Postoperative Troponin Research Articles

Troponin testing after noncardiac surgery: a population-based historical cohort study on variation and factors associated with testing in Ontario.

International practice guidelines make different recommendations for postoperative troponin testing to detect perioperative myocardial infarction and myocardial injury after noncardiac surgery. To gain insights into current testing patterns, we evaluated predictors of routine troponin testing after three commonly performed major noncardiac surgeries. We conducted a population-based historical cohort study of adults having major orthopedic, colorectal, or vascular surgery in Ontario, Canada from 1 January 2010 to 31 December 2017. We used hierarchical logistic regression modelling to assess the association of patient, surgery, and hospital factors with postoperative troponin testing, while accounting for clustering at the hospital level. We characterized hospital-level variation by the intraclass correlation coefficient (ICC), which was adjusted for various characteristics. The cohort included 176,454 eligible patients. Hospital-specific adjusted testing rates ranged from 0-20.1% for orthopedic surgery, 0-43.8% for colorectal surgery, and 19.6-88.0% for vascular surgery. Older age, urgent surgery status, and surgery duration were consistently associated with higher rates of testing for all three surgeries. Higher Revised Cardiac Risk Index scores were associated with higher odds of testing for orthopedic and colorectal surgery, but not for vascular surgery. Even after adjustment, the ICCs were 9.2%, 7.4%, and 24.1% for orthopedic, general, and vascular surgery, respectively. Troponin testing varied substantially across hospitals for selected major noncardiac surgery procedures even after accounting for differences in patient-level cardiac risk factors. Our observations lend support to a more standardized approach for troponin testing after noncardiac surgery.

Custodiol-HTK Solution Vs. Conventional Cardioplegia for Myocardial Protection During Coronary Artery Bypass Grafting Following Recent ST-Elevation Myocardial Infarction

Abstract Background: Histidine-tryptophan-ketoglutarate (HTK), Bretschneider's, or Custodiol is an intracellular crystalloid cardioplegic solution which is claimed to offer single shot cardioplegia for myocardial protection during complex cardiac procedures for up to 3 h. We aimed to compare the clinical outcome of early coronary artery bypass grafting (CABG) using blood cardioplegia vs. Custodiol solution for myocardial protection in patients with recent ST-elevation myocardial infarction (STEMI). Materials and Methods: This prospective comparative study included 100 patients with recent STEMI who underwent early CABG at our institution between January 2019 and December 2020. The patients were divided into two groups: group A (n = 50) received blood cardioplegia and group B (n = 50) received Custodiol-HTK crystalloid cardioplegia. Results: There were non-significant differences in postoperative mortality and complication rates between both the groups except for significantly higher proportion of post-operative arrythmias after Custodiol cardioplegia (26% vs. 8%, P = 0.01). Custodiol was associated with significantly lower levels of blood troponin and higher levels of blood lactate for 6 h after CABG. Custodiol results in significantly shorter durations of mechanical ventilation (11.98 ± 4.03 vs. 18.28 ± 8.84 h, P < 0.001) and intensive care unit (ICU) stay (70.04 ± 14.80 vs. 80.20 ± 19.91 h, P = 0.01), with non-significantly shorter duration of post-operative hospital stay (7.98 ± 2.76 vs. 9.24 ± 3.41 days, P = 0.06). Conclusion: Custodiol as a single shot without interruption of the operative technique offers shorter durations of mechanical ventilation and ICU stay than blood cardioplegia, with more acceptable levels of post-operative troponin in high-risk patients who underwent early CABG for recent STEMI.

Intraoperative Hypotension and Myocardial Injury After Noncardiac Surgery in Adults With or Without Chronic Hypertension: A Retrospective Cohort Analysis.

