Cardiac Complications in Patients Undergoing Major Noncardiac Surgery

Development and preliminary assessment of a machine learning model to predict myocardial infarction and cardiac arrest after major operations

INTRODUCTION

Accurate prediction of complications often informs shared decision-making. Derived over 10 years ago to enhance prediction of intra/post-operative myocardial infarction and cardiac arrest (MI/CA), the Gupta score has been criticized for unreliable calibration and inclusion of a wide spectrum of unrelated operations. In the present study, we developed a novel machine learning (ML) model to estimate perioperative risk of MI/CA and compared it to the Gupta score.

METHODS

Patients undergoing major operations were identified from the 2016-2020 ACS-NSQIP. The Gupta score was calculated for each patient, and a novel ML model was developed to predict MI/CA using ACS NSQIP-provided data fields as covariates. Discrimination (C-statistic) and calibration (Brier score) of the ML model were compared to the existing Gupta score within the entire cohort and across operative subgroups.

RESULTS

Of 2,473,487 patients included for analysis, 25,177 (1.0%) experienced MI/CA (55.2% MI, 39.1% CA, 5.6% MI and CA). The ML model, which was fit using a randomly selected training cohort, exhibited higher discrimination within the testing dataset compared to the Gupta score (C-statistic 0.84 vs 0.80, p < 0.001). Furthermore, the ML model had significantly better calibration in the entire cohort (Brier score 0.0097 vs 0.0100). Model performance was markedly improved among patients undergoing thoracic, aortic, peripheral vascular and foregut surgery.

CONCLUSIONS

The present ML model outperformed the Gupta score in the prognostication of MI/CA across a heterogenous range of operations. Given the growing integration of ML into healthcare, such models may be readily incorporated into clinical practice and guide benchmarking efforts.

Impact of postoperative cardiovascular complications on 30-day mortality after major abdominal surgery: an international prospective cohort study

Cardiovascular complications after major surgery are associated with increases in morbidity and mortality. There is confusion over definitions of cardiac injury or complications, and variability in the assessment and management of patients. This international prospective cohort study aimed to define the incidence and timing of these complications and to investigate their impact on 30-day all-cause mortality. We performed a prospective, international cohort study between January 2022 and May 2022. Data were collected on consecutive patients undergoing major abdominal surgery in 446 hospitals from 28 countries across Europe. The primary outcome measure was cardiovascular complications as defined by the Standardised Endpoints for Perioperative Medicine-Core Outcome Measures for Perioperative and Anaesthetic Care initiative up to 30 days after surgery. The secondary outcome was 30-day postoperative mortality. This study included 24,203 patients, of whom 611 (2.5%) developed cardiovascular complications. In total, 458 (1.9%) patients died within 30 days of surgery, of which 123 (26.9%) deaths were judged to be cardiac-related. Mortality rates were higher in patients who developed postoperative cardiovascular complications than in those who did not (19.8% vs. 1.4%), which persisted after risk adjustment (hazard ratio (95%CI) 4.15 (3.14-5.48)). We estimated an absolute risk reduction (95%CI) of 0.4 (0.3-0.5) in mortality in the absence of all cardiovascular complications. This would confer a relative risk reduction in mortality of 21.1% if all cardiovascular complications were prevented. Postoperative cardiovascular complications are relatively common and occur early after major abdominal surgery. However, over 1 in 5 postoperative deaths were attributable to these complications, highlighting an important area for future randomised trials.

Percutaneous Transforaminal Endoscopic Discectomy for Adjacent Segment Disease versus Lumbar Disc Herniation in Elderly Patients

Purpose

Percutaneous transforaminal endoscopic discectomy (PTED) was used as a minimally invasive treatment option for lumbar disc herniation (LDH). However, studies focusing on the clinical outcomes of PTED for elderly patients with adjacent segment disease (ASD) were limited. This study aims to compare the clinical outcomes of PTED between ASD and LDH in elderly patients.

Patients and Methods

This retrospective study enrolled 39 patients with ASD and 39 patients with LDH. Both groups had undergone PTED in Beijing Chaoyang Hospital from July 4, 2016 to July 30, 2021. Visual analog scale for back pain (VAS-BP) and leg pain (VAS-LP) and Oswestry disability index (ODI) were used to value the clinical outcomes of patients preoperatively, immediately postoperatively, 12, and 24 months postoperatively, and at final follow-up. Patients' satisfaction was evaluated based on the MacNab criteria.

Results

All operations were completed. The excellent or good clinical outcomes at final follow-up was demonstrated by 87.15% (34/39) and 89.74% (35/39) in ASD and non-ASD patients, respectively. Clinical improvement was observed immediately postoperatively in both groups and sustained stability during the postoperative follow-up. The ASD group demonstrated significantly longer hospital stays (p = 0.02) and operative time (p < 0.01) than the non-ASD group.

