Postoperative Troponin Research Articles

Postoperative High-Sensitivity Troponin Monitoring Following Noncardiac Surgery: Evaluating the Effect on Mortality of Associated Perioperative Clinical Events

Postoperative High-Sensitivity Troponin Monitoring Following Noncardiac Surgery: Evaluating the Effect on Mortality of Associated Perioperative Clinical Events

External aortic cross-clamping and endoaortic balloon occlusion in minimally invasive mitral valve surgery.

Minimally invasive cardiac surgery has increasingly been used for patients with valvular pathology. Two techniques of aortic occlusion are utilized with this technique: transthoracic aortic clamp (TTC) and endoaortic balloon occlusion (EAO). Both possibilities present peculiar advantages and limitations whose current evidence is based on few observational studies. We performed an analysis with the primary objective to evaluate outcomes and the incidence of major complications of these two techniques. The data of 258 patients who underwent minimally invasive mitral valve surgery through right mini-thoracotomy from January 2013 to July 2018 were reviewed. One hundred sixty-five patients were operated on with TTC and in 93 cases EAO was used. Univariate and multivariate analyses were performed to identify predictors of adverse outcome. The mean age of the cohort was 60.4±13.9 years, patients with TTC were significantly older and had higher EuroSCORE II and reoperations were carried out mostly with EAO. Isolated mitral valve surgery was mostly performed (74%) and in 26% of the cases, other procedures were combined. No differences were detected in terms of types of operation, cardiopulmonary bypass (CPB) and cross-clamp times between the two techniques. Similar postoperative troponin I and CK-Mb values were recorded. Twenty-four patients (11%) suffered at least one complication. Of note, a new neurologic deficit occurred in six patients; in four cases a cerebral stroke, with all patients in the EAO group (P=0.06). There was no case of aortic dissection, no patient suffered peripheral ischemia nor femoral vessels complications. Thirty-day mortality was 1.9% (TTC 1.2% vs. EAO 3.2%; P=0.51), 30-day mortality excluding reoperations was 1.2% (TTC 1.2% vs. EAO 1.1%; P=0.61). Both techniques proved to be safe. Although non-statistically significant, there was a higher rate of cerebral stroke in the EAO group. However, EAO system shows technical advantages in avoiding tissue dissection and remains our choice in redo operations.

OC84 TRANSTHORACIC CLAMP AND ENDOAORTIC OCCLUSION FOR MINIMALLY INVASIVE CARDIAC SURGERY

Background and Aim: Two techniques of aortic occlusion have been used in small thoracotomy cardiac surgery: transthoracic clamp (TTC) and endoaortic balloon occlusion (EAO). Both techniques present peculiar advantages and limitations whose current evidences are based on observational studies. We report our experience comparing early outcomes of these two techniques. Methods: 235 consecutive patients underwent minimally invasive cardiac surgery through right mini-thoracotomy from January 2013 to March 2018.One-hundred forty-two patients were operated on with TTC, in 93 cases EAO was used. Mean age was 60.1 ± 13.6, patients with TTC were significantly older (62.4 ± 12.4 TTC vs. 56.1 ± 14.5 EAO, p = 0.0002); reoperations were carried out mostly with EAO (2% TTC vs. 12% EAO, p = 0.005). No differences were detected between the two techniques in terms of types of operation, CPB and cardioplegic arrest times. Results: Similar values of postoperative Troponin I and CK-Mb were recorded. New neurologic deficit occurred in 6 patients, 2 temporary deficit in the TTC patients and 4 strokes in the EAO group (p = 0.048). There was no case of aortic dissection, no patient suffered peripheral ischaemia. Overall hospital mortality was 2.1%, 1.4% in TTC and 3.2% in EAO (p = 0.62); hospital mortality, excluding redo-operations was 1.4%, 1.4% in TTC and 1.2% in EAO (p = 0.98). Conclusions: Both TTC and EAO provided to be safe.A higher rate of cerebral stroke was observed in the EAO group. However, the use of endo-aortic balloon inflation system showed technical advantages in avoiding tissue dissection and aortic manipulations. It remains our choice in redo operations.