The risk of myocardial injury progressively increases at intraoperative mean arterial pressures (MAPs) ≤65 mm Hg. Higher pressures might be required in chronically hypertensive patients. We aimed to test the hypothesis that the harm threshold is higher in patients with chronic hypertension than in normotensive patients. We conducted a single-center retrospective cohort analysis of adults >45 years old who had noncardiac surgery between 2010 and 2018 and scheduled, rather than symptom-driven, postoperative troponin measurements. The MAP thresholds under which risk started to increase were compared between patients with chronic hypertension (baseline MAP ≥110 mm Hg) and normotensive patients (baseline MAP <110 mm Hg). The primary outcome was a composite of in-hospital mortality and myocardial injury within 30 days, defined by any postoperative 4th-generation troponin T measurement ≥0.03 ng/mL apparently due to cardiac ischemia. Multivariable logistic regression and moving average smoothing methods were used to evaluate confounder-adjusted associations between the composite outcome and the lowest intraoperative MAP sustained for either 5 or 10 cumulative minutes, and whether the relationship depended on baseline pressure (normotensive versus hypertensive). Among 4576 eligible surgeries, 2066 were assigned to the normotensive group with mean (standard deviation [SD]) baseline MAP of 100 (7) mm Hg, and 2510 were assigned to the hypertensive group with mean baseline MAP of 122 (10) mm Hg. The overall incidence of the composite outcome was 5.6% in normotensive and 6.0% in hypertensive patients ( P = .55). The relationship between intraoperative hypotension and the composite outcome was not found to depend on baseline MAP in a multivariable mixed effects logistic regression model. Furthermore, no statistical change points were found for either baseline MAP group. Baseline blood pressure of the hypertensive patients was only moderately increased on average, and the event rate was low. Nonetheless, we were not able to demonstrate a difference in the harm threshold between normotensive and chronically hypertensive patients. Our results do not support the theory that hypertensive patients should be kept at higher intraoperative pressures than normotensive patients.

The association of preoperative dialysis with troponin trends and short term outcomes among advanced kidney disease patients undergoing coronary artery bypass grafting

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Coronary artery disease continues to be the leading cause of death in patients with stage IV-V chronic kidney disease (CKD IV-V). However, the prognosis and early outcomes for advanced CKD patients undergoing coronary artery bypass grafting (CAB) worsen as the estimated glomerular filtration rate (eGFR) deteriorates. Therefore, we compared postoperative clinical outcomes and troponin trends in patients having advanced CKD according to preoperative dialysis status in a single centre experience. Methods A total of 51 patients with CKD IV and V who underwent CAB between 2016-2021 were included in the study. Data on patient characteristics and postoperative outcomes were collected retrospectively, and independently for our Society of Thoracic Surgeons database. Characteristics were compared between patients having CKD IV vs. CKD V. The differences in postoperative cardiac troponin trends and outcomes were evaluated between patients who did vs. did not undergo preoperative dialysis. The statistical analysis was conducted applying appropriate parametric or non-parametric (for skewed variables) testing methods, and a p value &amp;lt; 0.05 was considered to be statistically significant. Results 47% (24) of subjects had CKD IV, while the rest featured CKD V. Patients with CKD IV tended to be older (61.8 ± 9.2 vs. 56.3 ± 11.5 years, p = 0.07), more obese (BMI: 31.4 ± 6.8, 27.4 ± 4.9 kg/m2, p = 0.02) and had significantly higher preoperative GFR (23 ± 4.9 vs. 9 ± 3.3 mL/min, p &amp;lt; 0.001) (Table.1). When comparing patients who underwent preoperative dialysis vs. those who did not, troponin levels were the highest at 18h postoperative in both groups, however, troponin levels were comparable between both groups at all time points (Table.2). Although, there was no difference in hospital length of stay and mortality between these groups, patients who did not undergo preoperative dialysis had longer intensive care unit length of stay (ICU LOS). Conclusion In this single centre experience preoperative dialysis was not associated with a significant difference in trends of postoperative cardiac enzymes. Although preoperative dialysis was associated with shorter ICU LOS, complex pre-procedural surgical risk assessment remains paramount in reducing complications and mortality in this high-risk population. Abstract Figure. Abstract Figure.

Procedure-Specific Relationships Between Postoperative Troponin T and a Composite of Mortality and Low Cardiac Output Syndrome: A Retrospective Cohort Analysis.

