Setting Of Non-cardiac Surgery Research Articles

The relative merits of using a high-sensitivity cardiac Troponin T assay compared to a nonhigh-sensitivity troponin T assay after noncardiac surgery

Troponin elevation after noncardiac surgery is associated with an elevated risk of 30-day mortality. Little is known about relative merit of using a high-sensitivity Troponin T (hsTnT), the fifth-generation assay, vs the nonhigh sensitivity Troponin T (non-hsTnT), the fourth-generation assay, in the noncardiac surgery setting. We aimed to identify whether hsTnT can identify additional patients at risk that would have gone undetected with non-hsTnT measurement. The VISION Study included 40,004 noncardiac surgery patients with postoperative troponin measurements. Among them, 1,806 patients had both fourth-generation non-hsTnT and fifth-generation hsTnT concomitant measurements (4,451 paired results). We compared the absolute concentrations, the timing, and the impact of different thresholds on predicting 30-day major cardiovascular complications (composite of death, nonfatal cardiac arrest, coronary revascularization, and congestive heart failure). Based on the manufacturers' threshold of 14 ng/L, 580 (32.1%) patients had postoperative hsTnT concentrations greater than the threshold, while their non-hsTnT concentrations were below the manufacturer's threshold. These 580 patients had higher risk of major cardiovascular events (OR 2.33; CI 95% 1.04-5.23; P = .049) than patients with hsTnT concentrations below the manufacturer threshold. Among patients with myocardial injury after noncardiac surgery, only 50% would be detected by the fourth-generation non-hsTnT assay at 6 to 12 hours postoperative as compared to 85% with the fifth-generation hsTnT assay (P-value < .001). Within the first 3 postoperative days, fifth-generation hsTnT identified at least 1 in 3 patients with troponin elevation that would have gone undetected by fourth-generation non-hsTnT using published thresholds in this setting. Furthermore, fifth-generation hsTnT identified patients with an elevation earlier than fourth-generation non-hsTnT, indicating potential to improve postoperative risk stratification.

Assessment and Management of Ischaemic Heart Disease in Non-Cardiac Surgery.

In the setting of non-cardiac surgery, cardiac complications contribute to over a third of perioperative deaths. With over 230 million major surgeries performed annually, and an increasing prevalence of cardiovascular risk factors and ischaemic heart disease, the incidence of perioperative myocardial infarction is also rising. The recent European Society of Cardiology guidelines on cardiovascular risk in noncardiac surgery elevated practices aiming to identify those at most risk, including biomarker monitoring and stress testing. However the current evidence base on if, and how, the risk of cardiac events can be modified is lacking. This review focuses on patient, surgical and cardiac risk assessment, as well as exploring the data on perioperative revascularization and other risk-reduction strategies.

Advances in Neuroimaging and Monitoring to Defend Cerebral Perfusion in Noncardiac Surgery.

Noncardiac surgery conveys a substantial risk of secondary organ dysfunction and injury. Neurocognitive dysfunction and covert stroke are emerging as major forms of perioperative organ dysfunction, but a better understanding of perioperative neurobiology is required to identify effective treatment strategies. The likelihood and severity of perioperative brain injury may be increased by intraoperative hemodynamic dysfunction, tissue hypoperfusion, and a failure to recognize complications early in their development. Advances in neuroimaging and monitoring techniques, including optical, sonographic, and magnetic resonance, have progressed beyond structural imaging and now enable noninvasive assessment of cerebral perfusion, vascular reserve, metabolism, and neurologic function at the bedside. Translation of these imaging methods into the perioperative setting has highlighted several potential avenues to optimize tissue perfusion and deliver neuroprotection. This review introduces the methods, metrics, and evidence underlying emerging optical and magnetic resonance neuroimaging methods and discusses their potential experimental and clinical utility in the setting of noncardiac surgery.