Postoperative abnormal liver function in children with heart surgery

To investigate the incidence of postoperative abnormal liver function test (aLFT) for the children with heart surgery, and to analyze the clinical characteristics and risk factors. Methods: A total of 143 children younger than 18 years old who underwent heart surgery in 2017 were enrolled in this study. The liver function were examined one day preoperation and consecutive 5 days after operation. The clinical data of perioperative period were recorded and the risk factors for aLFT were analyzed. Results: There were 43/143 (30%) cases had aLFT, including 5/143 (3.5%) acute liver injury (ALI). In the 6 liver function tests, total bilirubin, and glutamic-oxalacetic aminotransferase and glutamic-pyruvic aminotransferase increased to the peak at the first day and the second day after operation, respectively, and albumin declined to the lowest level at the fourth day after operation. aLFT happened most common at the first day after operation(22/43, 51.2%). The patients in the aLFT(+) group had smaller body size, more proportion of the risk adjustment for congenital heart sugery-1 (RACHS-1) score ≥ 3 and cyanosis, longer cardiopulmonary bypass (CPB) time, higher postoperative cardiac troponin (cTnI) value, higher inotropic score (IS), more transfusion, and longer mechanical ventilation time than those in the aLFT(-) group. The aLFT(+) group had longer ICU and hospital time, higher morbidity and mortality than those in the aLFT(-) group (P<0.05). Logistic regression showed that RACHS-1≥3, cyanosis, CPB time, cTnI, IS, transfusion, and mechanical ventilation time were the risk factors for aLFT. Multiple factor analysis showed the mechanical ventilation time was an independent risk factor for aLFT (P<0.05). Conclusion: aLFT is common in children after congenital heart operation, which could deteriorate to poor outcome. The mechanical ventilation time is an independent risk factor for aLFT.

Effect of Fast Cardioplegic Arrest Induced by Adenosine on Cardiac Troponin Levels After Heart Valve Surgery

Cellular injury is not avoidable with current cardioplegic solutions. The effect of adenosine on reducing cardiac injury post-surgery is controversial. The objective of the current study is to evaluate the effect of fast cardioplegic arrest induced by adenosine on high sensitive cardiac troponin I after heart valve surgery. Forty-five (45) patients with rheumatic heart diseases underwent heart valve surgery using conventional approach through median sternotomy. They were classified into two groups, group I (n=21) patients received 0.25mg/kg adenosine into the aortic root just after aortic cross-clamping and before infusion of the cold hyperkalaemic crystalloid cardioplegia via antegrade route and group II (n=24) who received cold crystalloid hyperkalaemic cardioplegia without adenosine. Cardiac troponin I was measured preoperatively and on postoperative days 0, 3 and 7. There was no significant difference between both groups in the demographic, preoperative and operative data. Adenosine significantly reduced arrest time. Postoperative high sensitive cardiac troponin I increased significantly in both groups compared to the preoperative levels and the rise continued till postoperative day 3. Troponin levels were significantly lower in the adenosine group compared to the control at all measurements. The clinical outcomes were non-significant different between groups. Using adenosine in inducing fast cardioplegic arrest in heart valve surgery after aortic cross clamp and prior to infusion of the cold cardioplegia had significantly decreased postoperative cardiac troponin levels which was used as a proxy for cellular injury compared to the control group.

Perioperative Troponin is a Predictor of Both Short- and Intermediate-term Mortality Among Patients Undergoing Major Urologic Surgery

ObjectiveTo determine whether a positive troponin is a predictor of intermediate- and long-term mortality in patients undergoing major urologic surgeries at our institution. MethodsThis is a retrospective analysis of patients undergoing major urologic surgery at the Cleveland Clinic from 2010-2015. Patients were stratified by the presence and maximum value of troponin blood-draw, if performed within 30 days of surgery. Survival analysis was performed using Kaplan-Meier function (univariate) and Cox regression analysis (continuous) to assess mortality risk. ResultsWithin 30 days of surgery, 1305 (15.5%) patients a troponin drawn, and 304 (3.6%) of them had an abnormal troponin level (>0.01 ng/mL). Patients with positive troponin drawn for cause within 30 days of surgery had a significantly decreased overall survival at 5 years of 70.6% (95% CI 62.6, 77.2) when compared to patients with negative troponin (81.7% [95% CI 77.4, 85.3]) and no troponin drawn (90.4% [95% CI 89.0, 91.6]). ConclusionFor cause serum troponin blood draw and peak levels demonstrated a positive correlation with all-cause mortality in patients undergoing major urologic surgeries Prospective studies are needed to better understand the utility of postoperative troponin as predictive marker of mortality.

