Preoperative Cardiac Risk Factors Research Articles

Preoperative cardiac risk factors associated with in-hospital mortality in elderly patients without heart failure undergoing hip fracture surgery: a single-centre study

IntroductionIn the present study, our aim was to ascertain the preoperative cardiac risk factors related to the in-hospital mortality in the elderly patients (aged over 65 years) who required preoperative...

The Effect of Left Ventricular Assist Devices (LVAD) on Pulmonary Hypertension: A Single Center Review

Purpose Recently published case series have demonstrated that long-term LVAD support may reverse pulmonary hypertension in end-stage heart failure. This study's purpose was to review our local experience through right-heart catheterization follow-up of LVAD patients. Methods Patients were identified through the local VAD coordinator and our perioperative surgical database. Pre- and peri-operative data were captured from our database while catheterization data were gathered from electronic records. Pulmonary hypertension was defined as having a pre-implant mean pulmonary artery (PA) pressure >25 mmHg. Hemodynamics were captured from 1 year prior to LVAD insertion to loss of follow-up or death. A population-averaged panel-data model using generalized estimating equation (GEE) was used to determine the effects of pre-operative variables on longitudinal pulmonary hemodynamics . Results From 2004 to 2018, 95 patients underwent LVAD implantation at our institution. Hemodynamics were available on 72 of these patients, of which 52 had pre-operative pulmonary hypertension. Average follow-up was 697±574 days. Mean PA pressures over time are represented in Figure 1. Most had normalization of their PA pressures following LVAD implantation and this process occurred within the first year in the majority of patients. Following GEE model fitting, no pre-operative variables appeared to affect post-operative PA pressures significantly, including whether the patient was diagnosed with pulmonary hypertension prior to LVAD implantation. Cardiac risk factors as well as pre-operative ejection fraction also did not appear to significantly affect changes in post-operative PA pressures. Conclusion In this single-center retrospective analysis, LVAD implantation appeared to lower pulmonary artery pressures in patients with end-stage heart failure. The development of pre-operative pulmonary hypertension and other cardiac risk factors did not appear to significantly affect this process.

Impact of Cardiac Risk Factors on Complications Following Cranial Vault Remodeling: Analysis of the 2012 to 2016 National Safety Quality Improvement Program-Pediatric Database.

Congenital cardiac malformations have been reported in 8% of patients with craniosynostosis undergoing cranial vault remodeling (CVR), but associations with surgical outcomes are unknown. This study evaluated postoperative complications in patients who underwent CVR for craniosynostosis with or without cardiac risk factors (CRF) using the National Safety Quality Improvement Program-Pediatric (NSQIP-P) database. NSQIP-P database was queried for patients <2 years with craniosynostosis who underwent CVR from 2012 to 2016 based on diagnosis and procedure codes. The primary outcome was a composite of available NSQIP-P complications. Analysis compared patients with craniosynostosis based on the presence or absence of CRF. Univariate and multiple logistic regression identified risk factors associated with postoperative complications. A total of 3293 patients met inclusion criteria (8% with CRF). Two-thirds of patients experienced at least 1 complication, though patients with CRF experienced a greater proportion (74% vs 66%, P = 0.001). Univariate analysis identified associations between post-operative complications and age, ASA class, supplemental oxygen, neuromuscular disorders, preoperative nutritional supplementation, interventricular hemorrhage, and CRF. On multivariate regression, only older age (OR 1.17, 95% CI 1.01-1.36) and longer operative duration (OR 1.01, 95% CI 1.01-1.01) were associated with greater odds of postoperative complications. The most common complication in patients with craniosynostosis who undergo CVR is bleeding requiring transfusion. Older age and longer operative duration were associated with postoperative complications. Although patients with CRF have more postoperative complications, CRF was not a risk factor on adjusted analysis.