Conclusion

PTED is an effective and minimally invasive treatment option for revision surgery of ASD, especially for elderly patients. However, the long-term prognosis of PTED treating ASD still needs further exploration.

Impact of neuromuscular block on myocardial injury after non-cardiac surgery (MINS) incidence in the early postoperative stage of older patients undergoing laparoscopic colorectal cancer resection: a randomized controlled study

BACKGROUND

Myocardial injury after non-cardiac surgery (MINS) is a common and serious complication in older patients. This study investigates the impact of neuromuscular block on the MINS incidence and other cardiovascular complications in the early postoperative stage of older patients undergoing laparoscopic colorectal cancer resection.

METHODS

70 older patients who underwent laparoscopic colorectal cancer resection were separated into the deep neuromuscular block group and moderate neuromuscular block group for 35 cases in each group (n = 1:1). The deep neuromuscular block group maintained train of four (TOF) = 0, post-tetanic count (PTC) 1-2, and the moderate neuromuscular block group maintained TOF = 1-2 during the operation. Sugammadex sodium was used at 2 mg/kg or 4 mg/kg for muscle relaxation antagonism at the end of surgery. The MINS incidence was the primary outcome and compared with Fisher's exact test. About the secondary outcomes, the postoperative pain was analyzed with Man-Whitney U test, the postoperative nausea and vomiting (PONV) and the incidence of cardiovascular complications were analyzed with Chi-square test, intraoperative mean artery pressure (MAP) and cardiac output (CO) ratio to baseline, length of stay and dosage of anesthetics were compared by two independent samples t-test.

RESULTS

MINS was not observed in both groups. The highest incidence of postoperative cardiovascular complications was lower limbs deep vein thrombosis (14.3% in deep neuromuscular block group and 8.6% in moderate neuromuscular group). The numeric rating scale (NRS) score in the deep neuromuscular block group was lower than the moderate neuromuscular block group 72 h after surgery (0(1,2) vs 0(1,2), P = 0.018). The operation time in the deep neuromuscular block group was longer (356.7(107.6) vs 294.8 (80.0), min, P = 0.008), the dosage of propofol and remifentanil was less (3.4 (0.7) vs 3.8 (1.0), mg·kg-1·h-1, P = 0.043; 0.2 (0.06) vs 0.3 (0.07), μg·kg-1·min-1, P < 0.001), and the length of hospital stay was shorter than the moderate neuromuscular block group (18.4 (4.9) vs 22.0 (8.3), day, P = 0.028). The differences of other outcomes were not statistically significant.

CONCLUSIONS

Maintaining different degrees of the neuromuscular block under TOF guidance did not change the MINS incidence within 7 days after surgery in older patients who underwent laparoscopic colorectal cancer resection.

TRIAL REGISTRATION

The present study was registered in the Chinese Clinical Trial Registry (10/02/2021, ChiCTR2100043323).

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

INTRODUCTION

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.

METHODS

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).

RESULTS

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).

CONCLUSIONS

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.

Risk of perioperative discontinuation of SGLT2 inhibitors

When sodium-glucose cotransporter-2 (SGLT2) inhibitors were primarily prescribed for treatment of diabetes mellitus, guidelines recommended withholding SGLT2 inhibitors before surgery to mitigate the associated risk of ketoacidosis. However, currently, SGLT2 inhibitors are an established therapy for patients with heart failure, and there is evidence that withholding SGLT2 inhibitors can worsen these patients' cardiovascular risk profile. We present an updated risk-benefit analysis of withholding SGLT2 inhibitors before surgery, focusing on patients with heart failure and addressing the risk of ketoacidosis and its treatment in these patients. Clinicians should consider perioperative continuation of SGLT2 inhibitors when prescribed for treatment of heart failure.

Risk Factors for Hospital Readmission Following Noncardiac Surgery: International Cohort Study

Objective

To determine timing and risk factors associated with readmission within 30 days of discharge following noncardiac surgery.

Background

Hospital readmission after noncardiac surgery is costly. Data on the drivers of readmission have largely been derived from single-center studies focused on a single surgical procedure with uncertainty regarding generalizability.

Methods

We undertook an international (28 centers, 14 countries) prospective cohort study of a representative sample of adults ≥45 years of age who underwent noncardiac surgery. Risk factors for readmission were assessed using Cox regression (ClinicalTrials.gov, NCT00512109).

Results

Of 36,657 eligible participants, 2744 (7.5%; 95% confidence interval [CI], 7.2-7.8) were readmitted within 30 days of discharge. Rates of readmission were highest in the first 7 days after discharge and declined over the follow-up period. Multivariable analyses demonstrated that 9 baseline characteristics (eg, cancer treatment in past 6 months; adjusted hazard ratio [HR], 1.44; 95% CI, 1.30-1.59), 5 baseline laboratory and physical measures (eg, estimated glomerular filtration rate or on dialysis; HR, 1.47; 95% CI, 1.24-1.75), 7 surgery types (eg, general surgery; HR, 1.86; 95% CI, 1.61-2.16), 5 index hospitalization events (eg, stroke; HR, 2.21; 95% CI, 1.24-3.94), and 3 other factors (eg, discharge to nursing home; HR, 1.61; 95% CI, 1.33-1.95) were associated with readmission.