Myocardial injury after coronary artery bypass grafting (CABG) is defined as troponin concentrations >10 times 99th percentile upper reference limit (URL) according to the Fourth Universal Definition. However, troponin concentrations after non-CABG cardiac surgery which indicate greater-than-expected myocardial injury and increased risk for complications remain unclear. Our goal was to assess procedure-specific relationships between troponin T and a composite outcome of low cardiac output syndrome and in-hospital mortality in cardiac surgical patients. Patients having cardiac surgery between January 2010 and December 2017 were categorized into 4 groups by procedure: (1) CABG; (2) mitral valve repair; (3) aortic valve repair/replacement (AVR); (4) mitral valve replacement (MVR) or CABG + valve surgeries. Exclusion criteria were elevated preoperative troponin T, preoperative kidney failure, circulatory arrest, or preoperative/planned mechanical circulatory support. Logistic regression was used to assess the association between troponin T and composite outcome, both overall and by procedure, including assessment of the interaction between procedure and troponin T on outcome. Among 10,253 patients, 37 (0.4%) died and 393 (3.8%) developed the primary outcome. Troponin T concentrations differed by procedure (P < .001). Compared to CABG, AVR had 0.53 (99.2% confidence interval [CI], 0.50-0.56; unadjusted P < .001) times lower troponin T concentrations, while MVR/CABG + valve were 1.54 (99.2% CI, 1.45-1.62, unadjusted P < .001) times higher. There were linear relationships between log2 troponin T concentration and log odds mortality/low cardiac output syndrome. The (unadjusted) relationships were parallel for various types of surgery (interaction P = .59), but at different levels of the outcome. The relative increase in odds for mortality/low cardiac output syndrome per a similar increase in troponin T concentrations did not differ among cardiac surgical procedures, but the absolute troponin T concentrations did. Troponin concentrations should thus be interpreted in context of surgical procedure.

Propensity-Matched Analysis of Del Nido Cardioplegia in Adults Undergoing Cardiac Surgery with Prolonged Cross-Clamping Time.

There is not enough data in the literature regarding the safety and efficiency of del Nido cardioplegia in patients with prolonged cross-clamping time. This study aims to determine the efficacy and safety of del Nido cardioplegia compared to cold blood cardioplegia in patients with prolonged aortic cross-clamping time. In this retrospective study, patients with an aortic cross-clamping time ≥ 90 minutes were included. One hundred consecutive adult patients undergoing cardiac surgery using del Nido cardioplegia comprised the study group, and 100 consecutive adult patients undergoing cardiac surgical procedures using cold blood cardioplegia comprised the control group. Propensity score matching yielded 88 del Nido cardioplegia and 88 cold blood cardioplegia patients. There were no significant differences when comparing the matched groups regarding the requirement for intraoperative defibrillation, postoperative peak troponin T levels, inotropic support, intra-aortic balloon pump requirement, and left ventricular ejection fraction at discharge and on the sixth postoperative month; also, there were no significant differences when comparing cardiopulmonary bypass time and total operation time. Mean cross-clamping time was significantly shorter in the del Nido group (P&lt;0.001). Del Nido cardioplegia may be a safe alternative to cold blood cardioplegia in adults undergoing cardiac surgical procedures with prolonged aortic cross-clamping time.

Tepid Modified Del Nido Cardioplegia in Adults Undergoing Cardiac Surgery: A Propensity-Matched Analysis.

Del Nido cardioplegia was reported to provide adequate myocardial protection and clinical outcomes with improved surgical flow in adult cardiac surgical procedures. And many clinicians have already modified the traditional formula. This study aims to investigate the efficacy and safety of tepid modified del Nido cardioplegia compared to cold blood cardioplegia in adult patients undergoing cardiac surgery. This retrospective study included one hundred consecutive adult patients undergoing cardiac surgical procedures using tepid modified del Nido cardioplegia. One hundred consecutive adult patients undergoing cardiac surgical procedures with cold blood cardioplegia were the control group. Propensity score matching yielded 89 modified del Nido and 89 cold blood cardioplegia patients. There were no significant differences when comparing the two matched groups regarding the requirement for intraoperative defibrillation (P=0.36), postoperative peak troponin T levels (0.18), perioperative inotropic support (P=0.26), intra-aortic balloon pump requirement (P=0.62), and postoperative left ventricular ejection fraction at discharge (P=0.4) and on the sixth postoperative month (P=0.37). Mean cross-clamping time (P=0.005), cardiopulmonary bypass time (P=0.03), and total operation time (P=0.03) were significantly shorter in the del Nido group. Tepid modified del Nido cardioplegia may be a safe alternative to cold blood cardioplegia in adult patients undergoing cardiac surgical procedures.