Increased complications in pediatric surgery are associated with comorbidities and not with Down syndrome itself

BackgroundDown syndrome (DS) is a genetic condition associated with multiple comorbidities. While physicians may perceive that DS patients have more postoperative complications, the literature remains unclear. This study compared postoperative complications for children with and without DS who underwent abdominal and thoracic procedures. MethodsThe National Surgical Quality Improvement Program Pediatric was queried for patients aged <18 years, who underwent abdominal and noncardiac thoracic operations (by Current Procedural Terminology codes) from 2012 to 2015. The analysis compared patients based on the presence or absence of DS. The primary outcome was a composite of all postoperative complications as defined by the National Surgical Quality Improvement Program Pediatric. The analysis utilized chi-square, Student's t-test, and univariate and multiple logistic regression. ResultsThere were 91,478 patients included, of which 1476 (1.6%) had a diagnosis of DS. Patients with DS had higher rates of preoperative nutritional support (38.8% versus 15.0%), developmental delay (61.9% versus 10.4%), and cardiac risk factors (76.5% versus 13.8%). The overall rate of postoperative complications was 11.1%, with a greater proportion in DS patients (16.2% versus 10.8%, P < 0.001). On univariate analysis, DS was associated with increased odds of postoperative complications (odds ratio 1.6 95% confidence interval 1.4-1.9) compared with the non-DS group; however, DS was not a risk factor after adjusting for other covariates (adjusted odds ratio 0.86 95% confidence interval 0.7-1.1). ConclusionsA higher proportion of postoperative complications were observed in patients with DS. However, after adjusting for other risk factors, DS was not an independent risk factor. The increased rate of complications is likely related to the presence of multiple comorbidities in DS.

The Incidence of Perioperative Cardiac Events after Orthopedic Surgery: A Single Institutional Experience of Cases Performed over One Year

BackgroundOrthopedic patients with ischemic heart disease are at risk for postoperative cardiac complications.Questions/PurposesUsing information from two medical information retrieval systems which insured the capture of all events for the period of study, our goals were to determine the incidence of myocardial injury in at-risk patients after orthopedic surgery and to delineate the type and incidence of cardiac complications in this population.MethodsFor one year, at an orthopedic hospital, we identified all postoperative patients with a measured cTnI level using an electronic ordering system. Preoperative cardiac risk factors and postoperative cardiac complications were identified in patients undergoing a total hip arthroplasty (THA), total knee arthroplasty (TKA), and posterior spinal fusion (PSF). A postoperative myocardial infarction was defined by a cTnI > 0.1 ng/mL, ECG changes, new echocardiographic regional wall motion abnormalities, and evaluation by a cardiologist. Categorical variables were compared among groups with a Fisher’s exact or Chi-square test. Continuous variables were compared among groups with ANOVA or the Kruskal-Wallis test. The associations of cardiac risk factors with myocardial injury are expressed as odds ratios from logistic regression models.ResultsDuring a one-year period, from 10,627 inpatient orthopedic procedures, 805 patients were identified as at risk for postoperative myocardial ischemia. A total of 20.6% (166/805) of these patients had elevated serum cTnI levels (cTnI > 0.02 ng/mL), and there were ten documented postoperative MIs (10/805; 1.2%). For the at-risk TKA, THA, or PSF patients, 19% (102/532) had elevated cTnI levels and 31% (32/102) had postoperative cardiac complications, including arrhythmias (56%), congestive heart failure (2%), and MI (1%). Adjusting for sex, age, BMI, cardiac risk factors, and medications (statins and β-blockers), PSF patients had 3.9 times the risk of myocardial injury (p = 0.003) compared to TKA patients and 4.2 times that of THA patients.ConclusionsThe incidence of postoperative myocardial ischemia after major orthopedic surgery in patients with cardiac risk factors is high (8.7%), but the incidence of documented myocardial infarctions and serious cardiac complications remains low (1.2–2%). Patients with higher postoperative cTnI releases were more likely to have cardiac complications, and some procedures (spinal fusions) placed the patients at a higher risk.

Preoperative Cardiac Risk Assessment in Patients Undergoing Liver Transplant Due to Hepatocellular Carcinoma: Should It Be Different?

