[Perioperative myocardial damage in non-cardiac surgery patients]

[Diagnosis and Management of Perioperative Myocardial Ischemia after Elective Aortic Aneurysm Surgery]

INTRODUCTION

Perioperative myocardial ischemia (PMI) is a serious postoperative complication. Aortic operations represent an especially high-risk surgery concerning cardiac complications. This aim of this study was to analyse the clinical features of PMI after elective aortic aneurysm surgery.

PATIENTS AND METHODS

This study is a retrospective analysis of 863 patients who underwent elective aortic aneurysm surgery between 2005 and 2012 in the Department of Vascular and Endovascular Surgery of Heidelberg University Hospital with regard to PMI. The PMI diagnosis was based on a positive serum troponin diagnostic test. We evaluated the clinical course, time point of the diagnosis and features of diagnostics to characterise PMI. Moreover, we analysed the treatment options and management of the patients' discharge.

RESULTS

Thirty-one patients (3.6% of 863) with PMI after elective aortic aneurysm surgery were identified. Of these, 21 patients (67.7%) underwent open surgery and 10 patients (32.3%) received endovascular treatment. PMI was diagnosed in 24 patients (77%) during the first 3 days. More than half of these patients (16/31) were clinically asymptomatic. Electrocardiogram did not show pathological findings in 24 cases (77.4%). The first troponin measurement was not elevated in eight patients (25.8%). Drug therapy alone was used in 17 cases (54.8%) of PMI, coronary catheterisation was performed in 12 patients (38.7%) and two patients (6.5%) received aortocoronary bypass. Fourteen patients (45.1%) were discharged home and another 14 patients (44.1%) were transferred to another hospital or to a rehabilitation institution. Two patients died because of multi-organ failure.

CONCLUSION

PMI is not a rare complication after elective aortic surgery. The diagnosis of PMI can be challenging because of occult symptoms especially in a perioperative setting. Due to the potentially serious consequences, cardiac enzyme diagnostics should be initiated immediately if there is suspicion of PMI or routinely in defined at-risk patients after aortic surgery.

Clinical impact of perioperative myocardial infarction after pancreatic surgery

BACKGROUND

The aim of this study was to evaluate the incidence, clinical impact and outcome of perioperative myocardial infarction (PMI) in patients undergoing pancreatic surgery.

METHODS

A data of 1,625 patients undergoing pancreatic resection were prospectively collected and analysed with regard to PMI. Demographic aspects, co-morbidities and clinical course were evaluated. Cardiac risk factors (ASA and NYHA), postoperative complications and mortality were compared in a match-pair analysis (1:3) with patients without PMI.

RESULTS

Twenty-nine patients with PMI after pancreatic surgery were identified. PMI occurred after all types of pancreatic operations and was observed most frequently (72.2%) within the first postoperative week. In a total of 90%, PMI fulfilled the criteria of non-STEMI. Nearly half of the patients (48%) were clinically asymptomatic. Both ASA III and heart failure were more frequent in patients with PMI. The in-hospital mortality was significantly increased after PMI (p < 0.002), with post-pancreatectomy haemorrhage (PPH) as the most relevant underlying risk factor.

CONCLUSION

PMI is a rare but severe complication after pancreatic operations, contributing significantly to in-hospital mortality. Clinical management mainly includes an anti-coagulant approach. This may be related with an increased risk for PPH. Therefore, the use of anti-coagulant drugs in the early postoperative period-especially in asymptomatic patients-should be critically evaluated.

[Cardiac biomarkers in perioperative medicine : significance for noncardiac surgery patients]

Perioperative detection of cardiac biomarkers may help to identify patients at risk. Whether detection of these markers will be recommended in the preoperative setting for patients with cardiac diseases in the future has to be discussed as large prospective trials on this topic are missing. For preoperative evaluation of cardiac insufficiency quantification of brain natriuretic peptide (BNP) and amino-terminal pro-brain natriuretic peptide (NT-proBNP) are useful markers. Troponin is the marker of choice for detection of myocardial ischemia/infarction in the postoperative setting. In unstable patients coronary angiography and/or percutaneous coronary intervention (PCI) are indicated. However, in stable patients the decision for coronary angiography and/or PCI has to be made in each patient individually after interdisciplinary discussion between anesthesiologists, cardiologists and surgeons.