Del Nido versus warm blood cardioplegia in adult patients with a low ejection fraction

BackgroundDel Nido cardioplegia was recently introduced to adult cardiac surgery with encouraging results. The effect of Del Nido cardioplegia in patients with low ejection fraction (EF) has not been thoroughly evaluated. The objective of this study was to assess the safety of Del Nido cardioplegia in adult patients with low EF compared to intermittent warm blood cardioplegia.ResultsDuring 2018 and 2019, 73 adult patients with an EF of ≤ 40% underwent cardiac surgery using Del Nido cardioplegia. The patients were compared to a historical cohort of consecutive patients with low EF who had intermitted warm blood cardioplegia (n = 81). Patients who had Del Nido cardioplegia had significantly lower EuroSCORE II (2.73 (1.7–4.1) vs. 4.5 (2.4–7.4), P = 0.004). There were no differences in creatinine clearance and preoperative echocardiographic data between the groups. Cardiopulmonary bypass and cross-clamp times were non-significantly lower with Del Nido cardioplegia. There were no differences in stroke and postoperative echocardiographic data between the groups. No hospital mortality was reported in both groups. Peak troponin levels were significantly higher in patients who had Del Nido cardioplegia (0.88 (0.58–1.47) vs. 0.7 (0.44–1.01) ng/dL; P = 0.01); however, after multivariable regression analysis, cardiopulmonary bypass time was the only predictor of postoperative troponin level (coefficient 0.005 (95% CI: 0.003–0.008); P < 0.001). ICU stay was significantly longer in patients who had Del Nido cardioplegia (4 (3–6) vs. 2(1–4) days, P < 0.001), while postoperative hospital stay did not differ between the groups. After multivariable regression, the use of intermittent warm blood cardioplegia was significantly associated with shorter ICU stay (coefficient − 1.80 (95% CI − 3.06 – -0.55); P = 0.01).ConclusionsProlonged ICU was reported with Del Nido cardioplegia; however, there were no differences in the duration of hospital stay and the clinical outcomes between the groups. Despite the proven efficacy of intermittent warm blood cardioplegia, the use of Del Nido cardioplegia might be safe in patients with low EF.

Abstract 8909: High Hospital-Specific Postoperative Troponin Testing Intensity Was Associated With Improved Outcomes After Major Vascular Surgery

Background: Acute myocardial injury after non-cardiac surgery is associated with increased mortality and cardiovascular morbidity, but it is not known if systematic postoperative troponin testing will lead to improved patient outcomes. Methods: We defined a cohort of vascular surgery patients in Ontario, Canada from January 1, 2010 to December 31, 2017. Hospital-level troponin testing intensity (classified into tertiles) was determined by the proportion of patients that received postoperative troponin testing. Cox proportional hazards modeling was used to assess the association (expressed as hazard ratio [HR]) between hospital-specific testing intensity with 30-day and 1-year major adverse cardiovascular outcomes (MACE) while adjusting for patient-, surgery-, and hospital-level factors. MACE was defined as all-cause mortality, myocardial infarction, or coronary revascularization. Rates of postoperative consultations and new filled prescription medications (≥65y) were also assessed. Results: The cohort consisted of 18,467 patients. Mean age was 72y (SD9) and 74.0% were male. The proportion of patients that received postoperative troponin testing were 77.5%, 35.8%, and 21.6% in the high, medium, and low testing intensity groups, respectively. At 30-days, 5.3%, 5.3% and 6.5% of patients in high, medium, and low testing intensity group experienced MACE, respectively. Compared with low-testing intensity, high-testing intensity was associated with a lower hazard of 30-day MACE (HR 0.71; 95%CI 0.57-0.89) and at 1-year (HR 0.83; 95%CI 0.72-0.94; Figure 1). High testing intensity hospitals had higher rates of postoperative cardiology and internal medicine consults and higher rates of new prescription medications filled. Conclusion: Patients undergoing vascular surgery at hospitals with higher postoperative troponin testing intensity had better 30-day and 1-year outcomes than patients who had surgery at hospitals with lower testing intensity.