Conclusions

Readmission following noncardiac surgery is common (1 in 13 patients). We identified perioperative risk factors associated with 30-day readmission that can help frontline clinicians identify which patients are at the highest risk of readmission and target them for preventive measures.

Prognostic value of extended cardiac risk assessment before elective open abdominal aortic surgery

BACKGROUND

Major vascular surgery is associated with a high perioperative risk and significant mortality. Despite advances in risk stratification, monitoring, and management of perioperative complications, cardiac complications are still common. Stress echocardiography is well established in coronary artery disease diagnostics; however, its prognostic value before high-risk aortic surgery is unknown. This prospective, single-center study compared the outcome of patients undergoing extended cardiac risk assessment before open abdominal aortic surgery with the outcome of patients who had received standard preoperative assessment.

METHODS

The study included patients undergoing elective open abdominal aortic surgery. Patients who underwent standard preoperative assessment before the start of a dedicated protocol were compared with patients who had extended cardiac risk assessment, including dobutamine stress echocardiography, as part of a stepwise interdisciplinary cardiovascular team approach. The combined primary endpoint was cardiovascular death, myocardial infarction, emergency coronary revascularization, and life-threatening arrhythmia within 30 days. The secondary endpoint was acute renal failure and severe bleeding.

RESULTS

In total, 77 patients (mean age 68.1 ± 8.1 years, 70% male) were included: 39 underwent standard and 38 underwent cardiac risk assessment. The combined primary endpoint was reached significantly more often in patients before than after implementation of the extended cardiac stratification procedure (15% vs. 0%, p = 0.025). The combined secondary endpoint did not differ between the groups.

CONCLUSIONS

Patients with extended cardiac risk assessment undergoing elective open abdominal aortic surgery had better 30-day outcomes than did those who had standard preoperative assessment.

Unveiling unique clinical phenotypes of hip fracture patients and the temporal association with cardiovascular events

Cardiovascular events are the leading cause of death among hip fracture patients. This study aims to identify subphenotypes of hip fracture patients and investigate their association with incident cardiovascular events, all-cause mortality, and health service utilisation in Hong Kong and the United Kingdom populations. By the latent class analysis, we show three distinct clusters in the Hong Kong cohort (n = 78,417): Cluster 1 has cerebrovascular and hypertensive diseases, hyperlipidemia, and diabetes; Cluster 2 has congestive heart failure; Cluster 3 consists of relatively healthy patients. Compared to Cluster 3, higher risks of major adverse cardiovascular events are observed in Cluster 1 (hazard ratio 1.97, 95% CI 1.83 to 2.12) and Cluster 2 (hazard ratio 4.06, 95% CI 3.78 to 4.35). Clusters 1 and 2 are also associated with a higher risk of mortality, more unplanned accident and emergency visits and longer hospital stays. Self-controlled case series analysis shows a significantly elevated risk of major adverse cardiovascular events within 60 days post-hip fracture. Similar associations are observed in the United Kingdom cohort (n = 27,948). Pre-existing heart failure is identified as a unique subphenotype associated with poor prognosis after hip fractures.

Prognostic relevance of ventricular arrhythmias in surgical patients with gastrointestinal tumors

BACKGROUND

Individuals diagnosed with gastrointestinal tumors are at an increased risk of developing cardiovascular diseases. Among which, ventricular arrhythmia is a prevalent clinical concern. This suggests that ventricular arrhythmias may have predictive value in the prognosis of patients with gastrointestinal tumors.

AIM

To explore the prognostic value of ventricular arrhythmias in patients with gastrointestinal tumors receiving surgery.

METHODS

We retrospectively analyzed data from 130 patients undergoing gastrointestinal tumor resection. These patients were evaluated by a 24-h ambulatory electrocardiogram (ECG) at the Sixth Affiliated Hospital of Sun Yat-sen University from January 2018 to June 2020. Additionally, 41 general healthy age-matched and sex-matched controls were included. Patients were categorized into survival and non-survival groups. The primary endpoint was all-cause mortality, and secondary endpoints included major adverse cardiovascular events (MACEs).