Postoperative Serum Troponin Trends in Infants Undergoing Cardiac Surgery

Troponin-I (TN-I) levels are elevated following pediatric cardiac surgery with speculation that particular patterns may have prognostic significance. There is lack of procedure-specific data regarding postoperative TN-I levels in infants undergoing cardiac surgery. We hypothesized that TN-I elevation varies with type of surgery and persistent elevation predicts poor prognosis. We prospectively measured serial TN-I levels (preoperatively, 4, 8, 12, 24, and 48 hours postoperatively) in 90 infants (age < 1 year) undergoing cardiac surgery: off cardiopulmonary bypass (CPB) (n = 15), on CPB (n = 43), and on CPB with ventricular incision (CPB with ventricular incision; n = 32). All patients had undetectable baseline TN-I levels. The area under the curve of TN-I levels over the 48-hour period was significantly different among the surgical groups (P < 0.002), and highest in patients with CPB with ventricular incision. Generally, TN-I levels peaked by 4 hours after surgery and returned to near-normal levels within 48 hours. A persistent TN-I rise beyond 8 hours after surgery was a strong predictor of postoperative hypoperfusion injury (defined as a composite endpoint of end-organ injury resulting from inadequate perfusion, odds ratio 21.5; P = 0.001) and mortality (30% in those with persistently high TN-I, compared with 3.5% in the remaining patients; P < 0.001), independent of patient age, anatomy and/or complexity of surgery, and level of postoperative support. Our data provide benchmark values for TN-I levels following cardiac surgery in infants. Extent of TN-I elevation correlates with type of surgery. Persistent TN-I elevation beyond 8 hours after surgery is strongly associated with postoperative hypoperfusion injury and mortality.

Transit time flow measurement and high frequency ultrasound epicardial imaging to guide coronary artery bypass surgery.

Transit-time flow measurement (TTFM) should be routinely used in CABG surgery to verify graft function. Most recently, a 2D high-frequency-ultrasound (HF-US) epicardial imaging probe has been released (MiraQ™, Medistim, Oslo, Norway), which allows to evaluate the cannulation/clamping site of the aorta morphologically and to evaluate the completed anastomosis. We aimed to evaluate the use of TTFM and HF-US on surgical strategy during CABG surgery. A total of 65 consecutive patients undergoing CABG surgery were evaluated. The target vessels, the clamping/cannulation site and the anastomosis were evaluated by HF-US. TTFM was performed on all grafts and the mean flow (mL/min) and pulsatility indices (PI) were recorded. Troponin-I levels (ng/L) were obtained within the first 4 postoperative days. A total of 3.3±0.9 grafts were performed, with 98.5% LIMA use and a sequential graft was performed in 55.4%. The mean PI and flow (mL/min) were 2.3±2.7 and 70.8±50.6 for the right coronary artery system, 2.4±2.2 and 82.0±47.6 for the circumflex system, and 2.1±1.2 and 78.0±35.0 for the LAD system, respectively. Postoperative troponin-I levels showed a maximum on postoperative day 1. A surgical strategy change, based on imaging, was done in 15%. Moreover, we observed a correlation of PI and flow with maximum postoperative troponin-I levels. The present study evaluated the combination of TTFM and HF-US in CABG surgery. Epicardial scanning was helpful to evaluate the potential opening site of the vessel, to evaluate the completed anastomosis or to evaluate the clamping or cannulation site. Troponin-I levels were directly correlated to mean graft flow and PI levels.

Myocardial protection in on-pump coronary artery bypass grafting surgery: analysis of the effectiveness of the use of retrograde Celsior®.