Incidence and prognosis of myocardial injury in patients with severe trauma

PurposeSevere trauma can lead to end organ damages of varying severity, including myocardial injury. In the non-cardiac surgery setting, there is extensive evidence that perioperative myocardial injury is associated with increased morbidity and mortality. The impact of myocardial injury on outcome after severe trauma has not been investigated adequately yet. We hypothesized that myocardial injury is associated with increased in-hospital mortality in patients with severe trauma.Materials/methodsThis retrospective cohort study included patients ≥ 18 years with severe trauma [defined as injury severity score (ISS) ≥ 16] that were admitted to the resuscitation room of the Emergency Department of the University Hospital Duesseldorf, Germany, between 2016 and 2019. The main endpoint was in-hospital mortality. Main exposure was myocardial injury at arrival [defined as high-sensitive troponin T (hsTnT) > 14 ng/l]. For statistical analysis, receiver operating characteristic curve (ROC) and multivariate binary logistic regression were performed.ResultsOut of 368 patients, 353 were included into statistical analysis (72.5% male, age: 55 ± 21, ISS: 28 ± 12). Overall in-hospital mortality was 26.1%. Myocardial injury at presentation was detected in 149 (42.2%) patients. In-hospital mortality of patients with and without myocardial injury at presentation was 45% versus 12.3%, respectively. The area under the curve (AUC) for hsTnT and mortality was 0.76 [95% confidence interval (CI) 0.71–0.82]. The adjusted odds ratio of myocardial injury for in-hospital mortality was 2.27 ([95%CI 1.16–4.45]; p = 0.017).ConclusionMyocardial injury after severe trauma is common and independently associated with in-hospital mortality. Thus, hsTnT might serve as a new prognostic marker in this cohort.

Predicting cardiac risk in noncardiac surgery: a narrative review.

Risk stratification endeavors to categorize patients into groups based on the level of risk for each group. Improved perioperative screening tests using more sensitive cardiac biomarkers have revealed that about 68% of perioperative myocardial infarctions (MI) are asymptomatic and may only be detected by routine postoperative screening with troponin measurements. This is important since myocardial injury not meeting criteria for myocardial infarction is associated with increased risk of 30-day mortality (Botto et al. in Anesthesiology 120:564-578, 2014). Traditional risk indices including the revised cardiac risk index (RCRI) and the myocardial infarction cardiac arrest (MICA) index were developed based on overt clinical signs of myocardial infarction and significantly underestimate adverse cardiac events. Recently, brain type natriuretic peptides (BNP) and its precursor n- terminal pro-brain type natriuretic peptide (nt-proBNP) have been shown to be powerful prognostic markers. Incorporating serum biomarkers into updated clinical risk indices is likely to improve their performance. Further studies are needed to determine appropriate clinical interventions to treat isolated elevations in cardiac troponin levels and further mitigate the increased risk of morbidity and mortality. The objective of this review is to summarize the current literature on the clinical diagnoses of perioperative myocardial injury in the setting of noncardiac surgery.

Perioperative management of antiplatelet therapy in noncardiac surgery.

Perioperative management of antiplatelet agents (APAs) in the setting of noncardiac surgery is a controversial topic of balancing bleeding versus thrombotic risks. Recent data do not support a clear association between continuation or discontinuation of APAs and rates of ischemic events, bleeding complications, and mortality up to 6 months after surgery. Clinical factors, such as indication and urgency of the operation, time since stent placement, invasiveness of the procedure, preoperative cardiac optimization, underlying functional status, as well as perioperative control of supply-demand mismatch and bleeding may be more responsible for adverse outcome than antiplatelet management. Perioperative management of antiplatelet therapy (APT) should be individually tailored based on consensus among the anesthesiologist, cardiologist, surgeon, and patient to minimize both ischemic/thrombotic and bleeding risks. Where possible, surgery should be delayed for a minimum of 1 month but ideally for 3-6 months from the index cardiac event. If bleeding risk is acceptable, dual APT (DAPT) should be continued perioperatively; otherwise P2Y12 inhibitor therapy should be discontinued for the minimum amount of time possible and aspirin monotherapy continued. If bleeding risk is prohibitive, both aspirin and P2Y12 inhibitor therapy should be interrupted and bridging therapy may be considered in patients with high thrombotic risk.

