Incidence Of Postoperative Cardiac Events Research Articles

Abstract 9608: Overuse of Cardiac Evaluation and Testing in Patients at Low Cardiac Risk Prior to Laparoscopic Bariatric Surgery

Introduction: Preoperative cardiac testing is common prior to bariatric surgery despite the low incidence of postoperative cardiac events. We sought to determine what proportion of patients who underwent preoperative cardiac testing and evaluation prior to laparoscopic bariatric surgery were at low cardiac risk. Methods: We reviewed preoperative cardiac testing and evaluations performed for patients undergoing laparoscopic bariatric surgery at Hershey Medical Center from January 1 st 2015 through December 31 st 2019. Cardiac risk was evaluated using the Revised Cardiac Risk Index (RCRI) and the National Surgical Quality Improvement Program Myocardial Infarction and Cardiac Arrest risk calculator (NSQIP MICA). Patients with a RCRI score ≤1, or a NSQIP MICA cardiac risk estimate less than 1%, were considered to be at low cardiac risk. Results: 1,134 patients underwent laparoscopic bariatric surgery during the study time period, of which 1,093 (96.4%) were low cardiac risk by RCRI and 1,133 (99.9%) were low cardiac risk by NSQIP MICA. 587 patients (51.8%) were referred to cardiology for preoperative evaluation. 643 patients (56.7%) underwent one or more preoperative cardiac tests (see figure for breakdown of cardiac risk for each cardiac evaluation). Out of 1,134 patients, 1 (0.1%) had myocardial infarction within 30 days of surgery. There were 0 patients with either cardiac arrest or death within 30 days of surgery. Conclusions: A large majority of patients undergoing cardiac evaluation and testing prior to laparoscopic bariatric surgery were at low cardiac risk, regardless of whether cardiac risk was assessed by the RCRI or by the NSQIP MICA. Preoperative cardiac testing and evaluation were common despite excellent cardiac outcomes. Use of tools such as the RCRI or NSQIP MICA to identify patients at low cardiac risk at the time of bariatric enrollment may help to reduce the overuse of preoperative cardiac evaluation and testing in low risk patients.

Adverse cardiac events after vascular surgery are prevalent despite negative results of preoperative stress testing

ObjectiveCardiac risk assessment is a critical component of vascular disease management before surgical intervention. The predictive risk reduction of a negative cardiac stress test result remains poorly defined. The objective of this study was to compare the incidence of postoperative cardiac events among patients with negative stress test results vs those who did not undergo testing. MethodsWe reviewed all patients who underwent elective open abdominal aortic aneurysm repair, suprainguinal bypass, endovascular aneurysm repair (EVAR), carotid endarterectomy (CEA), and infrainguinal bypass within the Vascular Study Group of New England from 2003 to 2017. We excluded patients with positive stress test results (n = 3312) and studied two mutually exclusive groups: elective surgery patients with a negative stress test result and elective surgery patients with no stress test (total n = 26,910). The primary outcome was a composite of in-hospital postoperative cardiac events (dysrhythmia, heart attack, heart failure) or death. ResultsA preoperative stress test was obtained in 66.3% of open repairs, 42.8% of suprainguinal bypasses, 37.1% of EVARs, 36.0% of CEAs, and 31.2% of infrainguinal bypasses. The proportion of patients receiving a preoperative stress test varied widely across centers, from 37.1% to 80.0%. The crude odds ratio of in-hospital postoperative cardiac event or death was 1.37 (95% confidence interval [CI], 1.07-1.76) for open repair and 1.52 (CI, 1.13-2.03) for suprainguinal bypass, indicating that patients with negative stress test results before these procedures were 37% and 52% more likely to suffer a postoperative event or die compared with patients selected to proceed directly to surgery without testing. Conversely, the crude odds ratio was 0.92 (CI, 0.66-1.29) for EVAR, 0.92 (CI, 0.70-1.21) for CEA, and 1.13 (CI, 0.90-1.40) for infrainguinal bypass, indicating that patients undergoing these procedures had a similar likelihood of sustaining an event whether they had a negative stress test result or proceeded directly to surgery without a stress test. ConclusionsThe use of cardiac stress testing before vascular surgery varies widely throughout New England. Whereas patients are often appropriately selected to proceed directly to surgery, a negative preoperative stress test result should not assuage the concern for an adverse outcome as these patients retain a substantial likelihood of cardiac events, especially after large-magnitude procedures.

