Postoperative Cardiac Morbidity Research Articles

Results of a multidisciplinary spinal cord ischemia prevention protocol in elective repair of Crawford's extent I-III thoracoabdominal aneurysm by fenestrated and branched endografts

Aim: Fenestrated/branched endografting (F/B-EVAR) is an established technique to treat thoracoabdominal aortic aneurysms (TAAAs) in high-risk patients. Spinal cord ischemia/infarction (SCI) is a possible postoperative complication leading to deterioration in quality of life and decreased survival. Several strategies have been suggested in order to minimize its occurrence. The aim of this study was to report the outcomes of a dedicated multidisciplinary SCI prevention protocol for elective F/B-EVAR in Crawford’s extent I-III TAAAs. Methods: All consecutive Crawford’s I-III TAAAs undergoing elective F/B-EVAR from 2010 to 2022 (March) in a single center were prospectively collected and retrospectively analyzed. A dedicated SCI prevention protocol was always adopted. The protocol included several surgical precautions, such as the collateral arterial network optimization, the adoption of a staged repair, and the early limbs reperfusion. Routine use of cerebral spinal fluid drainage (CSFD) was embraced. More anesthesiological measures were the maintenance of perioperative mean arterial pressure > 80 mm Hg, and blood hemoglobin levels > 10 mg/dL. Neurological measures were constituted by intraoperative monitoring with motor-evoked (MEPs) and somatosensory-evoked potentials (SSEPs) plus hourly bedside neurological evaluation during ICU stay. Preoperative comorbidity and postoperative complications were classified according to the Society of Vascular Surgery Reporting Standards. SCI, cardiac/pulmonary morbidities, postoperative hemodialysis, and 30-day/in-hospital mortality were assessed as early outcomes. Survival was evaluated during follow-up. Results: Out of 104 patients, there were 6 (6%), 51 (49%), and 47 (45%) Crawford’s extent I, II, and III TAAAs, respectively. A staged TAAA repair, according to endograft design, anatomical and clinical characteristics, was performed in 83 (80%) cases. The mean hospital stay was 25 ± 22 days. Eight (8%) patients developed SCI, 2 (2%) transitory, and 6 (6%) permanent. Among those with permanent deficits, only 3 (3%) patients had permanent paraplegia with inability to walk. Out of 104 patients, 5 (5%) had cerebral hemorrhage, two among SCI patients. Postoperative cardiac and pulmonary morbidity was reported in 6 (6%) and 6 (6%) cases, respectively. Hemodialysis was necessary in 3 (3%) patients. Three patients died within 30 postoperative days and other 4 during a prolonged/complicated hospitalization, for an overall in-hospital mortality of 7%. The mean follow-up was 30 ± 18 months. The overall estimated 3-year survival was 62%, with a significant difference in survival at 2 years between patients with and without postoperative SCI (SCI: 18% vs. no-SCI: 69%; P < 0.001). Conclusions: A dedicated multidisciplinary SCI prevention protocol in elective F/B-EVAR for Crawford’s I-III TAAAs is feasible and safe, with encouraging rates of SCI (8% overall SCI, 6% permanent impairment, and 3% paraplegia). The 30-day mortality (3%), cardiopulmonary morbidities (6%), and dialysis rate (3%) were satisfactory, as well as the estimated survival at 3 years (62%). Patients with SCI had a significantly lower survival (18% vs. 69%) at 2 years.

The effect of perioperative cardiac risk factors on postoperative outcomes in the elderly patients undergoing hip replacement surgery

Purpose: Cardiac risk factors are among the most important determinants of postoperative outcomes in elderly surgical patients. This study aimed to determine the effect of perioperative cardiac risk factors on postoperative adverse outcomes in elderly patients undergoing total hip replacement surgery.
 Materials and Methods: Patients aged 65 and older who underwent total hip replacement surgery at Cukurova University Hospital between 2014 and 2019 were analyzed retrospectively. The primary outcome measures were postoperative adverse outcomes and mortality rate.
 Results: Two hundred twenty-three patients with total hip replacement surgery within five years of experience in our hospital were screened. 34.5% had postoperative cardiac, pulmonary, cerebral, and infectious morbidity and systemic inflammatory response syndrome, and the in-hospital mortality rate was 2.2%. On multivariate analysis, perioperative risk factors associated with postoperative adverse outcomes included American Society of Anesthesiologists (ASA) II physical status (aOR 5.63, 95% CI 1.75-18.11), preoperative poor functional capacity (aOR 9.50, 95% CI 3.14-28.79), traumatic fracture (aOR 2.75, 95% CI 1.22-6.24), preoperative anemia (aOR 2.15, 95% CI 1.05-4.37), and prolonged surgery (aOR 1.02, 95% CI 1.01-1.02).
 Conclusion: A significant relationship was determined between preoperative poor functional capacity, pre-existing anemia, traumatic hip fracture, ASA II physical status, prolonged case duration and the risk of postoperative complications in elderly patients undergoing total hip replacement surgery.