RESULTS

Colorectal tumors comprised 90% of cases. Preoperative ambulatory ECG monitoring revealed that among the 130 patients with gastrointestinal tumors, 100 (76.92%) exhibited varying degrees of premature ventricular contractions (PVCs). Ten patients (7.69%) manifested non-sustained ventricular tachycardia (NSVT). The patients with gastrointestinal tumors exhibited higher PVCs compared to the healthy controls on both conventional ECG [27 (21.3) vs 1 (2.5), P = 0.012] and 24-h ambulatory ECG [14 (1.0, 405) vs 1 (0, 6.5), P < 0.001]. Non-survivors had a higher PVC count than survivors [150.50 (7.25, 1690.50) vs 9 (0, 229.25), P = 0.020]. During the follow-up period, 24 patients died and 11 patients experienced MACEs. Univariate analysis linked PVC > 35/24 h to all-cause mortality, and NSVT was associated with MACE. However, neither PVC burden nor NSVT independently predicted outcomes according to multivariate analysis.

CONCLUSION

Patients with gastrointestinal tumors exhibited elevated PVCs. PVCs > 35/24 h and NSVT detected by 24-h ambulatory ECG were prognostically significant but were not found to be independent predictors.

Perioperative adverse cardiac events in maxillofacial surgery: A systematic review and meta-analysis

Background and Aims

Maxillofacial surgeries, including procedures to the face, oral cavity, jaw, and head and neck, are common in adults. However, they impose a risk of adverse cardiac events (ACEs). While ACEs are well understood for other non-cardiac surgeries, there is a paucity of data about maxillofacial surgeries. This systematic review and meta-analysis report the incidence and presentation of perioperative ACEs during maxillofacial surgery.

Methods

We included primary studies that reported on perioperative ACEs in adults. To standardise reporting, ACEs were categorised as 1. heart rate and rhythm disturbances, 2. blood pressure disturbances, 3. ischaemic heart disease and 4. heart failure and other complications. The primary outcome was ACE presentation and incidence during the perioperative period. Secondary outcomes included the surgical outcome according to the Clavien-Dindo classification and trigeminocardiac reflex involvement. STATA version 17.0 and MetaProp were used to delineate proportion as effect size with a 95% confidence interval (CI).

Results

Twelve studies (34,227 patients) were included. The incidence of perioperative ACEs was 2.58% (95% CI 1.70, 3.45, I2 = 96.17%, P = 0.001). Heart rate and rhythm disturbances resulted in the greatest incidence at 3.84% among the four categories. Most commonly, these ACEs resulted in intensive care unit admission (i.e. Clavien-Dindo score of 4).

Conclusion

Despite an incidence of 2.58%, ACEs can disproportionately impact surgical outcomes. Future research should include large-scale prospective studies that may provide a better understanding of the contributory factors and long-term effects of ACEs in patients during maxillofacial surgery.

The incidence of adverse outcome in donors after living donor liver transplantation: A meta-analysis of 60,829 donors

The scarcity of liver grafts has prompted developments in living donor liver transplantations (LDLT), with previous literature illustrating similar outcomes in recipients compared to deceased donor transplants. However, significant concerns regarding living donor morbidity and mortality have yet to be examined comprehensively. This study aims to provide estimates of the incidence of various outcomes in living liver donors. In this meta-analysis, Medline and Embase were searched from inception to July 2022 for articles assessing the incidence of outcomes in LDLT donors. Complications in the included studies were classified into respective organ systems. Analysis of incidence was conducted using a generalized linear mixed model with Clopper-Pearson intervals. Eighty-seven articles involving 60,829 living liver donors were included. The overall pooled incidence of complications in LDLT donors was 24.7% (CI: 21.6%-28.1%). The incidence of minor complications was 17.3% (CI: 14.7%-20.3%), while the incidence of major complications was lower at 5.5% (CI: 4.5%-6.7%). The overall incidence of donor mortality was 0.06% (CI: 0.0%-0.1%) in 49,027 individuals. Psychological complications (7.6%, CI: 4.9%-11.5%) were the most common among LDLT donors, followed by wound-related (5.2%, CI: 4.4%-6.2%) and respiratory complications (4.9%, CI: 3.8%-6.3%). Conversely, cardiovascular complications had the lowest incidence among the subgroups at 0.8% (CI: 0.4%-1.3%). This study presents the incidence of post-LDLT outcomes in living liver donors, illustrating significant psychological, wound-related, and respiratory complications. While significant advancements in recent decades have contributed towards decreased morbidity in living donors, our findings call for targeted measures and continued efforts to ensure the safety and quality of life of liver donors post-LDLT.

Postoperative Myocardial Injury and Inflammatory Biomarkers in Patients Undergoing Vascular Surgery: A Subanalysis of the Platelet Reactivity and Postoperative Myocardial Injury after Major Vascular Surgery (PROMISE) Study

BACKGROUND

Postoperative myocardial injury (PMI) is associated with morbidity and mortality, but the aetiology remains unclear. We studied whether PMI is associated with perioperative systemic inflammation. The objective is the examination of the relationship between inflammatory biomarkers (Interleukin 6[IL-6], C-reactive protein [CRP]) and PMI, detected by elevated cardiac troponin (cTn), in patients undergoing elective open abdominal aortic surgery.