The Prognostic Role of Early Postoperative Troponin I in Lung Transplantation—A Retrospective 7-Year Analysis

Postoperative cardiac troponin I concentration is predictive of worsened outcomes in cardiac surgery. Lung transplantation (LT) surgery shares common features with cardiac surgery, but postoperative troponin has yet to be investigated. The authors aimed to evaluate the association between early postoperative troponin concentration and the 1-year mortality after transplantation. A retrospective, observational, single-center study. At a tertiary care, university hospital. Patients who underwent lung transplantation from January 2011 to December 2017 INTERVENTIONS: For each patient, preoperative, intraoperative, and postoperative data were collected, as well as the troponin I measurement at the moment of postoperative intensive care unit admission. Two hundred twenty LT procedures were analyzed. Troponin I was elevated in all LT patients, with a median of 3.82 ng/mL-1 (2-6.42) ng/mL-1 significantly higher in non-survivors than in survivors with 5.39 (2.88-7.44) v 3.50 ng/mL (1.74-5.76), p = 0.005. In the multivariate analysis, the authors found that only the Simplified Acute Physiology Score II score (hazard ratio [HR] 1.03; 95% confidence interval [CI] [1.001; 1.05]; p = 0.007) and the need to maintain extracorporeal life support at the end of surgery (HR 2.54; 95% CI [1.36; 4.73]; p = 0.003) were independently associated with the 1-year mortality. The multiple linear regression model found that troponin levels were associated with the need for extracorporeal life support (ECLS) (p = 0.014), the amount of transfused packed red blood cells (p = 0.008), and bilateral LT (p < 0.001). Early postoperative troponin serum levels were not independently associated with 1-year mortality. Early postoperative troponin I levels were correlated to bilateral LT, the need for ECLS, and intraoperative blood transfusion.

Usefulness of postoperative high-sensitive troponin T measurement and implications for defining type 5 infarction.

Background and aim of the studyGuidelines indicate for type 5 myocardial infarction (MI) that postoperative troponin need not be exclusively ischemic but may also be caused by epicardial injury. Complexity arises from the introduction of high‐sensitive troponin. This study attempts to contribute to the understanding of postoperative high‐sensitive cardiac troponin T (hs‐cTnT) increase.MethodsThe median enzyme increase of different cardiac operations was compared. Linear regression analyses were used to determine correlations between enzyme rise and independent parameters. Receiver‐operating characteristics (ROC) served to evaluate the discriminatory power of enzyme rise in detecting ischemia and to determine possible thresholds.ResultsAmong 400 patients, 2.8% had intervention‐related ischemia analogous to type 5 MI definition. The median postoperative hs‐cTnT/creatine kinase myocardial band (CK‐MB) increase varied according to types of surgery, with highest increase after mitral valve and lowest after off‐pump coronary surgery. After ruling out patients with preoperatively elevated hs‐cTnT, regression analysis confirmed Maze procedure (p < .001), intra‐pericardial defibrillation (p = .002), emergency intervention (p = .01), blood transfusions (p = .02), and cardiopulmonary bypass time (p = .03) as significant factors associated with hs‐cTnT increase. In addition, CK‐MB increase was associated with mortality (p = .002).ROC confirmed good discriminatory power for hs‐cTnT and CK‐MB with ischemia‐indicating thresholds of 1705.5 ng/L (hs‐cTnT) and 113 U/L (CK‐MB) considering different types of operations.ConclusionsThe Influence of the type of surgery and intervention‐related parameters on hs‐cTnT increase was confirmed. Potential thresholds indicating perioperative ischemia appear to be significantly elevated for high sensitive markers.

Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association.

Myocardial injury after noncardiac surgery is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay and are attributable to a presumed ischemic mechanism, with or without concomitant symptoms or signs. Myocardial injury after noncardiac surgery occurs in ≈20% of patients who have major inpatient surgery, and most are asymptomatic. Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction. Consequently, surveillance of myocardial injury after noncardiac surgery is warranted in patients at high risk for perioperative cardiovascular complications. This scientific statement provides diagnostic criteria and reviews the epidemiology, pathophysiology, and prognosis of myocardial injury after noncardiac surgery. This scientific statement also presents surveillance strategies and treatment approaches.