In Response

In Response We appreciate comments by Poelaert1 regarding our article titled “Is Compliance With Surgical Care Improvement Project Cardiac (SCIP-Card-2) Measures for Perioperative β-Blockers Associated With Reduced Incidence of Mortality and Cardiovascular-Related Critical Quality Indicators After Noncardiac Surgery?”2 Poelaert1 suggests that our findings show that “initiating beta-blockers in the preoperative setting of noncardiac surgery may increase the risk of cardiac failure.” Importantly, a limitation of our study was the inability to explore the potential effects of initiating β-blockers in the preoperative setting, and whether their initiation was associated with a higher risk for cardiac failure or all-cause mortality. To be precise, our retrospective finding was that, compared to continuation, “perioperative withdrawal of β-blockers was associated with increased risk for mortality within 48 hours after noncardiac surgery and with decreased risk for need of vasopressor during the early postoperative period and a shorter stay in postanesthesia care unit.” Indeed, we had no specific data regarding how many individuals among the 343,533 cases without β-blocker therapy before admission then received β-blocker therapy during the perioperative period. Hence, we restricted our Surgical Care Improvement Project Cardiac-2 definition of preoperative/perioperative β-blocker therapy, as well as analysis and conclusions, to the patient population receiving β-blocker therapy before admission. Poelaert1 also asserts that our study did not explore reasons for discontinuation of β-blocker therapy and, thus, is limited in terms of its findings and generalizability. In particular, he highlights the importance of considering type of β-blocker therapy when it comes to studying their effects on outcome after noncardiac surgery. In support of this statement, Poelaert1 claims that, due to their intrinsic sympathomimetic activity (ISA), continuation of some earlier generation β-blockers such as metoprolol can be potentially beneficial in the perioperative setting, while preoperative discontinuation of third-generation β-blockers such as labetalol and carvedilol, which lack ISA and have α1-antagonistic effect, may reduce risk of adverse events and mortality. Indeed, we agree that when it comes to variation in β-blocker therapy and studying potential effects on perioperative outcomes, these differentiating pharmacokinetic (cytochrome P450 2D6-dependent metabolism) and pharmacodynamic (relative β1 receptor selectivity, β1/β2 receptor affinity, and ISA) properties should be taken into consideration.3 Unfortunately, given that β-blocker therapy was a binary variable in our data source, we could not ascertain the various β-blocker therapies, and whether this factor was associated with their discontinuation in the postoperative period. Nevertheless, in our study, >85% of cases had a history of hypertension, and >30% had a history of coronary artery disease. It is highly likely that the majority of these individuals received metoprolol therapy given the past and current recommendations of guidelines for β-blocker therapy4 and the cost-effective prescribing of β-blocker therapy in the United States.5 Therefore, we believe that it is reasonable to consider the observed relationship between β-blocker withdrawal and mortality and cardiovascular-related critical quality indicators in our study as potentially related to withdrawal of metoprolol therapy. Of note, metoprolol does not have ISA, but, as previously acknowledged, its pharmacokinetic and pharmacodynamic properties may significantly influence its efficacy and safety relative to perioperative cardiovascular morbidity and mortality.3 Finally, Poelaert1 highlights the lack of information on type of surgery in our study. As clarification, we detailed extensively on the type of surgery relative to factors relevant to the study focus, including classifying risk of surgery type according to Revised Cardiac Risk Index suggested by Lee et al6 and modified by Kristensen et al.7 As described in the study, we used this composite risk index in our statistical modeling, both to account for surgical and patient characteristics while avoiding overfitting due to the limited number of perioperative events and to enable assessment of interaction between demographic and clinical risk factors (including type of surgery) and patterns of β-blocker use relative to all-cause mortality and cardiovascular complications. We thank Poelaert1 for his interesting comments, and while beyond the scope of our study, we agree that further research is warranted to explore how differences among types of β-blocker therapy, the de novo initiation of perioperative β-blocker therapy, and withdrawal or continuation of other cardiovascular medications are associated with mortality and cardiovascular-related risk indicators in noncardiac surgery patient cohorts. Miklos D. Kertai, MD, PhDDivision of Cardiothoracic AnesthesiologyDepartment of AnesthesiologyVanderbilt University Medical CenterNashville, Tennessee[email protected] Mary Cooter, MScDivision of Cardiothoracic Anesthesiology and Critical Care MedicineDepartment of AnesthesiologyDuke University Medical CenterDurham, North Carolina Richard J. Pollard, MDDepartment of Anesthesia Critical Care and Pain ManagementBeth Israel Deaconess Medical CenterHarvard Medical SchoolBoston, Massachusetts Mark Stafford-Smith, MD, FRCPCDivision of Cardiothoracic Anesthesiology and Critical Care MedicineDepartment of AnesthesiologyDuke University Medical CenterDurham, North Carolina