METHODS

This prospective, single-center, observational cohort study included 54 patients undergoing elective open abdominal aortic surgery between March 2018 and April 2021. Patients were routinely treated with aspirin. IL-6 and CRP were measured preoperatively, directly after surgery, 24 hr and 48 hr postoperatively. The primary outcome was cTn release assessed by a fifth-generation high-sensitive cTn assay. Multivariable generalized linear regression models were used to evaluate the association between inflammatory biomarkers and cTn concentrations.

RESULTS

Fifteen patients (27.8%) developed PMI. IL-6 directly and 24 hr postoperatively was associated with elevated cTn concentrations (1.28 [1.07-1.54], P = 0.009) and 1.75 [1.18-2.59], P = 0.006, respectively). Also, CRP directly and 24 hr postoperatively was associated with elevated cTn concentrations (1.25 [1.06-1.47], P = 0.009) and 1.61 [1.1-2.33], P = 0.013, respectively). No association was found between IL-6 or CRP and cTn concentrations when measured at 48 hr postsurgery.

CONCLUSIONS

Biomarkers of inflammation are associated with elevated postoperative cTn concentrations in the early postoperative period in patients undergoing elective open abdominal aortic surgery.

Safety and complications of continuation of aspirin therapy in patients undergoing robot-assisted laparoscopic simple prostatectomy

To evaluate the safety and feasibility of continued perioperative aspirin at the time of robotic assisted simple prostatectomy (RASP). We performed a retrospective review of our IRB approved institutional database of patients who underwent RASP between 2013 and 2022. Comparative groups included patients taking aspirin in the perioperative period and those not taking aspirin pre-operatively. The primary outcome was any post-operative bleeding related complication using the modified Clavien-Dindo classification. Secondary outcomes included the identification of risk factors for increased blood loss in the entire study population, operative time, and blood transfusion requirement. 143 patients underwent RASP of which 55 (38.5%) patients continued perioperative aspirin therapy and 88 (61.5%) patients did not. Baseline demographics were similar between groups. Patients taking perioperative aspirin had a higher rate of hypertension (74.5% vs 58.0%, p = 0.04) and other cardiovascular disease (30.9% vs 11.4%, p = 0.007). Postoperative complications were similar between the groups (Clavien-Dindo ≥ 3; p = 0.43). Median blood loss (150 cc vs 150 cc, p = 0.38), percentage drop in hemoglobin (13.4 vs 13.2, p = 0.94) and blood transfusion rate (3.6 vs 1.1, p = 0.56) were also similar between groups. The median blood loss was 150 ml for the whole study population. On regression analysis, neither aspirin nor any other variable was associated with increased blood loss (> 150 ml). Aspirin can be safely continued perioperatively in patients undergoing RASP without any risk of bleeding related complications, blood loss, or increased transfusion rate.

Magnitude and associated factors of intraoperative cardiac complications among geriatric patients who undergo non-cardiac surgery at public hospitals in the southern region of Ethiopia: a multi-center cross-sectional study in 2022/2023

Background

Intraoperative cardiac complications are a common cause of morbidity and mortality in non-cardiac surgery. The risk of these complications increased with the average age increasing from 65. In a resource-limited setting, including our study area, the magnitude and associated factors of intraoperative cardiac complications have not been adequately investigated. The aim of this study was to assess the magnitude and associated factors of intraoperative cardiac complications among geriatric patients undergoing non-cardiac surgery.

Methods

An institutional-based multi-center cross-sectional study was conducted on 304 geriatric patients at governmental hospitals in the southern region of Ethiopia, from 20 March 2022 to 25 August 2022. Data were collected by chart review and patient interviews. Epi Data version 4.6 and SPSS version 25 were used for analysis. The variables that had association (p < 0.25) were considered for multivariable logistic regression. A p value < 0.05 was considered significant for association.

Result

The overall prevalence of intraoperative cardiac complications was 24.3%. Preoperative ST-segment elevation adjusted odds ratio (AOR = 2.43, CI =2.06-3.67), history of hypertension (AOR = 3.42, CI =2.02-6.08), intraoperative hypoxia (AOR = 3.5, CI = 2.07-6.23), intraoperative hypotension (AOR = 6.2 9, CI =3.51-10.94), age > 85 years (AOR = 6.01, CI = 5.12-12.21), and anesthesia time > 3 h (AOR =2.27, CI = 2.0.2-18.25) were factors significantly associated with intraoperative cardiac complications.

Conclusion

The magnitude of intraoperative cardiac complications was high among geriatric patients who had undergone non-cardiac surgery. The independent risk factors of intraoperative cardiac complications for this population included age > 85, ST-segment elevation, perioperative hypertension (stage 3 with regular treatment), duration of anesthesia >3 h, intraoperative hypoxia, and intraoperative hypotension. Holistic preoperative evaluation, optimization optimal and perioperative care for preventing perioperative risk factors listed above, and knowing all possible risk factors are suggested to reduce the occurrence of complications.