Liver transplant is a high-risk surgery for cardiac events. The risk of 30-day major cardiac adverse events is estimated at more than 5%. In this retrospective study, we evaluated our preoperative cardiac risk assessment approach. We evaluated 58 adult patients who underwent liver transplant between May 2011 and May 2015. Preoperative cardiac risk factors and results of diagnostic tests were noted. Patients were divided into 2 groups: patients with or without hepatocellular carcinoma. Electrocardiogram, echocardiogram, and treadmill tests were performed for preoperative cardiac evaluation in all candidates for liver transplant. Results of these tests showed our preference for myocardial perfusion scintigraphy and/or coronary angiography and heart catheterization. Mean age of patients was 46.5 ± 14.5 years. The most common cardiovascular risk factor was family history of coronary artery disease (24.1%) in all patients. Diabetes mellitus (15.5%) was the most common risk factor in the patient group without hepatocellular carcinoma. Three patients had already known coronary artery disease (5.2%). Of 16 patients (27.6%) who underwent coronary angiography, 4 were in the hepatocellular carcinoma group. Coronary revascularization by stent implantation was necessary for 1 patient in the hepatocellular carcinoma group; 1 patient in the group without hepatocellular carcinoma underwent preoperative coronary bypass surgery. No consensus exists for cardiovascular risk stratification and preoperative cardiovascular evaluation of liver transplant candidates. Noninvasive stress tests are not always feasible for all liver transplant candidates because of poor mobility and poor exercise capacity. With early diagnoses of cardiovascular conditions and preventive recommendations, liver transplant can be performed safely before spread of the disease, which is essential for carcinoma patients. Angiographic evaluation of liver transplant candidates for hepatocellular carcinoma is strongly recommended.

Burden of preoperative cardiovascular disease risk factors on breast cancer surgery outcomes.

Cardiovascular comorbidities have been studied sporadically in breast cancer surgery. No study has provided a comprehensive assessment of the severity and relative influence of preoperative cardiac risk factors on surgical outcomes. 78,338 breast cancer surgery patients were identified from the 2006 to 2012 National Surgical Quality Improvement Program (NSQIP) database. We estimated the impact of chronic conditions (diabetes, hypertension, obesity, smoking), acute cardiac events (myocardial infarction, congestive heart disease, angina), and past cardiac procedures (cardiac surgery, percutaneous coronary intervention) on 30-day postoperative complications, reoperation, and readmission. Nearly 65% of patients had chronic conditions, <1% had acute events, and 3% had past procedures. The prevalence of outcomes was low: 5% had complications, 4% underwent reoperation, and 4% were readmitted. Over 65% of complications were wound-related. All risk factor categories were associated with complications (ORs from 1.26 to 4.18). Acute events had the strongest effect on overall (OR 3.54, CI 2.55-4.91) and medical (OR 4.18, CI 2.73-6.41) complications. Chronic conditions and past procedures also predicted reoperation and readmission (ORs from 1.57 to 2.68). The odds of all outcomes increased with the number of chronic conditions (ptrend < 0.001). Cardiovascular disease has a significant impact on outcomes even in minimal-risk breast cancer surgery. J. Surg. Oncol. 2016;114:144-149. © 2016 Wiley Periodicals, Inc.

A meta-analysis of intraoperative factors associated with postoperative cardiac complications

Background: Preoperative cardiac risk is commonly determined with the help of risk scores and risk stratification tools. This predetermined cardiac risk may be profoundly changed by intraoperative surgical events. This meta-analysis aimed to identify intraoperative factors that independently predict postoperative cardiac complications in the presence of preoperative cardiac risk factors. Method: A PubMed Central search was conducted from January 1966 to June 2010, to identify independent intraoperative predictors of postoperative cardiac complications in observational perioperative studies and randomised controlled trials which controlled for preoperative cardiac risk factors. Results: Eleven studies were identified for inclusion in this meta-analysis. Intraoperative blood transfusion [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.8-3.4] was the only independent intraoperative risk predictor identified in more than one study. Other identified independent intraoperative factors included a > 20 mmHg fall in mean arterial blood pressure for > 60 minutes (OR 3.0, 95% CI 1.8-4.9), > 30% increase in baseline systolic pressure (OR 8.0, 95% CI 1.3-50), tachycardia in the recovery room (> 30 beats per minute from baseline for > 5 minutes) (OR 7, 95% 1.9-26), new onset atrial fibrillation (OR 6.6, 95% CI 2.5-20), hypothermia (OR 2.2, 95% CI 1.1-5) and remote ischaemic preconditioning (OR 0.22, 95% CI 0.070.67). None of these studies controlled for blood transfusion. Conclusion: Both surgical and haemodynamic intraoperative events significantly increased the risk of postoperative cardiac complications. Intraoperative blood transfusion has the strongest evidence that supports this finding. It is possible that modification of these intraoperative risk factors by anaesthetists and surgeons might reduce postoperative cardiac events.