Midterm results of complicated penetrating abdominal aortic ulcer treated by aortobi-iliac endograft and embolization.

Penetrating aortic ulcer (PAU) is determined by atherosclerotic degeneration of the tunica media with disruption of the intima. Usually it is detected in the thoracic aorta, with few series describing an abdominal location. The aim of the study was to report early and late outcomes of the endovascular repair of complicated infrarenal abdominal PAU (a-PAU) by aortobi-iliac endograft and embolization. Data from all complicated a-PAU submitted to endovascular repair by aortobi-iliac endograft (Cook-Zenith Alpha) between 2016 and 2021 (February) were analyzed. The a-PAU coil embolization was performed to decrease the risk of persistent type II endoleak whenever possible. Complicated a-PAU were defined according with the presence of symptoms, aortic rupture, or saccular or pseudo-aneurysm. Technical success, 30-day morbidity and mortality, and reinterventions were assessed as early outcomes. Survival, endoleaks, and freedom from reinterventions were evaluated during follow-up. Of 1153 endovascular aortic procedures, 45 cases (4%) of complicated a-PAU were identified. Fourteen cases (31%) were managed in urgent setting (symptoms, n= 10 [22%]; shock, n= 4 [9%]). The median diameter of a-PAU was 49mm (interquartile range, 14mm). Thirteen patients (29%) had severe femoral or iliac access (angle >90°, circumferential calcification [>50%], hemodynamic iliac stenosis or obstruction, an external iliac artery diameter of less than 7mm, or a previous femoral surgical graft). The a-PAU embolization was performed in 30 cases (67%). Technical success was achieved in all patients. Postoperative cardiac, pulmonary and renal morbidity occurred in one (2%), two (4%), and eight (18%) patients, respectively. Two patients (4%) required reintervention within 30days for access related complications. The 30-day mortality was 2%. At a median follow-up of 24months (interquartile range, 18months), no type I or III endoleaks, iliac leg occlusion, or graft infection occurred and no patient required late reinterventions; the 36-month survival rate was 72%. No a-PAU enlarged or ruptured during follow-up. Endovascular repair of complicated a-PAU by a low-profile aortobi-iliac endograft and embolization is safe and effective. Excellent technical results are reported even in challenging anatomic features. Midterm clinical results are satisfactory in terms of aortic-related complications or mortality, freedom from reintervention, and survival.

Utilizing Machine Learning Algorithms to Evaluate Sex-based Differences in Preoperative Hemoglobin Thresholds in Open Vascular Surgery

Preoperative anemia is prevalent in over 40% of vascular surgical patients with sex-specific differences. Several studies have implicated preoperative anemia as a predictor of postoperative cardiac morbidity and all-cause mortality. Given that rescue transfusions are associated with postoperative mortality, morbidity, and prolonged length of stay, there is an urgent need to risk modify these patients in the preoperative setting. The objective of the present study is to assess the impact of sex differences in identifying a safe preoperative hemoglobin threshold.

Association of intraoperative hypotension with postoperative morbidity and mortality: systematic review and meta-analysis.

BackgroundIntraoperative hypotension, with varying definitions in literature, may be associated with postoperative complications. The aim of this meta-analysis was to assess the association of intraoperative hypotension with postoperative morbidity and mortality.MethodsMEDLINE, Embase and Cochrane databases were searched for studies published between January 1990 and August 2018. The primary endpoints were postoperative overall morbidity and mortality. Secondary endpoints were postoperative cardiac outcomes, acute kidney injury, stroke, delirium, surgical outcomes and combined outcomes. Subgroup analyses, sensitivity analyses and a meta-regression were performed to test the robustness of the results and to explore heterogeneity.ResultsThe search identified 2931 studies, of which 29 were included in the meta-analysis, consisting of 130 862 patients. Intraoperative hypotension was associated with an increased risk of morbidity (odds ratio (OR) 2.08, 95 per cent confidence interval 1.56 to 2.77) and mortality (OR 1.94, 1.32 to 2.84). In the secondary analyses, intraoperative hypotension was associated with cardiac complications (OR 2.44, 1.52 to 3.93) and acute kidney injury (OR 2.69, 1.31 to 5.55). Overall heterogeneity was high, with an I2 value of 88 per cent. When hypotension severity, outcome severity and study population variables were added to the meta-regression, heterogeneity was reduced to 50 per cent.ConclusionIntraoperative hypotension during non-cardiac surgery is associated with postoperative cardiac and renal morbidity, and mortality. A universally accepted standard definition of hypotension would facilitate further research into this topic.