Design and rationale of the atrial fibrillation occurring transiently with stress (AFOTS) follow-up cohort study.

Atrial fibrillation occurring transiently with stress (AFOTS) describes the first detection of AF in a patient who is hospitalized for a non-cardiac medical illness or following non-cardiac surgery. Uncertainty exists whether episodes of AFOTS are due to reversible precipitants and will not recur after recovery, or if they are paroxysmal atrial fibrillation (AF) that is detected during inpatient cardiac monitoring. Previous studies have used retrospective, non-systematic and ultimately low-sensitivity protocols to investigate the recurrence of AF in patients with AFOTS. The prospective, multi-center, investigator-initiated AFOTS Follow-Up Cohort Study will enroll 138 case patients with AFOTS in the setting of non-cardiac surgery or medical illness, matched 1:1 with control patients for age, sex, stressor, and hospital unit. Participants will wear a 14-day ECG heart monitor at 1 and 6 months after hospital discharge. Over 12 months of follow-up, we will collect data regarding participant's medications, and clinical events. The primary endpoint is detection of 30 or more seconds of AF after hospital discharge. To date, 50% of the target sample has been enrolled. The study is expected to complete enrolment in mid-2019 and conclude 1 year later. The AFOTS follow-up study will employ a systematic protocol to detect AF and will provide a precise and valid estimate of AF recurrence following AFOTS. This study will establish whether patients with AFOTS have an increased propensity to AF after hospitalization as compared to matched controls and may inform the management of this population.

ACEI and ARB continuation in the setting of noncardiac surgery

ACEI and ARB continuation in the setting of noncardiac surgery

An HIV-positive status and short term perioperative mortality – a systematic review

Background: A contemporary summary describing the impact of an HIV-positive status on short term perioperative mortality is lacking.Objective: To collate and summarise published data related to short term perioperative mortality from studies comparing HIVpositive and HIV-negative patient groups.Method: We conducted a systematic review of the published literature by performing structured searches of two medical literature databases. Pre-defined inclusion/exclusion criteria were used to identify potentially relevant manuscripts. Further screening of the reference lists of eligible manuscripts, as well as a prior systematic review was also performed to identify any additional manuscripts that may have been relevant. Data retrieved from eligible manuscripts included, amongst other variables: study and population descriptions, surgical category (cardiac or noncardiac surgery), as well the incidence of short term perioperative mortality. Crude odds ratios were calculated for each eligible manuscript to describe the association between HIV status and short term perioperative mortality.Results: Our systematic review consisted of 12 manuscripts describing 12 studies. The majority of manuscripts described studies conducted in countries with a low burden of HIV infection. Most manuscripts described findings from a noncardiac surgery setting. Crude associations between an HIV-positive status and a higher odds of short term perioperative mortality were noted for data from 2 of the 12 manuscripts, while the association was unclear in the remaining 10 manuscripts. Conclusion: Evidence supporting a higher odds of short term perioperative mortality in patients with an HIV-positive status is unconvincing. Further research is required to adequately investigate this.