Early readmission for congestive heart failure predicts late mortality after cardiac surgery

Early readmission in patients hospitalized for medical congestive heart failure is common, expensive, and associated with a worse late survival. Our objective was to compare late survival in patients' readmission for congestive heart failure with readmission for other causes in patients undergoing cardiac surgery. Of 3654 consecutive patients undergoing cardiac surgery at a single institution between April 2004 and June 2010, 3492 (96%) were discharged from the hospital before 30 days and analyzed. Survival curves by readmission reason were compared using the log-rank test. Multivariable analyses adjusted for patient demographics, known preoperative cardiac risk factors, and surgical characteristics. The readmission rate at 30 days was 13% (465/3492): 23% for arrhythmias/heart block, 12% for congestive heart failure, 40% for surgery related causes, 14% for infection, and 11% for noncardiac causes. Independent risk factors for readmission include age, gender, congestive heart failure, and cardiopulmonary bypass time. Eight percent (268/3492) of discharged patients died within the 6-year study: 14% in the readmission group versus 7% in the nonreadmission group (P < .01). Patients who had been readmitted for congestive heart failure had worse late survivals compared with all patients who had been readmitted for causes related to their surgery. Readmission within 30 days after cardiac surgery for congestive heart failure predicts late mortality. Targeted postoperative management may be warranted in patients with surgical congestive heart failure.

Perioperative statin therapy reduces mortality in normolipidemic patients undergoing cardiac surgery

Statins might have pleiotropic effects, independent of their ability to reduce lipid levels. Recent data have suggested that statins improve early survival and cardiovascular outcomes after coronary artery bypass graft surgery. The effectiveness of statin therapy in normolipidemic cardiac surgery patients is as yet unclear. We evaluated 3056 consecutive patients who had undergone cardiac surgery between April 2004 and April 2009. Perioperative statin therapy was defined as continued treatment both before (≥ 6 months) and after the index surgery (included as a discharge medication). Hyperlipidemia (HL) was defined as a total cholesterol level greater than 200 mg/dL within 6 months before surgery. Four groups were analyzed: (1) statin-untreated normolipidemic (NL-, n=1052); (2) statin-treated normolipidemic (NL+, n=206); (3) statin-untreated hyperlipidemic (HL-, n=638); and (4) statin-treated hyperlipidemic (HL+, n=1160) patients. Adjusted hazard ratios accounted for the known preoperative cardiac risk factors. Mortality was ascertained by retrospective database review and the Social Security Death Index. The mean follow-up was 2.2 years. The crude rate of 30-day mortality was 3.0% (32/1052), 0% (0/206), 8.0% (51/638), and 0.7% (8/1160) for the NL-, NL+, HL-, and HL+ groups, respectively. The overall all-cause crude mortality rate was 9.6% (101/1052), 3.9% (8/206), 17.2% (110/638), and 6.5% (75/1160) for the NL-, NL+, HL-, and HL+ groups, respectively. Statin therapy for NL patients undergoing cardiac surgery independently reduced the overall all-cause mortality (adjusted hazard ratio, 0.34; 95% confidence interval, 0.16-0.71; P=.004). Perioperative statin therapy was associated with reduced mid-term mortality for patients undergoing cardiac surgery, irrespective of their baseline lipid status. This clinical evidence suggests that the beneficial effects of statins might extend beyond their lipid-lowering ability.