ELECTIVE INTRA-AORTIC BALLOON PUMP IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFT

Introduction:Preoperative electiveintra-aortic balloon pump (IABP)prompts improve result in helpless left ventricular function patients going throughcoronary artery bypass graft (CABG).The aim of this work was to assess the efficacy of preoperative intra-aortic balloon pump treatment on postoperative cardiac performance, morbidity and mortality. Method:a prospective, cohort study was conducted on 40 patients with preoperative left ventricular ejection fraction< 40%, who went throughcoronary artery bypass graft. These patients were divided preoperatively into two groups:Group I (N.=20) received intraaortic balloon pump insertion 1-2 hours prior to aortic cross clamp.Group II (N.= 20) control group who did not receive intra-aortic balloon pump preoperatively. Results:Both group were matched regarding age, sex distribution and body surface area,mean cardiac index in group I wassignificantly higher(2.5± 0.21 vs. 2±0.32) (P<0.0001). The mean cardiopulmonary bypass time in group I was significantly less (72.56± 21.62 vs. 86.68±20.57) (P=0.04).The ventilation time (hours) and total intensive care unit stay (days) were significantly less in group I (p<0.0001). Conclusion: poor left ventricular function patients going through coronary artery bypass grafting possibly need perioperative intra-aortic balloon pump support to diminish morbidity and mortality.

Fenestrated and Branched Thoraco-abdominal Endografting after Previous Open Abdominal Aortic Repair

Proximal para-anastomotic aneurysms, or aneurysmal degeneration of the native aorta above a previous open abdominal aortic repair (Pr-AAAs), are challenging scenarios. The aim of this study was to report the early and mid term outcomes of endovascular repair of Pr-AAAs by fenestrated and branched endovascular aneurysm repair (FB-EVAR). From 2006 to 2017, pre-operative, intra-operative, and post-operative data from patients undergoing FB-EVAR for Pr-AAAs at two European vascular surgery units were prospectively collected and retrospectively analysed. Early results were considered in terms of technical success (target visceral vessel cannulation and stenting, absence of type I - III endoleak, iliac limb occlusion and 24h mortality); spinal cord ischaemia (SCI) and 30 day and in hospital mortality. Survival, target visceral vessel (TVV) patency, and freedom from re-interventions were also considered at the mid term follow up. Five hundred and forty-four patients underwent FB-EVAR to treat juxta/pararenal or thoraco-abdominal aneurysms. Of these patients, 108 (19.8%) cases were Pr-AAAs (94% male; mean±standard deviation [SD] age 71±4 years; American Society of Anesthesiologists' grade 3-4 in 74% and 26%, respectively). The previous open aortic repair (OR) was performed 10±2 years before FB-EVAR. It was a tubular aorto-aortic repair in 63 (58.3%) cases, a bifurcated aortobi-iliac repair in 37 (34.2%) cases, and an aortobifemoral bypass repair in eight (7.4%) cases. A previous thoracic endovascular aneurysm repair (TEVAR) had been performed in seven patients (6.5%). The aortic lesion at the time of FB-EVAR was, according to the Crawford classification, a type I - III in 69 (63.9%) or a type IV 39 (36.1%) thoraco-abdominal aneurysm. The mean±SD aneurysm diameter was 64±6mm. Overall, 390 TVVs (3.6±1 TVV/case) were revascularised by an endograft with fenestrations (n=63 [58.3%]), with branches (n=26 [24.1%]), or with both fenestrations and branches (n=19 [17.6%]). Tubular, trimodular, or aorto-uni-iliac implants were planned in 68 (63.0%), 38 (35.2%), and two (1.8%) patients, respectively. Proximal TEVAR, carotid-subclavian bypass, and iliac branch devices were planned as adjunctive procedures in 41 (38.0%), five (4.6%), and three (2.8%) cases, respectively. Overall technical success was 93%, with technical failures including five TVV losses (coeliac trunk, n=1; renal arteries, n=4) and three deaths within 24h. Post-operative SCI occurred in seven patients (6.5%), four of which (3.7%) were permanent. SCI was more frequent in category I - III TAAAs (p=.042) and in endografts incorporating both fenestrations and branches (p=.023). Cardiac, pulmonary, and renal complications (reduction in glomerular filtration rate of ≥30% compared with baseline) occurred in 9%, 10%, and 20%, respectively. Bowel ischaemia was seen in three (2.8%) patients. Thirty day mortality was 4% and was associated with pre-operative chronic renal failure (p=.034), post-operative cardiac morbidity (p=.041), and bowel ischaemia (p=.003). Overall in hospital mortality was 5.5% (n=6). Mean±SD follow up was 38±18 months. Survival was 82%, 64%, and 54% at one, three, and five years, respectively, and target visceral vessel patency was 93%, 91%, and 91%, respectively. Permanent haemodialysis was needed in four patients (3.7%). There was no late aneurysm related mortality. Survival during follow up was statistically significantly affected by pre-operative chronic renal failure (p=.022), post-operative cardiac morbidity (p=.042), SCI (p=.044), and bowel ischaemia (p=.003). Freedom from re-intervention at one, three, and five years was 89%, 77%, and 74%, respectively. Endovascular treatment of aneurysmal aortic degeneration above a previous open abdominal repair with FB-EVAR is safe and effective. If those promising results are confirmed at later follow up, FB-EVAR should be considered a prominent therapeutic option, especially in high risk patients.