Effect of restrictive versus liberal transfusion strategies on outcomes in patients with cardiovascular disease in a non-cardiac surgery setting: systematic review and meta-analysis

Objective To compare patient outcomes of restrictive versus liberal blood transfusion strategies in patients with cardiovascular disease not undergoing cardiac surgery. Design Systematic review and meta-analysis. Data sources Randomised controlled...

Abstract 134: Postoperative Atrial Fibrillation and the Short-term Risk of Ischemic Stroke

Introduction: We have recently shown an association between new-onset postoperative atrial fibrillation (AF) and the long-term risk of ischemic stroke after noncardiac surgery. However, the degree of stroke risk with AF in the postoperative setting remains unclear. Hypothesis: New-onset postoperative AF is associated with an increased risk of ischemic stroke in the 30 days after surgery. Methods: Administrative claims data from all discharges at nonfederal acute care hospitals in California, New York, and Florida were used to identify patients who underwent inpatient surgery in 2007-2012. Our predictor variable was new-onset AF, defined using validated ICD-9-CM diagnosis and present-on-admission codes. Patients with prior stroke or AF were excluded. The outcome was postoperative stroke, defined as ischemic stroke occurring within 30 days of surgery. Cox proportional hazards analysis was used to examine the association between postoperative AF and stroke while adjusting for demographics and vascular risk factors. In sensitivity analyses, we limited the outcome to stroke occurring after discharge but within 30 days of surgery. Cardiac and noncardiac surgeries were analyzed separately. Results: Among 7,139,472 patients with inpatient surgery, 102,831 (1.44%) developed postoperative AF and 17,117 (0.24%) developed a postoperative stroke. After noncardiac surgery, the 30-day cumulative risk of stroke was significantly higher in those with postoperative AF (2.07%) than those without AF (0.18%). This difference was significant after adjustment for demographics and potential confounders (hazard ratio [HR], 4.3; 95% CI, 4.1-4.6). After cardiac surgery, postoperative AF was also associated with an increased cumulative risk of stroke (2.27%) compared to those without AF (1.17%), but the strength of association (HR, 1.8; 95% CI, 1.6-1.9) was less marked than in the setting of noncardiac surgery ( P value for interaction &lt;0.001). Postoperative AF was associated with stroke occurring after discharge and within 30 days of noncardiac surgery (HR, 1.9; 95% CI, 1.6-2.3), but not cardiac surgery (HR, 1.1; 95% CI, 0.9-1.3). Conclusions: Postoperative AF is associated with an increased short-term risk of stroke after noncardiac surgery.

The Preoperative Patient With a Systolic Murmur.

Context:Patients with undifferentiated systolic murmurs present commonly during the perioperative period. Traditional bedside assessment and auscultation has not changed significantly in almost 200 years and relies on interpreting indirect acoustic events as a means of evaluating underlying cardiac pathology. This is notoriously inaccurate, even in expert cardiology hands, since many different valvular and cardiac diseases present with a similar auditory signal.Evidence Acquisition:The data on systolic murmurs, physical examination, perioperative valvular disease in the setting of non-cardiac surgery is reviewed.Results:Significant valvular heart disease increases perioperative risk in major non-cardiac surgery and increases long term patient morbidity and mortality. We propose a more modern approach to physical examination that incorporates the use of focused echocardiography to allow direct visualization of cardiac structure and function. This improves the diagnostic accuracy of clinical assessment, allows rational planning of surgery and anaesthesia technique, risk stratification, postoperative monitoring and appropriate referral to physicians and cardiologists.Conclusions:With a thorough preoperative assessment incorporating focused echocardiography, anaesthetists are in the unique position to enhance their role as perioperative physicians and influence short and long term outcomes of their patients.