SS33. Sudden Death During Follow-up After New-onset Ventricular Tachycardia's in Vascular Surgery Patients

Vascular surgery patients are at increased risk for late sudden cardiac death. Identification of patients at risk during surgery offers the opportunity for focused therapy. We monitored 483 vascular surgery patients, without a history of cardiac arrhythmias, to identify perioperative new-onset ventricular tachyarrhythmia's (VT) using a continuous electrocardiographic device for 72 hours. Preoperative cardiac risk factors, left ventricular function, medical therapy, inflammation status, and perioperative ischemia were noted in all. New-onset perioperative VT, defined as sustained VT, was detected in 33 (7%) patients. Patients with perioperative VT had a significantly worse left ventricular function (p = 0.04), were undertreated with statins (p = 0.02), however their inflammation status did not differ (p = 0.18). Patients with VT had a higher incidence of myocardial ischemia, compared to patients without VT (30% vs 18%, p = 0.10). VT was preceded by ischemia in 74%. During a median follow-up of 2.0 years (IQR 1.1-3.1), cardiac death occurred in 56 patients, in 48 (86%) classified as sudden death. In patients with VT 27% died; 78% were due to sudden cardiac death. After adjusting for risk factors, new-onset perioperative VT was associated with sudden cardiac death (HR 2.3; 95% CI 1.2-5.7, figure). Late sudden cardiac death is associated with perioperative VT. Cardiac high-risk patients with perioperative VT might constitute a population that could benefit from preemptive ICD implantation, on top of optimal medical therapy.

Clostridium Difficile in Cardiac Surgery: Risk Factors and Impact on Postoperative Outcome

Clostridium difficile-associated diarrhea (CDAD) is a potentially preventable and often troublesome gastrointestinal complication after cardiac surgery. A retrospective study was performed of 8,405 cardiac surgery patients at two institutions between January 1997 and August 2004. Preoperative cardiac risk factors, perioperative factors including blood product transfusion, antibiotic utilization, and postoperative morbidity and mortality were recorded. Univariate and multivariate analyses were performed comparing C. difficile patients with a control group matched by date of surgery and institution. Sixty-six of the 8,405 patients identified with toxin-positive CDAD produced an overall incidence of 0.79% (0.70% at institution A and 1.09% at institution B), with a peak overall incidence of 5.45% in June 2003. Independent prognostic factors for CDAD by multivariate analysis included advancing age (odds ratio [OR] 1.028, 95% confidence interval [CI]: 1.001 to 1.056; p = 0.034), female sex (OR 2.026, 95% CI: 1.102 to 3.722; p = 0.022), blood product transfusion (OR 3.277, 95% CI: 1.292 to 8.311; p = 0.006), and increasing cumulative days of antibiotic administration (OR 1.046, 95% CI: 1.014 to 1.080; p = 0.004). There were no differences in the proportion of fluoroquinolones, cephalosporins, or penicillin derivatives administered between groups. The diagnosis of CDAD was associated with a greater median length of mechanical ventilation (25 hours versus 12 hours, p < 0.001), longer intensive care unit stay (5 days versus 2 days, p < 0.001), and extended hospital stay (21 days versus 7 days, p < 0.001), with no difference in 30-day mortality (7.6% versus 9.5%, p = 0.80). Although the overall incidence of CDAD was low, alteration in transfusion practices and antibiotic utilization may impact the development of CDAD among cardiac surgical patients.

Factors Affecting Long-term Mortality After Endovascular Repair of Abdominal Aortic Aneurysms

Endovascular repair of abdominal aortic aneurysms has made considerable advancements with respect to perioperative mortality. However, fewer data are available regarding factors affecting long-term mortality, including the impact of adverse perioperative cardiac events. Perioperative clinical cardiac risk factors are significant predictors of long-term mortality. Retrospective review of a prospective database of 468 patients who underwent endovascular abdominal aortic aneurysm repair from June 3, 1996, to January 31, 2005. Preoperative, intraoperative, and postoperative factors were analyzed using multivariate Cox proportional hazards models to identify statistically significant independent predictors of long-term survival (beyond 30 days and after discharge from the hospital). The mean age was 74 years, and 90% of the patients were male. Median follow-up was 2.57 years (interquartile range, 0.92-4.06 years). The leading cause of death was cardiac in nature. On multivariate analysis, the number of preoperative clinical cardiac risk factors (P < .001), spending 2 or more days in the intensive care unit (P < .001), and having an ST-segment elevation myocardial infarction (P < .001) were predictors of decreased long-term survival. Of note, having a perioperative non-ST-segment elevation myocardial infarction was not predictive of decreased survival (P = .09). Adverse cardiac events are the leading cause of long-term mortality following endovascular repair of abdominal aortic aneurysms. Preoperative clinical cardiac risk factors are significant predictors of long-term mortality, as are a prolonged intensive care unit stay and a perioperative ST-segment elevation myocardial infarction. A perioperative non-ST-segment elevation myocardial infarction did not influence long-term outcome.