Effects of ABO/RhD Blood Types and HbA1c Levels on The Postoperative Cardiac Morbidity in Morbidly Obese Patients Who Underwent Sleeve Gastrectomy

Effects of ABO/RhD Blood Types and HbA1c Levels on The Postoperative Cardiac Morbidity in Morbidly Obese Patients Who Underwent Sleeve Gastrectomy

Fenestrated and Branched Endografting After Previous Open Infra-renal Aortic Aneurysm Repair

Introduction - Proximal para-anastomotic aneurysms, or aneurysmal degenerations of the native aorta above a previous infra-renal aortic open repair (P-AAAs), are not rare challenging scenarios. The aim of this study was to report the early and mid-term outcomes following endovascular repair of P-AAAs with fenestrated and branched endografts (FB-EVAR) Methods - From 2006 to 2017, we prospectively collected and retrospectively analyzed pre, intra and postoperative data of patients undergoing FB-EVAR for P-AAAs at two European vascular surgery units. Early outcomes were: technical success (target visceral vessels cannulation and stenting, absence of Type I-III endoleak, iliac limb occlusion and 24-h mortality), spinal cord ischemia (SCI), and 30-day mortality. Mid-term outcomes were: survival, target visceral vessels (TVV) patency, and freedom from re-interventions. Fisher’s exact test, Kaplan Mayer and Log rank were used for the statistical analysis Results - During the study period, 108 patients (M:94%; age:71±4years; ASA 3-4:74%>26%) were enrolled. The previous aortic OR was a tubular aorto-aortic 63(58%), a bifurcated aorto bi-iliac 37(34%) or an aorto bi-femoral 8(8%) bypass. The OR was performed 10±2years prior to the FB-EVAR. A previous TEVAR had also been performed in 7 patients (6%). The aortic lesions at the time of FB-EVAR was a type I-III 69(64%) or type IV 39(36%) thoracoabdominal aneurysm according to the Crawford’s classification. The mean aneurysm diameter was 64±6mm. Overall, 390 TVVs (3.6±1 TVV/case) were perfused by endograft fenestrations (63;58%), branches (26;24%) or both fenestrations and branches (19;18%). Tubular, tri-modular or aorto-monoiliac implants were planned in 68 (63%), 38 (35%) and 2 (2%) patients, respectively. Proximal TEVAR, carotid-subclavian bypass and iliac branch devices were planned adjunctive procedures in 41 (38%), 5 (5%) and 3 (3%) cases, respectively. Technical success was 93%. Technical failures included 5 TVV-loss (celiac trunk:1; renal arteries:4) and 3 deaths within 24 hours (cardiac aetiology). Post-operative SCI was diagnosed in 7 patients (7%), including 4 (4%) permanent. Type I-III TAAAs (p .04) and endograft incorporating both fenestrations and branches (p .04) were associated with SCI. Cardiac and pulmonary morbidity was 9% and 10%, respectively. Post-operative renal failure (GFR reduction >30% of baseline) was diagnosed in 22 patients (20%). Bowel ischemia was depicted in 3 (3%) patients. The 30-day mortality was 4%. Preoperative chronic renal failure (p .03), post-operative cardiac morbidity (p .04), and bowel ischemia (p .003) were associated with 30-day mortality. The mean follow-up was 38±18 months. Survival at 1, 3 and 5 years was 82%, 64% and 54%, respectively. There was no late aneurysm-related mortality. Survival during follow-up was significantly impacted by pre-operative chronic renal failure (p .005), post-operative cardiac morbidity (p .04), and SCI (p .04). Target visceral patency at 1, 3 and 5 years was 93%, 91% and 91%, respectively. New onset of hemodialysis was required in 4 patients (4%). Aneurysm enlargement (>5mm) was detected in 6 (5.5%) cases. Freedom from re-interventions at 1, 3 and 5 years was 89%, 77% and 74%, respectively Conclusion - Endovascular treatment of aortic aneurysmal evolution above a prior open AAA repair with FB-EVAR is safe and effective. If those promising results are confirmed during late follow-up, FB-EVAR should be considered as a therapeutic option, especially in high-risk patients