Acute Kidney Injury After Major Surgery: A Retrospective Analysis of Veterans Health Administration Data.

Few trials of acute kidney injury (AKI) prevention after surgery have been conducted, and most observational studies focus on AKI following cardiac surgery. The frequency of, risk factors for, and outcomes after AKI following other types of major surgery have not been well characterized and may present additional opportunities for trials in AKI. Observational cohort study. 3.6 million US veterans followed up from 2004 to 2011 for the receipt of major surgery (cardiac; general; ear, nose, and throat; thoracic; vascular; urologic; and orthopedic) and postoperative outcomes. Demographics, health characteristics, and type of surgery. Postoperative AKI defined by the KDIGO creatinine criteria, postoperative length of stay, end-stage renal disease, and mortality. Postoperative AKI occurred in 11.8% of the 161,185 major surgery hospitalizations (stage 1, 76%; stage 2, 15%, stage 3 [without dialysis], 7%; and AKI requiring dialysis, 2%). Cardiac surgery had the highest postoperative AKI risk (relative risk [RR], 1.22; 95% CI, 1.17-1.27), followed by general (reference), thoracic (RR, 0.92; 95% CI, 0.87-0.98), orthopedic (RR, 0.70; 95% CI, 0.67-0.73), vascular (RR, 0.68; 95% CI, 0.64-0.71), urologic (RR, 0.65; 95% CI, 0.61-0.69), and ear, nose, and throat (RR, 0.32; 95% CI, 0.28-0.37) surgery. Risk factors for postoperative AKI included older age, African American race, hypertension, diabetes mellitus, and, for estimated glomerular filtration rate< 90mL/min/1.73m(2), lower estimated glomerular filtration rate. Participants with postoperative AKI had longer lengths of stay (15.8 vs 8.6 days) and higher rates of 30-day hospital readmission (21% vs 13%), 1-year end-stage renal disease (0.94% vs 0.05%), and mortality (19% vs 8%), with similar associations by type of surgery and more severe stage of AKI relating to poorer outcomes. Urine output was not available to classify AKI; cohort included mostly men. AKI was common after major surgery, with similar risk factor and outcome associations across surgery type. These results can inform the design of clinical trials in postoperative AKI to the noncardiac surgery setting.

Clinical significance of non-vitamin K antagonist oral anticoagulants in the management of atrial fibrillation.

Atrial fibrillation (AF) is the most commonly observed rhythm disorder in clinical practice. It is associated with a high risk of thromboembolic stroke and increased cardiovascular mortality. Vitamin K antagonists (VKAs), the only oral anticoagulants used for thromboembolic prophylaxis in AF patients over the past 60 years, have been effective in reducing thromboembolic stroke, compared with placebo and aspirin, in this group of patients. However, VKAs have a very narrow therapeutic window, so regular monitoring of the therapeutic effect is obligatory for their use. The need for regular assessment of blood anticoagulation often causes dissatisfaction and reduces patients' quality of life. Non-VKA oral anticoagulants (NOACs), such as dabigatran, a direct thrombin inhibitor, and 3 factor Xa inhibitors, namely rivaroxaban, apixaban, and edoxaban, have been developed in recent years and have increased the armamentarium available to the physician for thromboprophylaxis in non-valvular AF (NVAF) patients. This review describes the characteristics of NOACs, analyzing aspects related to their use in the thromboprophylaxis of NVAF patients. It also discusses how to optimize NOAC therapy in specific clinical conditions, such as renal or liver impairment, and concomitant assumption of drugs potentially interfering with NOACs action. Finally, it focuses on NOAC-related bleeding management in the setting of non-cardiac surgery or radiofrequency catheter ablation of NVAF.