Myocardial injury after gynecologic oncology surgery in septuagenarians and octogenarians: Is there a role for routine postoperative cardiac biomarker monitoring?

220 Background: Accumulating evidence correlates myocardial injury after noncardiac surgery (MINS), even when asymptomatic, with increased cardiac and non-cardiac morbidity and mortality. There is no literature on MINS specific to Gynecologic Oncology. We sought to evaluate the incidence and risk factors of MINS in patients aged ≥70. Methods: Elective laparotomies between 01/2016-09/2020 for patients aged≥70 at a tertiary hospital in ON, Canada, were reviewed using prospectively-collected National Surgical Quality Improvement Program (NSQIP) data. MINS was defined as peak serum high-sensitivity troponin-T concentration ≥0.04ng/mL within 30 days postoperatively. Logistic regression analysis was performed. Results: In this cohort of 258 patients, of 242 (93.8%) who underwent postoperative troponin screening, 40 (16.5%) experienced MINS without exhibiting ischemic symptoms or ECG changes. The diagnosis of MINS led to a prescription or optimization of cardiovascular medications for 35 patients (87.5%). On univariate analysis, Revised Cardiac Risk Index (RCRI) of 3-5(p = 0.002), history of coronary artery disease (p = 0.003) or insulin-dependent diabetes (p = 0.006), preoperative use of antiplatelets (p = 0.009), beta-blockers (p = 0.02), ACE-inhibitors (ACEI) or angiotensin-receptor blockers (ARB)(p = 0.002) and frailty as defined by the NSQIP modified frailty index-5 (p = 0.02), were associated with greater risk of MINS. Factors reflecting surgical complexity including surgical complexity score, operative duration, blood loss and advanced oncologic stage were not predictive. Multivariable analysis using backward selection procedure identified elevated RCRI and preoperative ACE/ARB as significant risk factors (OR 5.93, 95% CI 1.52-24.31, p = 0.01 and OR 2.4, 95% CI 1.18-5.06, p = 0.02). Conclusions: One in 6 patients in our cohort experienced asymptomatic MINS irrespective of surgical complexity. Our analysis highlights a possible opportunity to optimize cardiac risk factors and to potentially improve perioperative patient safety by reducing morbidity. Routine preoperative cardiac risk-stratification and postoperative cardiac biomarkers monitoring should be considered in elderly patients with gynecologic malignancies.[Table: see text]

Asymptomatic Troponin Leak After Major Vascular Reconstruction With Routine Postoperative Troponin Testing is Associated With Increased Short- and Long-term Mortality

Elevated troponin (Tn) values after major vascular surgical reconstruction (VSR) have been previously shown to correlate with significantly higher postoperative and short-term mortality. We evaluated the long-term outcomes in these patients.

The Charlson Comorbidity Index is associated with risk of 30-day mortality in patients with myocardial injury after non-cardiac surgery

Myocardial injury after non-cardiac surgery (MINS) is a well-known and relevant indicator of early postoperative mortality, but factors related to increased mortality in MINS patients are as yet unknown. The Charlson Comorbidity Index (CCI) is widely used to classify various comorbid conditions and underlying diseases. Our study aimed to determine the prognostic value of CCI with regard to mortality of patients with MINS. This study comprises 5633 patients who had MINS as diagnosed by a rise of postoperative cardiac troponin I above the normal range (≥ 0.04 ng/mL) from January 2010 to June 2019. Patients were divided into two groups according to median weighted CCI score: low CCI (≤ 2) and high CCI (> 2) groups. The primary outcome was 30-day mortality after surgery, and secondary outcomes were 1-year and overall mortalities. Of the 5633 patients, 3428 (60.9%) were in the low CCI group (1.21 ± 0.84) and 2205 (39.1%) were in the high CCI group (4.17 ± 1.82). After propensity score matching, mortality during the first 30 days after surgery was significantly greater in the high CCI group than the low CCI group (9.4% vs. 6.0%, respectively; hazard ratio 1.56, 95% confidence interval 1.23–1.98, p < 0.001). A high CCI score was associated with increased 30-day mortality in patients with MINS, suggesting that the CCI may need to be considered when predicting outcomes of MINS patients.