Preoperative and Postoperative N-terminal Pro B-type Natriuretic Peptide Levels Predict Cardiac Morbidity and Mortality in Patients Undergoing Colorectal Cancer Resection

Introduction: Cardiac complications are a major cause of perioperative morbidity and mortality in patients undergoing colorectal cancer surgery. A quick and reliable system for predicting postoperative cardiac morbidity is needed to predict cardiac events in order to improve outcome in surgery. The aim of this study was to investigate the role of the biochemical marker NT-proBNP in the prediction of postoperative all-cause mortality, cardiac-related mortality and cardiovascular events in patients undergoing colorectal cancer resections. Methods: 100 consecutive patients undergoing colorectal cancer surgery were prospectively recruited. Blood samples were taken preoperatively, 24h, 48h and 5-7 postoperative days to measure NT-proBNP levels. The predictive power of NT-proBNP levels was assessed using Receiver Operating Characteristics (ROC) curves. Results: Cardiac-related morbidity and mortality was 9%. Of eleven deaths, 5 were cardiac-related. Preoperative NT-proBNP was a good predictor of death with ROC area under curve (AUC) of 0.83 (95% C.I. 0.673, 0.993) a strong predictor of cardiac death with AUC of 0.914 (95% C.I. 0.823, 1.000) and a good predictor of cardiac complications with AUC of 0.875 (95% C.I. 0.757, 0.993). NT-proBNP levels 24 hours and 48 hours postoperatively were also strongly predictive of postoperative cardiac morbidity and mortality. Conclusion: Pre- and postoperative NT-proBNP have a role in predicting postoperative death and cardiac complications. This may have significant implications in the planning of postoperative care for high-risk patients.

L-carnitine on myocardial function after coronary artery bypass grafting.

This study aims to evaluate the effect of L-carnitine on postoperative cardiac performance and morbidity and complications in patients undergoing coronary artery bypass grafting. Between April 2005 and June 2008, a total of 60 patients (36 males, 24 females; mean age 60.6 years; range 57 to 65) who were scheduled for coronary artery bypass grafting were prospectively randomized to receive one of three different strategies of myocardial preservation. Group A (n=20) received antegrade crystalloid cardioplegia, Group B (n=20) received antegrade blood cardioplegia, and Group C (n=20) received antegrade blood cardioplegia with carnitine. Samples for lactate dehydrogenase (LDH), creatinine phosphokinase (CPK), creatinine phosphokinasemyocardial band (CK-MB), and Troponin-I were taken from coronary sinus during the operation and from peripheral venous line postoperatively. Blood samples were obtained before CPB, just after CPB and postoperative 1, 6, 12, 24 and 48 hours. Levels of CPK, CK-MB and Troponin-T levels were studied by immunoassay method. The patients who received carnitine had significantly improved cardiac output, cardiac index, and right and left ventricular stroke work immediately after cardiopulmonary bypass and at the first postoperative hour (p=0.01). Troponin-T levels decreased in all patients after 12 hours postoperatively, and this change was most prominent in Group C (p=0.001). Intravenous supplementation of carnitine during cardioplegia provides better results on the recovery of cardiac function and metabolic parameters after coronary artery bypass grafting.

The predictive value of risk indices for cardiac complications in living donor liver transplantation.

The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) risk tool and Revised Cardiac Risk Index (RCRI) are recommended tools for cardiovascular assessment before non-cardiac surgery to predict early postoperative cardiac morbidity and mortality. Their predictive value for postoperative cardiovascular morbidity and mortality after liver transplantation is unknown. We aimed to evaluate the validity of these two risk tools to predict early (30-day) cardiovascular complications and in-hospital all-cause mortality. Patients who underwent living donor liver transplantation were retrospectively analyzed. Consecutive 278 adult patients were included and their NSQIP and RCRI scores were calculated. Cardiovascular morbidity occurred in 5 (1.8 %) patients. In-hospital all-cause mortality occurred in 18 (6.4 %) patients. None-of the patients died from cardiac complications. Causes of cardiac morbidity were as follows; acute coronary syndrome in 1 patient, intraoperative cardiac arrest with successful resuscitation in 1 patient, heart failure in 3 patients. Neither the NSQIP nor the RCRI score were associated with cardiovascular morbidity. Only RCRI medium-high score, DM and Nonalcoholic steatohepatitis as transplant indications were associated with in-hospital all-cause mortality (p = 0.001). The NSQIP risk calculator and RCRI scores failed to accurately predict the risk of perioperative cardiac complications (Tab. 3, Ref. 30). Text in PDF www.elis.sk.