Elevated plasma levels of troponin I in surgical patients: analysis of risk factors and outcomes

A retrospective study of the application of troponin I assays in postoperative patients admitted to the intensive care and high dependency units in a busy district hospital was performed. Preoperative patient demographics and cardiac risk factors, prior medical history and type and urgency of surgery were correlated with the results of troponin assays: only patient gender was significantly associated, with more females having elevated serum troponin I. Outcomes were worse when troponin I was raised, with a significantly higher mortality and trend to more organ systems failed. The study was limited by small size (47 patients) and non-standardisation of the timing of troponin assay after admission. A larger prospective study needs to be performed with assays at agreed time or trigger points. The patient cohort was derived from admissions to the ICU or high dependency units (HDU) in a busy district general hospital during a 9-month period from January to September 2003. Data were collected retrospectively from the biochemistry laboratory database in order to identify those patients whose troponin I levels were assayed during this period. Serum troponin I was measured in 61 patients in the ICU or HDU setting. Of these, 14 were medical patients with myocardial infarction and were excluded from the study. The other 47 patients were surgical and they form the cohort for this study. Patients whose serum troponin was measured comprised 31 males and 16 females. Their mean age was 74 years (range 49–93, standard deviation [SD] 10 years). Among the 47 patients in whom a suspicion of myocardial dysfunction had precipitated the laboratory test, 36 had abnormally high serum levels of troponin I (troponin I > 0.05 units in our laboratory). In none of these cases had there been any demonstration of myocardial infarction on electrocardiography nor echocardiography. The remaining 11 patients were classified as having normal troponin I levels and no biochemical evidence of myocardial injury. All the patients in the normal troponin group were male, but the other cohort comprised 16 females and 20 males. This was a significant difference in sex distribution (P = 0.006, chi-squared test) (Table ​(Table11). Table 1 Analysing the outcomes of patients with raised troponin levels compared with those with normal values (summarised in Table ​Table2),2), the presence of an elevated serum troponin I was associated with a shorter duration of stay although this did not reach statistical significance (P = 0.12, unpaired t test). This contrasts with their having more organ failure as already defined: cases with abnormal serum troponin I levels had a mean of 2.0 organ systems fail during their stay in ICU/HDU, compared with 1.5 organ systems in the normal troponin I group. However, the apparent difference between the groups in numbers of organs failed did not achieve significance (P = 0.35, t test). Table 2 Among those with normal troponin tests, two of 11 patients died. This was a lower proportion than in the group with elevated serum troponin levels, in whom 13 of 36 patients died. This was statistically a highly significant difference (P < 0.001, chi-squared analysis).

Emergency and elective coronary artery bypass grafting: comparisons of risk profiles, postoperative outcomes, and resource requirements

Objective: To investigate the association between preoperative risk factors and postoperative outcomes in emergency and elective coronary artery bypass graft (CABG) patients and to quantify resource requirements. Design: Retrospective database review. Setting: New York State SPARCS database. Participants: Data from 4,001 emergency and 7,489 elective CABG patients were evaluated retrospectively. Interventions: Data were compared between groups using chi-squares, t tests, and logistic regression analysis. Measurements and Main Results: Preoperatively, 47.1% of patients in the emergency group had unstable angina and 34.1% had acute myocardial infarction compared with 33.9% and 15.2% in the elective group, respectively ( p < 0.0001). There were no marked differences in the preoperative noncardiac risk factors between groups. The mortality rate was 4.7% in the emergency group and 2.6% in the elective group ( p < 0.0001). The emergency group had more postoperative cardiac complications (18.3% v 8.3%, p < 0.0001). The length of hospital stay in the emergency group was 17.5 ± 15.8 days (median 14 days) compared with 12.9 ± 15.1 days (median 9 days) in the elective group ( p < 0.00001). Total hospital charges in the emergency and elective groups were $46,700 ± $42,400 (median $35,600) and $34,800 ± 36,400 (median $26,500) ( p < 0.00001), respectively. The median total cost was $26,300 for emergency and $19,600 for elective group ( p < 0.00001). Conclusion: Patients undergoing emergency CABG had greater postoperative morbidity and mortality, longer LOS, and higher total costs than patients undergoing elective surgery. This difference is predictable on the basis of preoperative cardiac risk factors. Emergency operations have a major impact on the rates of morbidity, mortality, and use of resources.