Pathophysiological mechanisms underlying increased circulating cardiac troponin in noncardiac surgery: a narrative review

Assay-specific increases in circulating cardiac troponin are observed in 20-40% of patients after noncardiac surgery, depending on patient age, type of surgery, and comorbidities. Increased cardiac troponin is consistently associated with excess morbidity and mortality after noncardiac surgery. Despite these findings, the underlying mechanisms are unclear. The majority of interventional trials have been designed on the premise that ischaemic cardiac disease drives elevated perioperative cardiac troponin concentrations. We consider data showing that elevated circulating cardiac troponin after surgery could be a nonspecific marker of cardiomyocyte stress. Elevated concentrations of circulating cardiac troponin could reflect coordinated pathological processes underpinning organ injury that are not necessarily caused by ischaemia. Laboratory studies suggest that matching of coronary artery autoregulation and myocardial perfusion-contraction coupling limit the impact of systemic haemodynamic changes in the myocardium, and that type 2 ischaemia might not be the likeliest explanation for cardiac troponin elevation in noncardiac surgery. The perioperative period triggers multiple pathological mechanisms that might cause cardiac troponin to cross the sarcolemma. A two-hit model involving two or more triggers including systemic inflammation, haemodynamic strain, adrenergic stress, and autonomic dysfunction might exacerbate or initiate acute myocardial injury directly in the absence of cell death. Consideration of these diverse mechanisms is pivotal for the design and interpretation of interventional perioperative trials.

What's New in Preoperative Cardiac Testing

More than 300 million surgeries are performed annually worldwide. Patients are progressively aging and often have multiple comorbidities that put them at increased cardiovascular risk in the perioperative period. The United States published latest guidelines regarding preoperative cardiac evaluation and risk stratification for patients undergoing non-cardiac surgery in 2014. There are multiple risk stratification tools available that can help guide management. Furthermore, newer laboratory tests, such as preoperative NT-proBNP and high-sensitivity troponin assays, may aid in preventing and diagnosing perioperative myocardial injury.

Perioperative copeptin: predictive value and risk stratification in patients undergoing major noncardiac surgery-a prospective observational cohort study

PURPOSE

Biomarkers can aid in perioperative risk stratification. While preoperative copeptin has been associated with adverse events, intraoperative information is lacking and this association may rather reflect a baseline risk. Knowledge about correlations between postoperative copeptin measurements and clinically relevant outcomes is scarce. We examined the association of perioperative copeptin concentrations with postoperative all-cause mortality and/or major adverse cardiac and cerebrovascular events (MACCE) at 12 months and 30 days as well as with perioperative myocardial injury (PMI).

METHODS

We conducted a prospective observational cohort study of adults undergoing noncardiac surgery with intermediate to high surgical risk in Basel, Switzerland, and Düsseldorf, Germany from February 2016 to December 2020. We measured copeptin and cardiac troponin before surgery, immediately after surgery (0 hr) and once between the second and fourth postoperative day (POD 2-4).

RESULTS

A primary outcome event of a composite of all-cause mortality and/or MACCE at 12 months occurred in 48/502 patients (9.6%). Elevated preoperative copeptin (> 14 pmol·L-1), immediate postoperative copeptin (> 90 pmol·L-1), and copeptin on POD 2-4 (> 14 pmol·L-1) were associated with lower one-year MACCE-free and/or mortality-free survival (hazard ratio [HR], 2.89; 95% confidence interval [CI], 1.62 to 5.2; HR, 2.07; 95% CI, 1.17 to 3.66; and HR, 2.47; 95% CI, 1.36 to 4.46, respectively). Multivariable analysis continued to show an association for preoperative and postoperative copeptin on POD 2-4. Furthermore, elevated copeptin on POD 2-4 showed an association with 30-day MACCE-free survival (HR, 2.15; 95% CI, 1.18 to 3.91). A total of 64 of 489 patients showed PMI (13.1%). Elevated preoperative copeptin was not associated with PMI, while immediate postoperative copeptin was modestly associated with PMI.

CONCLUSION

The results of the present prospective observational cohort study suggest that perioperative copeptin concentrations can help identify patients at risk for all-cause mortality and/or MACCE. Other identified risk factors were revised cardiac risk index, body mass index, surgical risk, and preoperative hemoglobin.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02687776); first submitted 9 February 2016.

Peripheral Nerve Blockade for Open Inguinal Hernia Repair in a Patient With Severe Cardiopulmonary Disease

Patients with severe cardiopulmonary morbidity present a unique challenge to peri- and intraoperative providers. Inducing general anesthesia in this patient population poses the risk of adverse events that could lead to poor surgical outcomes, prolonged debilitation, or death. Therefore, it is important that anesthesiologists become comfortable with preoperative evaluation as well as alternative strategies to providing surgical anesthesia. This case report details the clinical course of a patient with severe cardiopulmonary morbidity who underwent open inguinal hernia repair without oral or intravenous sedation after receiving multi-level paravertebral blocks in addition to isolated ilioinguinal and iliohypogastric nerve blocks. This medically challenging case provides educational value regarding preoperative evaluation, pertinent anatomy and innervation, and the importance of patient-centered care and communication.