Long-Term Cardiac Morbidity and Mortality in Patients With Aortic Valve Disease Following Liver Transplantation: A Case Matching Study

This retrospective study examined the role of aortic valve (AV) disease in patients who underwent orthotopic liver transplantation (OLT) to determine the incidence of postoperative cardiac morbidity and mortality when compared with a matched control group without AV disease. Patients were included in the AV group if diagnosed with aortic stenosis (AS) or aortic regurgitation or had received AV replacement prior to OLT. The AV group (n = 53) was matched to a control group (n = 212) with the following preoperative variables: type of organ transplanted, age, gender, race, body mass index, MELD, redo-transplantation, preoperative renal replacement therapy, nonalcoholic steatohepatitis, viral hepatitis, diabetes, and coronary artery disease. A 1:4 ratio was utilized to improve the efficiency and power of the analysis. No significant difference in survival or posttransplant cardiac complications (acute coronary syndrome, heart failure, or dysrhythmia) was observed between groups. However, statistically significantly more patients-11% (6/53)-required coronary intervention following OLT in the AV group, whereas 3% (7/212) required coronary intervention (χ2 = 5.8; P = .0156) in the control group. Following OLT, 9% (5/53) in the AV group required surgical or nonsurgical AV intervention, whereas no valvular events were observed in the control group. Event-free survival in the AV group, with an end point defined as AV intervention (n = 5) and death (n = 10), was 92% (49/53) at 1 year, 83% (44/53) at 3 years, and 72% (38/53) at 5 years. Patients with pretransplant AV replacement or AS have significant cardiac complications (myocardial infarction, AV replacement, or cardiac death) in 1 to 3 years post-OLT.

Study of Breast Surgery under Thoracic Epidural Analgesia

Thoracic epidural anaesthesia (TEA) reduces cardiac and splanchnic sympathetic activity and thereby influences perioperative function of vital organ systems. A recent meta-analysis suggested that TEA decreased postoperative cardiac morbidity and mortality. Objective is to Study of Breast Surgery under Thoraco Epidural Analgesia as sole anesthetic technique. This study was conducted on 20 cooperative female patients of age group 42-55 year with ASA grade I-III. Procedure was done in either sitting or lateral position. Under full aseptic precautions 18 G epidural needle was introduced between T3-T4 or T2-T3 space after infiltration of local anesthetic agent. After confirmation of the space epidural catheter was placed and 2.5 to 3.5 cm of catheter length was kept inside. After Proper Fixation of the catheter patients were made supine. A test dose of 2 ml Xylocaine 2% with adrenalin was injected before giving proper local anesthetic dosage. Patients pulse rate, Blood pressure and respiration were noted. Inj Xylocaine 1.5% 12 ml was injected through the catheter and analgesic effects were awaited. After checking adequate blockade surgery was allowed after positioning of sand bag under operative site. From Our study we conclude that midthoracic epidural analgesia technique is a safe alternative acceptable method for various breast surgery with excellent postoperative pain relief and early recovery.

Beta-adrenergic blockers for perioperative cardiac risk reduction in people undergoing vascular surgery.

People undergoing major vascular surgery have an increased risk of postoperative cardiac complications. Beta-adrenergic blockers represent an important and established pharmacological intervention in the prevention of cardiac complications in people with coronary artery disease. It has been proposed that this class of drugs may reduce the risk of perioperative cardiac complications in people undergoing major non-cardiac vascular surgery. To review the efficacy and safety of perioperative beta-adrenergic blockade in reducing cardiac or all-cause mortality, myocardial infarction, and other cardiovascular safety outcomes in people undergoing major non-cardiac vascular surgery. The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (January 2014) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2013, Issue 12). We searched trials databases and checked reference lists of relevant articles. We included prospective, randomised controlled trials of perioperative beta-adrenergic blockade of people over 18 years of age undergoing non-cardiac vascular surgery. Two review authors independently performed study selection and data extraction. We resolved disagreements through discussion. We performed meta-analysis using a fixed-effect model with odds ratios (ORs) and 95% confidence intervals (CIs). We included two studies in this review, both of which were double-blind, randomised controlled trials comparing perioperative beta-adrenergic blockade (metoprolol) with placebo, on cardiovascular outcomes in people undergoing major non-cardiac vascular surgery. We included 599 participants receiving beta-adrenergic blockers (301 participants) or placebo (298 participants). The overall quality of studies was good. However, one study did not report random sequence generation or allocation concealment techniques, indicating possible selection bias, and the other study did not report outcome assessor blinding and was possibly underpowered. It should be noted that several of the outcomes were only reported in a single study and neither of the studies reported on vascular patency/graft occlusion, which reduces the quality of evidence to moderate. There was no evidence that perioperative beta-adrenergic blockade reduced all-cause mortality (OR 0.62, 95% CI 0.03 to 15.02), cardiovascular mortality (OR 0.34, 95% CI 0.01 to 8.32), non-fatal myocardial infarction (OR 0.83, 95% CI 0.46 to 1.49; P value = 0.53), arrhythmia (OR 0.70, 95% CI 0.26 to 1.88), heart failure (OR 1.71, 95% CI 0.40 to 7.23), stroke (OR 2.67, 95% CI 0.11 to 67.08), composite cardiovascular events (OR 0.87, 95% CI 0.55 to 1.39; P value = 0.57) or re-hospitalisation at 30 days (OR 0.86, 95% CI 0.48 to 1.52). However, there was strong evidence that beta-adrenergic blockers increased the odds of intra-operative bradycardia (OR 4.97, 95% CI 3.22 to 7.65; P value < 0.00001) and intra-operative hypotension (OR 1.84, 95% CI 1.31 to 2.59; P value = 0.0005). This meta-analysis currently offers no clear evidence that perioperative beta-adrenergic blockade reduces postoperative cardiac morbidity and mortality in people undergoing major non-cardiac vascular surgery. There is evidence that intra-operative bradycardia and hypotension are more likely in people taking perioperative beta-adrenergic blockers, which should be weighed with any benefit.