The cardiac implications of breast reconstruction using the internal mammary artery as the recipient vessel

Microsurgical breast reconstruction is a popular choice in breast reconstruction. Recipient vessel use for these autologous tissue reconstructions has shifted from the thoracodorsal to the internal mammary vessels. Coronary artery bypass (CAB) surgery remains the optimal revascularization strategy in patients with significant, diffuse coronary artery disease. The conduits of choice for coronary revascularization are the internal mammary arteries (IMA) because of their superior long-term graft patency rate and improved patient survival. To review the cardiac risk factors in the breast reconstruction population, and to report the incidence of postoperative cardiac events at the London Health Sciences Centre, London, Ontario. The authors present the index cases illustrating cardiac complications following the use of internal mammary vessels. A retrospective, single-centre, cumulative audit of breast reconstruction practice from 2005 to 2009 was conducted. A total of 81 patients undergoing autologous breast reconstruction were reviewed. Two women were noted to have experienced postoperative myocardial infarction requiring intervention. Both were noted to have triple-vessel disease, an indication for CAB; however, during the breast reconstruction, their IMAs had been utilized. As a result, both women subsequently underwent triple-vesssel percutaneous intervention, with one woman later requiring CAB without IMA because of recurrent ischemia. While there is limited overlap with the breast reconstruction and cardiac disease population, there can be significant cardiac health implications in the postoperative status (both short and long term) of women undergoing autologous breast reconstruction using the IMAs as recipient vessels.

Stress-only or stress/rest myocardial perfusion imaging in patients undergoing evaluation for bariatric surgery

BackgroundBariatric surgery for management of obesity is being used with increasing frequency. Stress testing with myocardial perfusion imaging is often employed as part of the workup prior to anticipated bariatric surgery. The incidence of clinically significant abnormalities on stress MPI performed for this indication, however, has not been established. Methods and ResultsWe retrospectively reviewed a series of 383 consecutive stress MPI studies performed on patients undergoing workup prior to planned bariatric surgery. The study population had a mean age 42 ± 10 years, and was 83% female, with a body mass index of 49 ± 8. The majority of patients (81%) were able to exercise using either the Bruce or Modified Bruce protocol, and 67% underwent stress-only imaging. Overall SPECT MPI findings were normal in 89% and equivocal in 6% of patients. The incidence of abnormal findings on MPI was 5% (3% mild and 2% moderate-to-severe abnormalities). At 1 year, overall survival was 99.5%, with no difference between those with and without MPI abnormalities. Similarly, the incidence of post-operative cardiac events was very low (2%), and mostly due to atrial arrhythmias or borderline elevations of troponin. ConclusionIn a typical pre-bariatric surgery population, the incidence of abnormal stress MPI is low. The majority of patients were able to use a stress-only strategy for assessment of perfusion. At 1 year the incidence of adverse cardiovascular outcomes is very low. Additional studies should be focused on determining whether any subgroup of such patients may benefit more from pre-operative stress testing.

Effect of Severe Aortic Stenosis on the Outcome in Elderly Patients Undergoing Repair of Hip Fracture

Background: The perioperative assessment and management of elderly patients with hip fracture and significant aortic stenosis (AS) is an increasingly common clinical problem with little data available to guide perioperative management. Objectives: It was the aim of this study to examine the incidence of perioperative events in an elderly population of patients with severe AS undergoing repair of hip fracture as compared with controls without severe AS. Methods: Patients over the age of 70 with an echocardiographic diagnosis of severe AS defined as an aortic valve area ≤1.0 cm² who underwent surgery for hip fracture repair were retrospectively identified. An age-matched group of patients without a history of AS who underwent surgical repair of hip fracture was the control group. The primary outcome of the incidence of postoperative cardiac events defined as death, acute coronary syndrome or pulmonary edema within 30 days was compared. Results: Thirty-two patients with AS (median age 84.5 years, range 72–94; 27 females and 5 males) and 88 controls (median age 86 years, range 80–95; 67 females and 21 males) were entered into the study. There were no significant differences between the AS group and controls for 30-day mortality (6.2 vs. 6.8%) or for the total cardiac event rate (18.7 vs. 11.8%). Conclusions: Our results demonstrate that elderly patients with severe AS can safely undergo repair of hip fractures with a mortality and morbidity comparable with a control population. These patients should not be denied surgery on the basis of their aortic valve disease.

Cardiac Morbidity and Mortality after Surgery for Gastrointestinal Carcinomas

The number of Americans undergoing surgery for gastrointestinal (GI) cancer is increasing, as is the prevalence of cardiovascular disease. Clinical risk factors have been found to be useful in predicting cardiac events after vascular procedures. Their utility for predicting cardiac events after GI carcinoma surgery is unclear. We performed a retrospective review in order to determine whether clinical risk factors are useful in predicting cardiac events in patients undergoing GI carcinoma surgery and to ascertain the incidence of postoperative cardiac events. From 1998 to 2003, 333 patients were identified, with an average age of 56 years. One hundred one (30.3%) patients had one or more clinical risk factors. The overall cardiac event rate was 3.9 per cent. Age > 70 years was the only risk factor associated with a cardiac event. There was a trend toward increased cardiac risk with increasing number of risk factors. In the absence of clinical risk factors, cardiac events after surgery for GI carcinoma are low. There is an increased cardiac risk in patients > 70 years and a trend toward increased cardiac events as the number of clinical risk factors increases.