Endovascular abdominal aortic aneurysm repair with general versus local anesthesia: a comparison of cardiopulmonary morbidity and mortality rates.

The purpose of this study was to compare the cardiopulmonary morbidity and mortality rates after endovascular abdominal aortic aneurysm (EAAA) repair with local anesthesia (LA) with intravenous sedation versus general anesthesia (GA). Data from patients who underwent elective infrarenal EAAA repair between June 1996 and October 2000 were retrospectively reviewed. Patients with two or more Eagle clinical cardiac risk factors were considered to be at increased risk for a major postoperative cardiac event. Univariate and multivariate analyses for major cardiac and pulmonary morbidity and mortality rates were analyzed with respect to anesthetic type (GA versus LA), age, size of aneurysm, mean number of Eagle risk factors, and presence of two or more cardiac risk factors. Two hundred twenty-nine patients underwent EAAA repair. The GA (158 patients) and LA (71 patients) groups were significantly different with respect to mean age (73 versus 76 years; P =.01) and mean number of cardiac risk factors per patient (1.2 versus 1.6; P =.002). No difference was seen in the overall cardiopulmonary complication rate (13% for GA and 19% for LA; P =.3), pulmonary complication rate (3.8% for GA and 7% for LA; P =.3), or cardiopulmonary mortality rate (3.2% for GA and 2.8% for LA; P =.9). The major cardiac event rate was higher in patients with two or more Eagle risk factors (22%) versus those patients with one or less Eagle risk factors (3.4%; P <.001), irrespective of anesthetic type. In analysis of patients with one or less Eagle risk factors, no difference was seen in the major cardiac event rate by anesthetic type (3% for GA and 5% for LA; P =.6). Also, no difference was seen in major cardiac events in patients with two or more Eagle risk factors by anesthetic type (24% for GA and 22% for LA). On multivariate analysis, the mean number of Eagle risk factors per patient (P <.0001) and the presence of two or more Eagle risk factors were associated with major cardiac and cardiopulmonary complications, whereas age, size of AAA, and anesthetic type were not. No difference exists in overall cardiac and pulmonary morbidity and mortality rates after EAAA repair in comparison of GA and LA. The presence of two or more preoperative cardiac risk factors significantly increases the risk of a major postoperative cardiac event.

Relationship between cardiac troponin I (cTnI) release during cardiac operations and myocardial cell death

The awareness of the diagnostic difficulty and the documented high mortality risk of perioperative myocardial infarction (PMI) has led to the wide use of work up to rule out PMI after major noncardiac operations. This has caused stable postoperative patients to be kept in monitored hospital beds for extended periods of time and to be subjected to additional tests. We hypothesized that the mortality of PMI is high and, therefore, the wide use of postoperative work up to identify these patients is justifiable. We performed the following study to prove our hypothesis. All patients in the recovery room after major noncardiac operations who underwent work up to rule out PMI were identified and followed. The PMI work up included care in an electronically monitored unit, physical assessment, continuous ECG monitoring, and three 12lead electrocardiograms and cardiac enzymes obtained at six to eight hour intervals. Data collection included patient demographics; preoperative cardiac risk factors; incidence of intraoperative hypotension, hemorrhage and ECG changes; type of anesthesia and operative procedures and their durations; postoperative ECG and cardiac enzyme results; the incidence of PMI and patient outcome. Two hundred patients were studied; 85 males and 115 females. Their mean age was 62.9 years. Preexisting conditions included hypertension in 162 patients, peripheral arterial disease in 102, diabetes mellitus in 97, angina in 30, previous myocardial infarction in 41, and smoking in 107. Of 200 patients, 164 had an abnormal preoperative ECG. Vascular operations were performed in 104 patients, nonvascular abdominal operations in 48, and other operations in the remaining 48. Intraoperatively, hypotension occurred in 29 patients, blood loss of >500 ml in 25 and ECG changes in 10. There were no deaths. PMI occurred in 5/200 (2.5%) patients. Four had undergone vascular operations and one had had an abdominal operation. The mean age of the patients with PMI was 64.2 years. The duration of operation and blood loss were similar to those of patients without PMI. None of these patients developed cardiac failure or cardiogenic shock and none of them died.