Predicting major adverse cardiac events in spine fusion patients: is the revised cardiac risk index sufficient?

Observational cohort study. To determine the accuracy of the Revised Cardiac Risk Index (RCRI) in predicting major adverse cardiac events in patients undergoing spine fusion surgery of 3 levels or more. Preoperative cardiac testing is extensively guided by the RCRI, which was developed and validated in thoracic, abdominal, and orthopedic surgical patients. Because multilevel spine fusion surgery is often associated with major transfusion, we hypothesize that the RCRI may not accurately characterize the risk of cardiovascular morbidity in these patients. After institutional review board approval, perioperative data were collected from 547 patients who underwent 3 or more levels of spinal fusion with instrumentation. Postoperative cardiac morbidity was defined as any combination of the following: arrhythmia requiring medical treatment, myocardial infarction (either by electrocardiographic changes or troponin elevation), or the occurrence of demand ischemia. The surgical complexity was categorized as anterior surgery only, posterior cervical and/or thoracic fusion, posterior lumbar fusion, or any surgery that included transpedicular osteotomies. Logistic regression analysis was performed to determine RCRI performance. The RCRI performed no better than chance (area under the curve = 0.54) in identifying the 49 patients (9%) who experienced cardiac morbidity. The RCRI did not predict cardiac morbidity in our patients undergoing major spine fusion surgery, despite being extensively validated in low-risk noncardiac surgical patients. Preoperative testing and optimization decisions, previously based on the RCRI, may need to be revised to include more frequent functional cardiac imaging and more aggressive implementation of pharmacologic modalities that may mitigate cardiac morbidity, similar to the preoperative evaluation for major vascular surgery. 3.

Melatonin reduces cardiac morbidity and markers of myocardial ischemia after elective abdominal aortic aneurism repair: a randomized, placebo‐controlled, clinical trial

The aim was to examine the effect of perioperative melatonin treatment on clinical cardiac morbidity and markers of myocardial ischemia in patients undergoing elective surgery for abdominal aortic aneurism. Reperfusion injury results in increased cardiac morbidity in patients undergoing surgery for abdominal aortic aneurisms (AAA). A randomized, placebo-controlled, clinical trial including patients undergoing surgery for AAA was performed. The patients received by infusion over a 2-hr period either, 50mg melatonin or placebo intra-operatively, and 10mg melatonin or placebo orally, the first three nights after surgery. Postoperative cardiac morbidity was registered, and blood samples for analysis of troponin-I (TpI) were collected preoperatively, and at 5min, 6, 24, 48, 72, and 96hr after clamp removal/recirculation of the first leg. Continuous measurement of ST-segment depression was performed by Holter monitoring. A total of 26 patients received melatonin, while 24 received placebo. A significant reduction in cardiac morbidity was seen in the melatonin-treated patients compared with those given placebo [4% versus 29% (P=0.02)]. Five patients (19%) who received melatonin had increased TpI levels in the postoperative period compared with 12 patients (50%) who were given placebo (P=0.036). The median number of ST-segment deviations was less in the melatonin-treated patients compared with the placebo group [median 1 (range 0-4) versus 6 (range 0-13) (P=0.01)], but no differences were found in the duration of ST-segment deviations. Melatonin treatment in the perioperative period decreased clinical cardiac morbidity as well as the occurrence of myocardial ischemia after abdominal aortic aneurism repair.