Risk of Postoperative Ischemic Stroke and Myocardial Infarction in Patients Operated for Cancer

BACKGROUND

Risk assessment for ischemic stroke (IS) and myocardial infarction (MI) is done routinely before surgery, but the increase in risks associated with surgery is not known. The aim of this study is to assess the risk of arterial ischemic events during the first year after oncological surgery.

METHODS

We used Swedish healthcare databases to identify 443,300 patients who underwent cancer surgery between 1987 and 2016 and 4,127,761 matched comparison subjects. We estimated odds ratios (ORs) for myocardial infarction and ischemic stroke during the hospitalization with logistic regression and calculated 1-year cumulative incidences and hazard ratios (HRs) with 95% confidence intervals (CIs) for the outcomes after discharge.

RESULTS

The cumulative incidences of myocardial infarction and ischemic stroke during the first postoperative year were 1.33% and 1.25%, respectively. In the comparison cohort, the corresponding 1-year cumulative incidences were 1.04% and 1.00%. During the hospitalization, the OR for myocardial infarction was 8.81 (95% CI 8.24-9.42) and the OR for ischemic stroke was 6.71 (95% CI 6.22-7.23). After discharge, the average HR during follow-up for 365 days was 0.90 (95% CI 0.87-0.93) for myocardial infarction and 1.02 (95% CI 0.99-1.05) for ischemic stroke.

CONCLUSIONS

We found an overall increased risk of IS and MI during the first year after cancer surgery that was attributable to events occurring during the hospitalization period. After discharge from the hospital, the overall risk of myocardial infarction was lower among the cancer surgery patients than among matched comparison subjects.

Perioperative Management of Novel Pharmacotherapies for Heart Failure and Pulmonary Hypertension

Heart failure (HF) and pulmonary hypertension (PH) are increasingly prevalent comorbidities in patients presenting for noncardiac surgery. The unique pathophysiology and pharmacotherapies associated with these syndromes have important perioperative implications. As new medications for HF and PH emerge, it is imperative that anesthesiologists and other perioperative providers understand their mechanisms of action, pharmacokinetics, and potential adverse effects. We present an overview of the novel HF and PH pharmacotherapies and strategies for their perioperative management.

Myocardial Injury after Non-Cardiac Surgery in Patients Who Underwent Open Repair for Abdominal Aortic Aneurysm: A Retrospective Study

BACKGROUND

Myocardial injury after non-cardiac surgery (MINS) has been known to be associated with mortality in various surgical patients; however, its prognostic role in abdominal aortic aneurysm (AAA) open repair remains underexplored. This study aimed to investigate the role of MINS as a predictor of mortality in patients who underwent AAA open repair.

METHODS

This retrospective study investigated 352 patients who underwent open repair for non-ruptured AAA. The predictors of 30-day and 1-year mortalities were investigated using logistic regression analysis.

RESULTS

MINS was diagnosed in 41% of the patients after AAA open repair in this study. MINS was an independent risk factor of 30-day mortality (odds ratio [OR]: 10.440, 95% confidence interval [CI]: 1.278-85.274, p = 0.029) and 1-year mortality (OR: 5.189, 95% CI: 1.357-19.844, p = 0.016). Kaplan-Meier survival curves demonstrated significantly lower overall survival rates in patients with MINS compared to those without MINS (p = 0.003).

CONCLUSION

This study revealed that MINS is a common complication after AAA open repair and is an independent risk factor of 30-day and 1-year mortalities. Patients with MINS have lower overall survival rates than those without MINS.

Perioperative adverse cardiac events and mortality after non-cardiac surgery: a multicenter study

BACKGROUND

Perioperative adverse cardiac events (PACE), a composite of myocardial infarction, coronary revascularization, congestive heart failure, arrhythmic attack, acute pulmonary embolism, cardiac arrest, and stroke during 30-day postoperative period, is associated with long-term mortality, but with limited clinical evidence. We compared long-term mortality with PACE using data from nationwide multicenter electronic health records.

METHODS

Data from 7 hospitals, converted to Observational Medical Outcomes Partnership Common Data Model, were used. We extracted records of 277,787 adult patients over 18 years old undergoing non-cardiac surgery for the first time at the hospital and had medical records for more than 180 days before surgery. We performed propensity score matching and then an aggregated meta‑analysis.