We analyzed the adequacy of the myocardial protection achieved with a single dose of retrograde crystalloid Celsior®, compared with an accepted standard (microplegia), in on-pump coronary artery bypass grafting surgery (CABG). This was a retrospective comparative clinical study conducted in a single institution that included all the patients operated on who had elective isolated on-pump CABG, from March 2006 to June 2014. We evaluated maximum postoperative troponin T (TnT) as a marker of myocardial damage, adjusted for possible confounders using propensity score matching. We also analyzed markers of recovery of myocardial function, and the safety of the intravenous use of Celsior®. During the study period, 261 patients were included, divided in two groups: (a) continuous retrograde blood-based microplegia (114 patients); (b) retrograde single-dose crystalloid Celsior® (147 patients). The propensity score adjusted maximum TnT was significantly lower in the Celsior group [average treatment effect = -0.55 ng/dl; 95% confidence interval (CI) -1.10 to -0.1 ng/dl; p = 0.048]. There were no differences in the postoperative use of intra-aortic balloon of counterpulsation or in the requirements of high-dose inotropic medications. In-hospital mortality was equivalent in both study groups ( p = 0.73); surgical re-exploration because of bleeding was equivalent ( p = 0.37). There were no differences in prolonged mechanical ventilation ( p = 0.65) and intensive care unit length of stay ( p = 0.87). An isolated single dose of retrograde Celsior® may be an effective and safe myocardial protection strategy in on-pump CABG.

Association between preoperative ambulatory heart rate and postoperative myocardial injury: a retrospective cohort study

BackgroundResting heart rate is well established as a predictor of morbidity and mortality in the general population. However, the relationship between preoperative heart rate and perioperative outcomes, specifically myocardial injury, is unclear. MethodsThis retrospective cohort study included patients undergoing elective major non-cardiac surgery from 2008 to 2014 at a multisite healthcare system. The exposure was ambulatory heart rate measured during the outpatient preoperative clinic visit, whereas the outcome of interest was myocardial injury (peak postoperative troponin I concentration >30 ng L−1). Covariates included patient characteristics, comorbidities, and preoperative medications. We constructed several multivariable regression models that each modelled heart rate in a different manner, including as a simple continuous variable, categories, and fractional polynomials. ResultsThe cohort included 41 140 patients, of whom 4857 (11.8%) experienced myocardial injury. Based on pre-specified heart categories thresholds, a heart rate ≥90 beats min−1 was associated with an elevated odds of myocardial injury compared with a heart rate <60 beats min−1 (adjusted odds ratio, 1.22; 95% confidence interval, 1.06–1.39; P=0.005). This result was consistent regardless of the method used for categorisation. When fractional polynomials were used to model heart rate, a ‘J-shaped’ relationship between heart rate and odds of myocardial injury was observed. ConclusionsThis cohort study found that both very high preoperative heart rates, and possibly also very low heart rates, are associated with increased risk of myocardial injury. Whether heart rate is a modifiable risk factor, or rather simply a marker of underlying cardiac pathology, needs to be determined in further research.

P2662Prognostic value of postoperative high-sensitivity troponin among patients undergoing fenestrated and/or branched endovascular aortic aneurysm repair

P2662Prognostic value of postoperative high-sensitivity troponin among patients undergoing fenestrated and/or branched endovascular aortic aneurysm repair

Does A Low 6-Minute Walk Distance Predict Elevated Postoperative Troponin?

Our study of 100 major vascular and renal transplant patients evaluated the 6-minute walk test (6MWT) as an indicator of perioperative myocardial injury, using troponin as a marker. Using logistic regression and the area under the receiving operator characteristic curve, we compared the 6MWT to the Revised Cardiac Risk Index and metabolic equivalents. Only the 6MWT was associated with elevated postoperative troponins (95% CI, 0.98-0.99). However, the 6MWT area under the receiving operator characteristic curve (0.71 [95% CI, 0.57-0.85]) was not different from the Revised Cardiac Risk Index (P = .23) or metabolic equivalents (P = .14). The 6MWT may have a role in cardiac risk stratification in the perioperative setting.

Association of Perioperative Whole Blood Transfusion with Troponin I Release after Off-Pump Coronary Artery Bypass Surgery