Preoperative and Perioperative Predictors of Reactive and Persistent Depression After Cardiac Surgery: A Three-Month Follow-up Study

Depression is commonly reported in patients after cardiac surgery and increases the risk of postoperative cardiac morbidity or mortality or both. Although preoperative depression has been implicated as the strongest predictor of depression after surgery, the characteristics thought to influence reactive or persistent depression have been poorly investigated in cardiac surgery patients. Therefore, the main aim of this study was to examine whether pre-existing depression rather than perioperative variables may predict postoperative reactive or persistent depression. Overall, 96 patients completed a psychologic evaluation, including the Center for Epidemiologic Studies of Depression scale and the State and Trait Anxiety Inventory for depression and anxiety, respectively, before surgery and at 3-month follow-up. A total of 27 (28%) and 24 (25%) patients had depression preoperatively and at 3-month follow-up, respectively. Postoperative depression was predicted by preoperative scores in Center for Epidemiologic Studies of Depression scale (β = 0.29, p < 0.05) and European System for Cardiac Operative Risk Evaluation (β = 0.22, p < 0.04), but not by procedure-related variables (p > 0.75). Specifically, patients with reactive depression showed greater European System for Cardiac Operative Risk Evaluation than those without depression (p < 0.05), whereas patients with persistent depression had greater preoperative Center for Epidemiologic Studies of Depression scores than those whose depression improved after surgery (p < 0.01). The severity of pre-existing depression and biomedical risk factors can be markers of depression-related risk 3 months after cardiac surgery in patients with persistent and reactive depression, respectively. An integrated psychologic and biomedical evaluation is essential to anticipate which patients are likely to show depression after cardiac surgery.

Does the revised cardiac risk index predict cardiac complications following elective lung resection?

BackgroundRevised Cardiac Risk Index (RCRI) score and Thoracic Revised Cardiac Risk Index (ThRCRI) score were developed to predict the risks of postoperative major cardiac complications in generic surgical population and thoracic surgery respectively. This study aims to determine the accuracy of these scores in predicting the risk of developing cardiac complications including atrial arrhythmias after lung resection surgery in adults.MethodsWe studied 703 patients undergoing lung resection surgery in a tertiary thoracic surgery centre. Observed outcome measures of postoperative cardiac morbidity and mortality were compared against those predicted by risk.ResultsPostoperative major cardiac complications and supraventricular arrhythmias occurred in 4.8% of patients. Both index scores had poor discriminative ability for predicting postoperative cardiac complications with an area under receiver operating characteristic (ROC) curve of 0.59 (95% CI 0.51-0.67) for the RCRI score and 0.57 (95% CI 0.49-0.66) for the ThRCRI score.ConclusionsIn our cohort, RCRI and ThRCRI scores failed to accurately predict the risk of cardiac complications in patients undergoing elective resection of lung cancer. The British Thoracic Society (BTS) recommendation to seek a cardiology referral for all asymptomatic pre-operative lung resection patients with > 3 RCRI risk factors is thus unlikely to be of clinical benefit.

Elective Use of Intra‐Aortic Balloon Pump During Aortic Valve Replacement in Elderly Patients to Reduce Postoperative Cardiac Complications

This is a retrospective cohort study to determine if routine intra-aortic balloon pump (IABP) placement prior to aortic valve replacement in elderly patients with severe aortic stenosis without significant coronary artery stenosis reduces cardiac complications. Participants were patients aged ≥70 years without significant coronary stenosis, who had severe aortic stenosis, and were undergoing isolated aortic valve replacement. Our primary endpoint was postoperative cardiac morbidity rate as a composite of the adverse cardiac events: elevated creatine kinase with muscle and brain subunits (CK-MB)/CK (>5%), fatal ventricular arrhythmias requiring therapy, or catecholamine index of >10. Eighteen patients had elective IABP insertion prior to surgery, and 16 patients had no planned IABP insertion. One patient died (5.6%) in the elective IABP group (P = 1.0 compared with the non-IABP group). The overall rate of in-hospital death was 2.9% (1/34). In the non-IABP group, one patient had rescue IABP insertion after surgery (6.3%). The elective IABP group had a significantly lower cardiac morbidity rate than the non-IABP group (44.4 vs. 87.5%, respectively, P = 0.013). According to multivariate analysis using a logistic European system for cardiac operative risk evaluation value of >10% to define increased morbidity, elective IABP use significantly reduced cardiac morbidity (odds ratio, 0.11; 95% confidence interval, 0.02-0.67; P = 0.016). Additionally, the elective IABP group was more likely to show low CK-MB/CK than the non-IABP group (4.1 ± 1.9% vs. 6.1 ± 3.1%, respectively, P = 0.026). We concluded that among elderly aortic valve replacement patients without significant coronary artery stenosis, elective IABP use may reduce the incidence of major adverse cardiac events.