Association of Perioperative Myocardial Injury with 30-Day and Long-Term Mortality in Older Adult Patients Undergoing Orthopedic Surgery in China.

BackgroundMyocardial injury after noncardiac surgery (MINS) is common and associated with postoperative mortality. We assessed MINS occurrence and association with 30-day and long-term mortality in older adult patients undergoing orthopedic surgery in China.Material/MethodsThis was a retrospective study of consecutive patients who underwent orthopedic surgery between January 1, 2009, and December 31, 2017, at Beijing Jishuitan Hospital. MINS was defined as postoperative troponin I peak elevation above the 99th percentile upper reference limit (>0.034 μg/L) within 30 days after surgery. Outcomes were 30-day postoperative mortality and long-term all-cause mortality.ResultsFrom 34 901 patients, 5897 (16.9%) had serial troponin I measurements, and 266 (4.5%) had MINS after surgery. Mean patient age was 71.1±9.2 years; 32.9% were male. Among patients with MINS, 180 had myocardial infarction (MI) (3.2%). Patients with MI had higher 30-day and long-term mortality than those without MI (8.9% vs 1.2%; P<0.016 and 18.9% vs 3.5%; P=0.001). Male sex (OR 5.87, 95% CI 1.75–19.67; P=0.004), RCRI ≥2 (OR 5.05, 95% CI 1.67–15.31; P=0.004), and MI (OR 9.13, 95% CI 1.13–73.63; P=0.011) were independently associated with 30-day mortality. Age (HR 1.07, 95% CI 1.03–1.11; P=0.001), male sex (HR 2.96, 95% CI 1.51–5.80; P=0.002), RCRI ≥2 (HR 2.01, 95% CI 1.03–3.94; P=0.041), orthopedic trauma (HR 3.40, 95% CI 1.00–11.44; P=0.049), and MI (HR 7.33, 95% CI 2.22–24.20; P=0.001) were predictors of 2-year mortality.ConclusionsPerioperative MI was independently associated with 30-day and long-term mortality after orthopedic surgery, providing a potential indicator of high risk of mortality in patients who could benefit from targeted prevention and intervention.

The predictive value of high-sensitive troponin I for perioperative risk in patients undergoing gastrointestinal tumor surgery.

BackgroundThe incidence of cardiovascular events in perioperative period of gastrointestinal tumor surgery cannot be ignored, and studies have shown that level of postoperative troponin is related to the postoperative risk of non-cardiac surgery. However, the relationship between pre-operative troponin levels and perioperative risk of gastrointestinal tumor surgery is unclear. Thus, we aimed to evaluate the value of high-sensitive cardiac troponin I (hs-cTnI) prior to gastrointestinal tumor surgery for perioperative risk assessment.MethodsIn this retrospective cohort study, 1259 patients who underwent gastrointestinal tumor surgery and had been tested for hs-cTnI on admission within 7 days prior to surgery were retrospectively recruited from January 2018 to June 2020. The primary combined endpoint including in-hospital all-cause mortality, acute myocardial infarction, cardiac arrest or ventricular fibrillation and acute decompensated heart failure. The secondary endpoint included total hospital stay and requirement of intensive care treatment.FindingsCompared with patients with normal hs-cTnI, those with elevated hs-cTnI (> 0·028 ng/ml) were more likely to experience the combined endpoint (28·2% versus 2·7%, P < 0·001) and there was also an increasing rate of in mortality in elevated hs-cTnI group (2·4% versus 0·3%, P = 0·057). The length of total hospital stay was significantly longer in patients with elevated hs-cTnI (24·8 ± 16·3 versus 19·5 ± 7·9, P = 0·003) and the number of patients requiring intensive care treatment was also higher (22·6% versus 4·2%, P < 0·001). The area under the ROC curve assessing hs-cTnI in predicting in-hospital mortality was 0·787 [95% confidence interval (CI) 0·612–0·963, P = 0·015] and for combined endpoint was 0·822 [95% CI 0·766–0·879, P < 0·001]. Hs-cTnI > 0·028 ng/ml was associated with significantly higher cardiovascular event rate in patients with the revised cardiac index ≤ 1. The positive likelihood ratio of hs-cTnI (> 0·028 ng/ml) for predicting combined endpoint reaches 10.5 in patients with Lee index = 0. In multivariate logistic analyses, hs-cTnI was one of the best predictors for the combined endpoint [odds ratio (OR) 5·924 (95%CI: 2·869–12·233), P < 0·001].InterpretationHs-cTnI provides powerful prognostic information for patients undergoing gastrointestinal tumor surgery, and therefore provides reliable prognostic information incremental to revised cardiac index.