Background: Increased postoperative levels of Troponin I (TnI) after Off-pump Coronary Artery Bypass Grafting (OPCABG) surgery can often be observed in patients in the absence of significant perioperative hemodynamic instability or any evident intra-operative technical problems or signs of graft failure. A study undertaken by Biancari and his collegues (2012) found that Red Blood Cell transfusion was associated with increased TnI release after elective OPCABG1. Serum TnI level is an established indicator of myocardial injury. This prospective observational study was conducted in the Department of Cardiac Surgery, National Institute of Cardiovascular Diseases and Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, from January 2015 to December 2016 to assess whether intraoperative and immediate postoperative Whole Blood Transfusion resulted in increased release of TnI after isolated OPCABG operation.Materials &amp; Methods: A total of 40 patients (34 males and 6 females) undergoing OPCABG were consecutively enrolled in the study, 20 patients in the transfusion recipient group and 20 patients in the non-transfusion recipient group. The groups were compared for pre-operative baseline characteristics and co-morbidities, per-operative techniques and events, and postoperative or end-point variables including Postoperative TnI level measured 12 hours at the end of surgery and a number of other clinical outcomes.Results: Both transfusion recipient and non-transfusion recipient groups had statistically indifferent baseline characteristics, co-morbidity counts, operative techniques and operative events. No significant difference (p = 1.000) was noted in case-counts with increased Postoperative TnI level between the groups (85% in the transfusion recipient group versus 90% in the non-transfusion recipient group). All other clinical outcomes were also found to be similarly distributed with no statistical difference between the groups.Conclusion: In contrast to Red Blood Cell transfusion in several other studies, perioperative Whole Blood transfusion was not associated with increased postoperative Troponin I (TnI) release after isolated offpump coronary artery bypass grafting (OPCABG) operation.University Heart Journal Vol. 13, No. 2, July 2017; 55-58

Rapid Ventricular Pacing for Neurovascular Surgery: A Study on Cardiac and Cerebral Effects

Intraoperative rupture of a cerebral aneurysm during neurosurgery can be a devastating event that increases perioperative morbidity and mortality. Rapid ventricular pacing (RVP) is a technique to obtain flow arrest for short periods of time during dissection or rupture of the aneurysm. The objective of this study was to evaluate the neurological and cardiac effects of repetitive periods of RVP during cerebrovascular surgery. Data from patients who underwent repetitive RVP during craniotomy for cerebrovascular disorders were retrospectively analyzed from a single-center medical records database (Cegeka Medical Health Care Systems). We compared preoperative and postoperative troponin levels (cTnI) to assess cardiac ischemia. Preoperative and postoperative magnetic resonance imaging (MRI) results were screened for RVP-induced infarcts by evaluating diffusion restriction in the hemisphere contralateral to the operated side and the fossa posterior. A total of 37 patients were analyzed. An immediate decrease of systolic arterial blood pressure (<60 mm Hg) was achieved after initiation of RVP. Postoperative MRI did not reveal areas of diffusion restriction. RVP tended to be a predictor of postoperative cTnI increase. Preoperative and postoperative cTnI levels were higher in patients with a subarachnoid hemorrhage compared to patients without one. After 24 hours cTnI jevels normalized to preoperative values. Systolic arterial blood pressure decreased after RVP but normalized immediately when pacing stopped. MRI of the brain did not show RVP-related ischemia and the limited cTnI level increase normalized to preoperative values. Therefore, RVP during short periods of time seems to be a safe blood pressure-lowering technique for the brain and heart.

East Asian variant of aldehyde dehydrogenase 2 is related to worse cardioprotective results after coronary artery bypass grafting.

Aldehyde dehydrogenase 2 activity is associated with cardioprotection. Individuals carrying an East Asian variant of the ALDH2 genotype (ALDH2*2) have significantly reduced aldehyde dehydrogenase 2 activity. No previous studies have determined the effect of the ALDH2*2 genotype on cardioprotective results after coronary artery bypass grafting (CABG). In total, 207 patients who underwent selective off-pump CABG were prospectively enrolled. Their baseline characteristics and clinical results were collected. Preoperative and postoperative circulating oxidative stress levels (serum malondialdehyde adducts and hydroxynonenal adducts) were measured. After genotyping, the oxidative stress levels and clinical results were compared between the ALDH2*2 carriers and non-carriers. ALDH2*2 carriers exhibited higher levels of malondialdehyde (P = 0.02) and hydroxynonenal (P = 0.03) adducts after CABG. ALDH2*2 carriers had higher postoperative troponin I levels (P = 0.01) and 24-h inotropic scores (P = 0.02). The intensive care unit time (P = 0.03) and postoperative length of stay (P = 0.03) were longer in ALDH2*2 carriers. The postoperative pulmonary infection rate was higher (P = 0.03) in ALDH2*2 carriers. Patients with the ALDH2*2 genotype had higher postoperative oxidative stress levels and poorer clinical results after CABG. Special cardioprotective techniques should be considered for patients with a history of 'facial flushing' when performing CABG.