Peri‐operative silent myocardial ischaemia in patients undergoing lower limb joint replacement surgery: an indicator of postoperative morbidity or mortality?

One hundred and twenty-seven patients undergoing major lower limb joint replacement surgery were studied to determine the incidence of silent myocardial ischemia and to ascertain any link between pre-operative cardiac risk factors, silent myocardial ischaemia and postoperative morbidity. Patients underwent ambulatory ECG monitoring for 4 days (on the pre-operative night and for 3 days postoperatively). Postoperative cardiorespiratory symptomatology and morbidity was assessed by questionnaire at 3 months. Eighty-seven patients had risk factors for silent myocardial ischaemia; 42 patients (30 with risk factors) had peri-operative silent myocardial ischaemia. The median ischaemic loads (range) were 1.04 (0.32-13.31) min.h-1 pre-operatively and 5.53 (0.26-56.39), 6.69 (0.04-42.71) and 1.23 (0.1-53.74) min.h-1 on postoperative days 1-3, respectively. Risk factors did not predict the occurrence of silent myocardial ischaemia or an increased ischaemic load pre-operatively or overall postoperatively. New symptoms (chest pain, palpitations, breathlessness or fatigue) were associated with both silent myocardial ischaemia and ischaemic load (p < 0.05). Thus cardiac risk factors do not predict the occurrence of silent myocardial ischaemia or adverse outcome. Peri-operative silent myocardial ischaemia was associated with increased postoperative fatigue.

Carotid Endarterectomy Under Local Anesthesia: The Safer Alternative?

Carotid endarterectomy can be successfully accomplished using either local or general anesthesia. The purpose of this study was to attempt to discern any differences in perioperative morbidity associated with the two anesthetic tech niques. A retrospective review was undertaken of 324 consecutive carotid en darterectomies performed by fifteen surgeons between 1979 and 1985. There were no significant differences in preoperative cardiac, pulmonary, or renal risk factors between the two anesthetic groups. Postoperative fever (p &lt; 0.005), pulmonary complications (p &lt; 0.05), and neurologic morbidity (p &lt; 0.05) oc curred significantly more frequently in the general anesthesia group. The dura tion of postoperative hospitalization was shorter (p &lt; 0.0005) in the local anes thetic cohort (3.1 ± 2.3 days) than in the general anesthetic group (5.1 ± 8.07 days). Local anesthesia for carotid endarterectomy appeared to result in less morbidity and shorter hospitalization when compared with general anesthesia. There did not appear to be any cerebral protective effect of general anesthesia during carotid endarterectomy.

Prophylactic carotid endarterectomy for asymptomatic bruit. A look at cardiac risk.

We assessed the influence of preoperative cardiac risk factors in 57 patients undergoing 70 prophylactic carotid endarterectomies (PCE) and found that: (1) 47 (83%) had at least one cardiac risk factor and (2) nine of 15 deaths occurring in the late follow-up period (40 to 120 months) were due to cardiac causes. Perioperatively, one patient sustained a mild stroke. Although the cumulative stroke-free occurrence rate was kept to less than 6% over the five-year period, cardiac morbidity and mortality greatly influenced the quality of life after PCE. Therefore, PCE is suggested only for patients who have minimal preoperative cardiac risk factors or for those patients whose cardiac risk factors can be improved by medical therapy.