Association between tissue oxygenation and myocardial injury in patients undergoing major spine surgery: a prospective cohort study

ObjectiveTo describe the association between intraoperative tissue oxygenation and postoperative troponin elevation in patients undergoing major spine surgery. We hypothesised that a decrease in intraoperative skeletal muscle tissue oxygenation (SmO2)...

Del Nido cardioplegia in adult cardiac surgery: analysis of myocardial protection and post-operative high-sensitivity Troponin T.

del Nido cardioplegia has been adopted for use in adult cardiac surgery, despite a lack of robust randomised evidence supporting equivalence or superiority to conventional hyperkalaemic blood cardioplegia. We investigated the clinical surrogates of myocardial protection, and performed an extensive analysis of post-operative high-sensitivity Troponin T (hs-TnT) values in a general adult cardiac surgery population receiving del Nido, in comparison to a historical hyperkalaemic blood cohort. 171 consecutive patients of a single surgeon from between November 2018 and June 2020 received del Nido, and were compared to a historical cohort of 326 patients between January 2016 and November 2018 who received hyperkalaemic blood cardioplegia. Clinical markers of myocardial protection were compared, as were hs-TnT values at 6, 12, 24, and 72-h post-operatively. Equivalence between groups was determined using the two one-sided tests procedure. There was no difference between the groups in the incidence of post-operative low cardiac output state, inotropic support, or myocardial infarction. Del Nido patients had less defibrillation requirement, and more spontaneous resumption of normal sinus rhythm. High-sensitivity Troponin T values were similar at all time-points including in a coronary artery bypass graft subgroup, and in those patients with elevated pre-operative hs-TnT. In a broad cohort of adult cardiac surgery patients, including those undergoing coronary artery bypass surgery and those with recent myocardial infarction, del Nido provides equivalent myocardial protection and clinical outcomes when compared to hyperkalemic blood cardioplegia. Post-operative high-sensitivity Troponin T values were also equivalent between the groups.

Patient Selection for Routine Troponin Monitoring After Noncardiac Surgery.

BackgroundMyocardial infarction is an important complication after noncardiac surgery. Therefore, perioperative troponin surveillance is recommended for patients at risk. The aim of this study was to identify patients at high risk of perioperative myocardial infarction (POMI), in order to aid appropriate selection and to omit redundant laboratory measurements in patients at low risk.Methods and ResultsThis observational cohort study included patients ≥60 years of age who underwent intermediate to high risk noncardiac surgery. Routine postoperative troponin I monitoring was performed. The primary outcome was POMI. Classification and regression tree analysis was used to identify patient groups with varying risks of POMI. In each subgroup, the number needed to screen to identify 1 patient with POMI was calculated. POMI occurred in 216 (4%) patients and other myocardial injury in 842 (15%) of the 5590 included patients. Classification and regression tree analysis divided patients into 14 subgroups in which the risk of POMI ranged from 1.7% to 42%. Using a risk of POMI ≥2% to select patients for routine troponin I monitoring, this monitoring would be advocated in patients ≥60 years of age undergoing emergency surgery, or those undergoing elective surgery with a Revised Cardiac Risk Index class >2 (ie >1 risk factor). The number needed to screen to detect a patient with POMI would be 14 (95% CI 14–14) and 26% of patients with POMI would be missed.ConclusionsTo improve selection of high‐risk patients ≥60 years of age, routine postoperative troponin I monitoring could be considered in patients undergoing emergency surgery, or in patients undergoing elective surgery classified as having a revised cardiac risk index class >2.