Routine Pre-Operative Stress Testing for Patients Without Cardiac Symptoms Undergoing Major Thoracic Surger

PURPOSE: Major thoracic surgery is associated with a 5-10% incidence of post-operative cardiac events. It has been shown to be difficult, based on clinical criteria alone, to determine the severity of cardiac disease. We hypothesized that routine stress testing would identify patients at increased risk for cardiac complications and would lead to subsequent interventions, ultimately improving outcomes.

Cardiac Evaluation of the Diabetic Patient Prior to Peripheral Vascular Surgery

The benefit of preoperative cardiac evaluation in the diabetic patient undergoing peripheral vascular surgery is uncertain. To investigate this issue we performed a retrospective review of 192 procedures performed in diabetic patients for chronic lower extremity arterial occlusive disease. The incidence of adverse postoperative cardiac events was determined, as well as its association with several preoperative factors including symptoms of coronary artery disease (CAD), extent and results of preoperative noninvasive cardiac evaluation, and operative site (aorta vs. lower extremity). The overall death and cardiac complication rates were 10.2% for lower extremity and 25.7% for aortic procedures (p = 0.02). For myocardial infarction and cardiac death alone, the rates were 5.1% and 5.7%, respectively (p > 0.10). Although a history of symptomatic CAD predicted the occurrence of any cardiac complication (28.3% vs. 8.2% [p < 0.01] for the aortic and lower extremity revascularization groups combined), no factor was found to be associated with the occurrence of myocardial infarction and cardiac death alone. In patients with a history of symptomatic CAD, there was no significant difference in the incidence of complications whether or not preoperative noninvasive cardiac testing was performed (28.1% vs. 28.6%, p > 0.10) or, if testing was performed, if the results were abnormal or normal (35.3% vs. 20.0%, p > 0.10). Similar results were obtained in patients with no history of symptomatic CAD. In summary, this retrospective review of our experience with noninvasive evaluation to detect CAD in diabetic patients undergoing peripheral vascular surgery failed to show any benefit in terms of reducing the incidence of postoperative cardiac events.

Multicenter prospective study of nonruptured abdominal aortic aneurysms. I. Population and operative management

This article describes the patient population and operative management of 666 patients with nonruptured aneurysms of the abdominal aorta. Statistical significance of variables was determined by the chi-square test and logistic regression analysis. There were no statistically significant differences (p > 0.05) in mortality rate for abdominal aortic aneurysm (AAA) on the basis of indication for surgery (asymptomatic, 3.9%; asymptomatic but with evidence of enlargement, 4.9%; and symptomatic, 7.2%) or the urgency of operation (elective operation, 4.5%; and urgent operation, 7.1%). Characteristics of the 72 participating surgeons did not influence the operative mortality rate. A family history of AAA was documented in 6.1% of cases and was more common if the patient was female (p = 0.03) and less than 65 years of age (p = 0.04). Patients without clinical evidence of coronary artery disease had a 0.8% mortality rate from cardiac disease compared with 6.2% if any stigmata of coronary disease were present. Prior aortocoronary bypass surgery did not reduce the incidence of postoperative cardiac events or operative mortality rate. Patients having “routine” angiography did not have a less complicated operative course, fewer thrombotic complications, or lower mortality rate than those not having it. Those patients with an inflammatory AAA (4.5%) did not have a significantly higher incidence of pain. Heparin administration (84.8%) did not reduce the complications of graft thrombosis, “trash”, distal thrombosis, and/or amputation. The 6.8% of patients requiring suprarenal aortic cross-clamping had a higher incidence of postoperative renal dysfunction (p = 0.02) and intraoperative blood loss (p < 0.001), but cardiac events were not more frequent. When the aortic cross-clamping time was prolonged (more than 70 minutes), the requirement for crystalloid fluid administration increased (p < 0.001) and postoperative myocardial infarction was more common (p = 0.004). After ligation of the left renal vein in 7.9%, renal damage or dialysis was more frequent (p = 0.01). Patients having an intra-abdominal graft (tube, 38.5% and biiliac, 30.7%) had fewer wound infections (p = 0.02) and graft thromboses (p < 0.001) than the patients with a femoral anastomosis. When the internal iliac artery flow was interrupted bilaterally (12%), diarrhea (p = 0.03) and ischemic colitis (p = 0.03) were more frequent complications. Reimplantation of the inferior mesenteric artery was carried out in 4.8%. After renal artery bypass in 2.1%, the mortality rate was not increased, but the incidence of transient renal dysfunction was increased (p = 0.03). In the 6.6% having concomitant nonvascular surgery with potential for bacterial contamination, there were no cases of wound infection, but graft sepsis was the cause of death in one case. Observations from this prospective multicenter study can be generalized to reflect current surgical practice and standards of AAA surgery on a national level.