The Need for Large Clinical Studies in Perioperative Medicine

The Need for Large Clinical Studies in Perioperative Medicine

Case report: acute coronary artery spasm in a patient in the setting of non-cardiac surgery

Case report: acute coronary artery spasm in a patient in the setting of non-cardiac surgery

A randomised controlled pilot trial to evaluate and optimize the use of anti-platelet agents in the perioperative management in patients undergoing general and abdominal surgery—the APAP trial (ISRCTN45810007)

Surgeons are increasingly confronted by patients on long-term low-dose acetylsalicylic acid (ASA). However, owing to a lack of evidence-based data, a widely accepted consensus on the perioperative management of these patients in the setting of non-cardiac surgery has not yet been reached. Primary objective was to evaluate the safety of continuous versus discontinuous use of ASA in the perioperative period in elective general or abdominal surgery. Fifty-two patients undergoing elective cholecystectomy, inguinal hernia repair or colonic/colorectal surgery were recruited to this pilot study. According to cardiological evaluation, non-high-risk patients who were on long-term treatment with low-dose ASA were eligible for inclusion. Patients were allocated randomly to continuous use of ASA or discontinuation of ASA intake for 5days before until 5days after surgery. The primary outcome was the incidence of major haemorrhagic and thromboembolic complications within 30days after surgery. A total of 26 patients were allocated to each study group. One patient (3.8%) in the ASA continuation group required re-operation due to post-operative haemorrhage. In neither study group, further bleeding complications occurred. No clinically apparent thromboembolic events were reported in the ASA continuation and the ASA discontinuation group. Furthermore, there were no significant differences between both study groups in the secondary endpoints. Perioperative intake of ASA does not seem to influence the incidence of severe bleeding in non-high-risk patients undergoing elective general or abdominal surgery. Further, adequately powered trials are required to confirm the findings of this study.

Severe Pulmonary Hypertension and Right Ventricular Failure Complicate a Total Abdominal Hysterectomy

The 2007 American College of Cardiology/American Heart Association guidelines report that no significant studies have been conducted assessing the perioperative risk of pulmonary hypertension in noncardiac surgery. However, the presence of right ventricular failure has been well documented to have poor prognostic implications. The presence of pulmonary hypertension and right ventricular failure present unique perioperative challenges. These include maintenance of adequate cardiac function, acid-base management, intraoperative monitoring, and postoperative pain management. The authors report the case of a patient with severe pulmonary hypertension who underwent an open total abdominal hysterectomy. The case was complicated by known right ventricular failure, severe portal hypertension, obstructive sleep apnea, extensive smoking history, and systemic anticoagulation therapy. The patient was not a candidate for postoperative neuraxial analgesia because of the timing and dose of systemic anticoagulation. Two-dimensional transesophageal echocardiography was used for real-time visualization and intraoperative cardiac monitoring. The patient was transferred to the intensive care unit for careful titration of opioids and slow ventilator wean to extubation. The postoperative course proceeded without significant morbidity or mortality. (a) Preoperative assessment of pulmonary hypertension, (b) postoperative pain control, (c) cardiovascular stability, and (d) intraoperative monitoring. This case illustrates the unique challenges associated with pulmonary hypertension and right ventricular failure in the setting of noncardiac surgery. This case also demonstrates that continuous, real-time data provided by transesophageal echocardiography can be used to successfully manage a complicated patient with pulmonary hypertension.

Bare‐metal stent thrombosis after noncardiac surgery greater than 10 years after stent implantation

We present a case of bare-metal stent thrombosis (ST) in a saphenous vein graft (SVG) after antiplatelet therapy cessation occurring in the setting of noncardiac surgery (NCS) greater than 10 years after stent implantation. This report represents the longest interval of ST in the setting of NCS and the longest interval between stent implantation and ST in a SVG.