Risk factor analysis for a complicated postoperative course after neonatal arterial switch operation: The role of troponin T

To find risk factors for a complicated early postoperative course after arterial switch operation (ASO) in neonates with d-transposition of the great arteries (dTGA). In addition to anatomical and surgical parameters, the predictive value of early postoperative troponin T (TnT) values in correlation to the early postoperative course after ASO is analyzed. Seventy-nine neonates (57 (72%) male) with simple dTGA treated by ASO between 2009 and 2016 were included in the analysis. A complicated early postoperative course (30 days) was defined by one of the following criteria: (A) moderate to severe cardiac dysfunction without rhythm disturbances, (B) rhythm disturbances causing hemodynamic instability with the need for medical treatment, (C) signs for ischemia in ECG, (D) need for surgical or catheter interventional reinterventions other than diagnostic, or (E) other reasons. Forty of 79 patients (51%) showed a complicated early postoperative course after ASO, with 2 patients dying after 13 and 16 days. Patients with a complicated early postoperative course had a longer PICU stay (P < .001), needed longer mechanical ventilator support (P = .001) and longer inotropic support (P = .03), and more reinterventions (surgical or catheter interventional) were necessary (P = .001). Only the presence of a VSD (P = .001) and longer surgery duration (P = .026) were associated to a complicated postoperative course. TnT values only showed a trend toward higher values in patients with a complicated postoperative course (P = .06). A secondary rise in TnT was seen in 10 patients, ranging from 11.6% to 410.2%, of whom 7 could be classified in the complicated postoperative group. The postoperative course after ASO in dTGA neonates is influenced by other cardiac comorbidities like a VSD with the need for surgical treatment, influencing surgery duration. Postoperative higher TnT values reflect a longer and more vulnerable intraoperative course with limited predictive value on the early postoperative course.

Remote ischemic preconditioning for cardioprotection in elective inpatient abdominal surgery \u2013 a randomized controlled trial

BackgroundPerioperative myocardial injury (PMI) is common in elective inpatient abdominal surgery and correlates with mortality risk. Simple measures for reducing PMI in this cohort are needed. This study evaluated whether remote ischemic preconditioning (RIPC) could reduce PMI in elective inpatient abdominal surgery.MethodsThis was a double-blind, sham-controlled trial with 1:1 parallel randomization. PMI was defined as any post-operative serum troponin T (hs-TNT) > 14 ng/L. Eighty-four participants were randomized to receiving RIPC (5 min of upper arm ischemia followed by 5 min reperfusion, for three cycles) or a sham-treatment immediately prior to surgery. The primary outcome was mean peak post-operative troponin in patients with PMI, and secondary outcomes included mean hs-TnT at individual timepoints, post-operative hs-TnT area under the curve (AUC), cardiovascular events and mortality. Predictors of PMI were also collected. Follow up was to 1 year.ResultsPMI was observed in 21% of participants. RIPC did not significantly influence the mean peak post-operative hs-TnT concentration in these patients (RIPC 25.65 ng/L [SD 9.33], sham-RIPC 23.91 [SD 13.2], mean difference 1.73 ng/L, 95% confidence interval − 9.7 to 13.1 ng/L, P = 0.753). The treatment did not influence any secondary outcome with the pre-determined definition of PMI. Redefining PMI as > 5 ng/L in line with recent data revealed a non-significant lower incidence in the RIPC cohort (68% vs 81%, P = 0.211), and significantly lower early hs-TnT release (12 h time-point, RIPC 5.5 ng/L [SD 5.5] vs sham 9.1 ng/L [SD 8.2], P = 0.03).ConclusionsRIPC did not at reduce the incidence or severity of PMI in these general surgical patients using pre-determined definitions. PMI is nonetheless common and effective cardioprotective strategies are required.Trial registrationThis trial was registered with Clinicaltrials.gov, NCT01850927, 5th July 2013.

Troponin T monitoring to detect myocardial injury after noncardiac surgery: a cost-consequence analysis.

