the advanced therapy for the prevention of cardiac complications in the pre­, intra­ and early postoperative period in patients with acute calculous cholecystitis (ACC) and coronary heart disease (CHD).Materials and methods. The study included 189 patients with ACC and CHD who were treated in the surgical department of Oleksandrivska Clinical Hospital in Kyiv. All patients underwent laparoscopic cholecystectomy under total anesthesia with intubation of the trachea with artificial lung ventilation and creation of a carboxyperitoneum (12 — 15 mm Hg). Patients were divided into two groups, depending on the method of perioperative cardioprotective therapy (PCT): the comparison group — 107 patients and the main group — 82 patients. The comparison group included patients who were given a standard PCT, taking into account international recommendations; the main group included patients who underwent improved PCT. The ratio of patients with functional class of heart failure (HF) by NYHA I/II/III/IV in the main group was 3.7/53.7/36.6/6.1 %, in the comparison group — 7.5/55.5/30.8/6.5 % (p = 0.647). The ratio by class TG13 I/II/III in the main group was 25.6/40.2/34.1 %, in the comparison group — 34.6/38.3/27.1 % (p = 0.363). The target points of the study were the frequency of cardiac complications in the preoperative, intraoperative and early postoperative periods.Results and discussion. Myocardial ischaemia occurred during anesthesia in the main group in 4 (4.9 %) patients compared with 23 (21.5 %) in the comparison group (p = 0.001) and lasted less — on average 8.8 ± 1.3 min in comparison with 14.9 ± 1.1 min (р = 0.027), respectively. Reduction of systolic blood pressure (SBP) less than 70 mm Hg. in the comparison group was fixed in 31 (29.0 %) patients, in the main group — in 5 (6.1 %) (p = 0.001). Episodes of decreasing blood oxygen saturation were recorded in 14 (17.1 %) patients of the main group compared with 50 (46.7 %) patients of the comparison group (p = 0.001). In 9 (8.4 %) patients of the comparison group, bundle­branch block occurred: left — in 6, right — in 3 patients, in the main group, this blockade was diagnosed in two cases. In addition, in the comparison group, 9 (8.4 %) patients had paroxysms of atrial fibrillation compared to 1 such patient in the main group. Functional class of HF by NYHA in the postoperative period increased in 13 (12.1 %) patients of the comparison group and did not increase in any patient of the main group (p = 0.001). Myocardial infarction developed in 6 (5.6 %) patients of the comparison group and in no patient of the main group (p = 0.029). Patients were in the intensive care unit at an average 2.1 ± 0.1 days (comparison group) and 1.4 ± 0.1 days (main group) (p = 0.001).Conclusions. The improved differentiated PCT, applied at all stages of the perioperative period, allowed a statistically significant reduction in the incidence of cardiac events in patients with ACC and concomitant CHD who underwent laparoscopic cholecystectomy compared with conventional therapy, in particular, myocardial ischaemia during anesthesia (4.9 % vs. 21.5 %), its duration (8.8 ± 1.3 min versus 14.9 ± 1.1 min); reduction of saturation (17.1 % vs. 46.7 %); paroxysm of atrial fibrillation (1.2 % versus 8.4 %); myocardial infarction (0 % vs. 5.6 %); decrease in SBP to less than 70 mm Hg. was observed in 29.0 % of cases compared with 6.1 %.