ACC/AHA task force report. Special report: guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)

Excellent results with calcineurin inhibitor-free initial immunosuppression in old recipients of old kidneys

The ever increasing demand for donor organs has forced transplant surgeons to liberalize selection criteria. To avoid initial nephrotoxicity to kidneys from donors over 65 years of age, immunosuppression was begun with an IL-2 receptor antibody, mycophenolate mofetil, and steroids in a total of 38 recipients over 65 years. Calcineurin inhibitors (CI) were added after sufficient graft function was reached. After a mean cold ischemia time of 14:01 hours and a delayed function rate of 31%, patient survival, graft survival, and serum creatinine were 97.4%, 94.7%, and 1.5 mg/dL at 1 and 92.1%, 92.1%, and 1.7 mg/dL at 2 years, respectively. Thus, excellent results can be achieved in old recipients of old donor kidneys with CI-free initial immunosuppression.

Incidence of coronary heart disease and cardiac events in patients undergoing kidney and pancreatic transplantation

One major cause of graft loss after kidney transplantation or simultaneous kidney and pancreas transplantation is death of the recipient due to cardiac events. Records of 261 patients who underwent sole kidney (group A) or combined kidney-pancreas transplantation (group B) were retrospectively analyzed. Patients were divided into groups with basic cardiac evaluation (chest X-ray, electrocardiogram) and patients with additional diagnostics [echocardiography, exercise stress test, myocardial perfusion test, and coronary angiography (CAG)]. The results of the performed CAGs were as follows: proven coronary artery disease (CAD) in 22 patients (12.43%) in group A and 37 patients (44.05%) in group B; stenosis of one main coronary artery of 70% or greater in 8.47% (group A) and 16.67% (group B) of the patients. Subsequent revascularization procedures were performed in 15 candidates (8.47%) of group A and 11 (13.10%) of group B. The incidence of posttransplant cardiac events (PCE) was lower in recipients in both groups who underwent additional cardiac evaluation. Late postoperative deaths were reported in 3.45% of kidney recipients with no additional evaluation (group A), in 2.06% of patients with further diagnostics (group A), and in only 1.19% of patients with invasive pretransplant evaluation (group B). Patients with known CAD and no further invasive diagnostics or subsequent revascularization are at great risk. PCE were observed in three of seven patients in this subgroup. Careful cardiac evaluation including echocardiography, exercise stress test, myocardial perfusion test, and CAG is associated with a low incidence of PCE.

[Preoperative evaluation and perioperative management of patients with increased cardiovascular risk]

Due to the increasing age in western countries, combined with high rates of major surgical interventions in high-risk patients, perioperative reduction of cardiovascular complications becomes increasingly more important for perioperative physicians. After identifying patients with increased perioperative risk, specific interventions need to be considered to reduce their risk for cardiovascular complications, either by perioperative medical therapy or specific treatment options (e.g. coronary intervention). Several trials have demonstrated an effect of perioperative beta-blocker-therapy in reducing cardiovascular complications among high-risk patients. Additionally, several monitoring techniques are effective in detecting cardiovascular complications. Nevertheless, it remains unclear whether they are associated with a measurable improvement of outcome. Based on the ACC/AHA-guidelines, the present review describes a stepwise approach to surgical patients to identify perioperative risks, based on specific patient related risk factors, the kind of surgery and on the specific setting (emergency versus elective surgery). In addition, strategies to reduce perioperative cardiovascular complications are discussed.

Surgical treatment of colon and rectal cancer

There are many indications for surgical intervention in the current treatment of cancer of the colon and rectum. The hallmark of surgical therapy remains en bloc resection of the primary tumor, accompanied by removal of the mesenteric lymph nodes. Surgical resection is also the principal and most successful treatment for local recurrences and isolated metastases. Although the application of minimally invasive techniques is growing in all aspects of surgery and is accepted in the treatment of benign lesions of the colon, laparoscopic resection for colorectal cancer cannot be recommended apart from randomized, controlled trials. Similarly, the role of sentinel lymph node biopsy in the surgical treatment of colorectal cancer remains to be defined. Various surgical modalities have been developed for the treatment of unresectable colorectal cancer metastatic to the liver. Further studies should help to elucidate the exact role of these therapies in the treatment of this common clinical problem. In summary, surgical treatment plays an important role in multiple aspects of the care of the patient with colorectal cancer.

Phaeochromocytoma and acute myocardial infarction

Phaeochromocytoma is uncommonly associated with myocardial infarction. We present a patient who, despite established alpha adrenoceptor blockade, sustained an acute myocardial infarction and was found to have coronary artery disease. Indications for coronary revascularization were not met, and adrenalectomy was successfully performed four weeks later. Factors contributing to the myocardial infarction, the role of beta adrenoceptor blockade, the timing of adrenalectomy and the place of coronary revascularization are discussed.

Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. CASS Investigators and University of Michigan Heart Care Program. Coronary Artery Surgery Study

BACKGROUND

The influence of prior coronary artery bypass surgery (CABG) versus medical therapy for reducing the risk of postoperative cardiac complications after noncardiac surgery continues to be debated. To further clarify this controversy we studied 24,959 participants in the Coronary Artery Surgery Study (CASS) database with suspected coronary disease by identifying those who required noncardiac surgery during more than 10 years of follow-up.

METHODS AND RESULTS

CASS registry enrollees were either treated with CABG or medical therapy after initial entry. During follow-up, patients who required noncardiac operations were evaluated for hospital death or out-of-hospital death within 30 days of noncardiac surgery and nonfatal postoperative myocardial infarction (MI). At a mean follow-up of 4.1 years, 3368 patients underwent noncardiac surgery, with abdominal (36%), urologic (21%), orthopedic (15%), and vascular being most common. Abdominal, vascular, thoracic, and head and neck surgery each had a combined MI/death rate among patients with nonrevascularized coronary disease >4%. Among 1961 patients undergoing higher-risk surgery, prior CABG was associated with fewer postoperative deaths (1.7% versus 3.3%, P=.03) and MIs (0.8% versus 2.7%, P=.002) compared with medically managed coronary disease. Contrariwise, 1297 patients undergoing urologic, orthopedic, breast, and skin operations had mortality of <1% regardless of prior coronary treatment. Prior CABG was most protective in patients with advanced angina and/or multivessel coronary artery disease.

CONCLUSIONS

In patients with known coronary artery disease, noncardiac surgeries involving the thorax, abdomen, vasculature, and head and neck are associated with the highest cardiac risk, which is reduced among patients with prior CABG.