Myocardial injury after noncardiac surgery (MINS) is a mostly asymptomatic condition that is strongly associated with 30-day mortality; however, it remains mostly undetected without systematic troponin T monitoring. We evaluated the cost and consequences of postoperative troponin T monitoring to detect MINS. We conducted a model-based cost-consequence analysis to compare the impact of routine troponin T monitoring versus standard care (troponin T measurement triggered by ischemic symptoms) on the incidence of MINS detection. Model inputs were based on Canadian patients enrolled in the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) study, which enrolled patients aged 45 years or older undergoing inpatient noncardiac surgery. We conducted probability analyses with 10 000 iterations and extensive sensitivity analyses. The data were based on 6021 patients (48% men, mean age 65 [standard deviation 12] yr). The 30-day mortality rate for MINS was 9.6%. We determined the incremental cost to avoid missing a MINS event as $1632 (2015 Canadian dollars). The cost-effectiveness of troponin monitoring was higher in patient subgroups at higher risk for MINS, e.g., those aged 65 years or more, or with a history of atherosclerosis or diabetes ($1309). The costs associated with a troponin T monitoring program to detect MINS were moderate. Based on the estimated incremental cost per health gain, implementation of postoperative troponin T monitoring seems appealing, particularly in patients at high risk for MINS.

Myocardial injury after non-cardiac surgery: Time to shed the ignorance

Perioperative cardiovascular complications are common and place a significant burden on public healthcare systems. A large proportion of such complications are due to a new clinical entity, i.e. myocardial injury after non-cardiac surgery (MINS). It is important to understand MINS, its prognosis and management in the perioperative period. A literature review of MINS was done. MINS is defined as an elevated postoperative cardiac troponin level that was considered as resulting from myocardial ischaemia without evidence of a non-ischaemic cause for the troponin elevation. The perioperative milieu (surgical stress response, sympathetic activation, hypercoagulability, hypotension, bleeding, anaemia and pain) contributes to the pathophysiology of a relative myocardial hypoperfusion and ischaemia, which differentiates MINS from myocardial infarction in non-surgical patients. Globally, >7% of adults ≥45 years of age suffer MINS, with South African (SA) studies confirming similar event rates. More than 80% of MINS patients are asymptomatic for myocardial ischaemia, and therefore would not fulfil the universal definition of myocardial infarction, despite having a similar prognosis to those with the latter condition. Accurate diagnosis of MINS therefore relies on routine daily postoperative cardiac troponin surveillance for 48 -72 hours postoperatively in patients with a >5% risk of major perioperative cardiovascular complications. This approach is cost-effective in SA. One in 10 patients with MINS dies within 30 days of surgery, and 1 in 5 develops major cardiovascular complications. Short-and long-term mortality could be improved by simple treatment strategies, including cardiovascular therapy intensification, and by ensuring aspirin use and statin therapy. All recommendations promote the involvement of a multidisciplinary team. MINS is a common, serious perioperative cardiovascular complication with public healthcare implications that has been underappreciated in SA. A multidisciplinary approach with simple treatment strategies should be adopted.

Conversion of Atrial Fibrillation after Cardiosurgical Procedures by Vernakalant® as an Atrial Repolarization Delaying Agent (ARDA).

Postoperative, new-onset atrial fibrillation (POAF) is one of the most common complications after cardiosurgical procedures. Vernakalant has been reported to be effective in the conversion of POAF. The aim of this study was to evaluate the efficacy and safety of vernakalant for atrial fibrillation after cardiac operations, and to investigate predictors for the success of vernakalant treatment.Patients and Methods: Post-cardiac surgery patients with new-onset of atrial fibrillation (AF) were consecutively enrolled in this study. Demographic data as well as intraoperative and postoperative parameters were analyzed. Vernakalant administration was primarily started 5.5 hours after new-onset POAF: 3 mg/kg intravenously over 10 min, and in case of non-conversion, a second dose of 2 mg/kg intravenously over 10 min.Results: 129 consecutive patients (70.2 ± 9.1 years) were included: 61 patients with coronary artery bypass graft (CABG) surgery, 49 patients with isolated valve procedures, and 19 patients with combined procedures (CABG and valve). Conversion in sinus rhythm was achieved after the first vernakalant dose in 57 patients (44%), and after the second dose in 41 patients (32%). The mean time to conversion was 13.7 ± 14.1 min. The patients receiving valve procedures depicted a significantly lower conversion rate. The following variables lowered conversion rate: no preoperative beta blocker, postoperative troponin levels >500 ng/L, and systolic blood pressure >140 mmHg. At the first follow-up, 92% of the converted patients showed sinus rhythm, while 80% of the non-responders showed sinus rhythm (P < .01).Conclusions: The POAF was effectively converted by vernakalant. The conversion rate of POAF after valve surgery was lower when compared to isolated CABG.