RESULTS

After 1:4 propensity score matching, 7,970 patients with PACE and 28,807 patients without PACE were matched. The meta‑analysis showed that PACE was associated with higher one-year mortality risk (hazard ratio [HR]: 1.33, 95% CI [1.10, 1.60], P = 0.005) and higher three-year mortality (HR: 1.18, 95% CI [1.01, 1.38], P = 0.038). In subgroup analysis, the risk of one-year mortality by PACE became greater with higher-risk surgical procedures (HR: 1.20, 95% CI [1.04, 1.39], P = 0.020 for low-risk surgery; HR: 1.69, 95% CI [1.45, 1.96], P < 0.001 for intermediate-risk; and HR: 2.38, 95% CI [1.47, 3.86], P = 0.034 for high-risk).

CONCLUSIONS

A nationwide multicenter study showed that PACE was significantly associated with increased one-year mortality. This association was stronger in high-risk surgery, older, male, and chronic kidney disease subgroups. Further studies to improve mortality associated with PACE are needed.

Innovative designs for trials informing the care of cardiac surgical patients: Part II

PURPOSE OF REVIEW

This review examines advances in clinical trial methodologies relevant to cardiac anesthesia. It focuses on innovative approaches, including factorial randomization, composite outcomes, and cluster randomized trials, which enhance the efficiency, practical relevance, and generalizability of trial outcomes.

RECENT FINDINGS

Factorial randomization is becoming popular because the approach allows investigators to simultaneously evaluate two or more interventions. Furthermore, factorial designs can evaluate interactions among treatments which is highly relevant information that cannot be obtained from separate trials. Composite outcomes are also increasingly utilized, combining multiple individual outcomes into a single measure, which increases statistical power and can better represent relevant physiology. Designing valid composites requires careful consideration of component outcome severity and incidence. Cluster randomized trials, including stepped wedge and multiple crossover designs, address the challenges of group-level effects and shared environments.

SUMMARY

The evolution of clinical trial designs is marked by a shift towards methodologies that enhance efficiency and provide more nuanced insights into treatment effects. These include factorial designs for simultaneous intervention assessment, composite outcomes for comprehensive physiological representation, and cluster trials for group-level effect analysis. Such advancements are shaping the future of clinical research, making it more relevant, efficient, and broadly applicable.

Introduction of a Post-Anaesthesia Care Unit in a Teaching Hospital Is Associated with a Reduced Length of Hospital Stay in Noncardiac Surgery: A Single-Centre Interrupted Time Series Analysis

BACKGROUND

A post-anaesthesia care unit (PACU) may improve postoperative care compared with intermediate care units (IMCU) due to its dedication to operative care and an individualized duration of postoperative stay. The effects of transition from IMCU to PACU for postoperative care following intermediate to high-risk noncardiac surgery on length of hospital stay, intensive care unit (ICU) utilization, and postoperative complications were investigated.

METHODS

This single-centre interrupted time series analysis included patients undergoing eleven different noncardiac surgical procedures associated with frequent postoperative admissions to an IMCU or PACU between January 2018 and March 2019 (IMCU episode) and between October 2019 and December 2020 (PACU episode). Primary outcome was hospital length of stay, secondary outcomes included postoperative complications and ICU admissions.

RESULTS

In total, 3300 patients were included. The hospital length of stay was lower following PACU admission compared to IMCU admission (IMCU 7.2 days [4.2-12.0] vs. PACU 6.0 days [3.6-9.1]; p < 0.001). Segmented regression analysis demonstrated that the introduction of the PACU was associated with a decrease in hospital length of stay (GMR 0.77 [95% CI 0.66-0.91]; p = 0.002). No differences between episodes were detected in the number of postoperative complications or postoperative ICU admissions.

CONCLUSIONS

The introduction of a PACU for postoperative care of patients undergoing intermediate to high-risk noncardiac surgery was associated with a reduction in the length of stay at the hospital, without increasing postoperative complications.

Prevalence and Clinical Outcomes of Noncardiac Surgery After Transcatheter Aortic Valve Replacement

Aortic stenosis is a prevalent valvular heart disease, especially in the older people. They often coexist with other co-morbidities, and noncardiac surgery carries a higher risk because of the underlying valve condition. Despite the growing concern about the safety and optimal management of noncardiac surgery post-transcatheter aortic valve replacement (TAVR), there is limited evidence on this matter. This study aims to assess the clinical outcomes of noncardiac surgeries after TAVR. This retrospective study included 718 patients who underwent TAVR. Of these, 36 patients underwent noncardiac surgery after TAVR. The primary end point was the incidence of cardiovascular adverse events post-TAVR and the secondary end point was the incidence of structural valve deterioration. Composite end points included disabling stroke, heart failure requiring hospitalization, and cardiac death as defined by Valve Academic Research Consortium 3. Most of these surgeries were orthopedic and classified as intermediate risk. All noncardiac surgeries were performed without perioperative adverse events. There was no observed structural valve deterioration, and the incidence of composite end points did not significantly differ between the surgical and nonsurgical groups during the follow-up period. Noncardiac surgery after TAVR can be performed safely and does not have a negative impact on prognosis. Further studies are warranted to determine the optimal strategy for noncardiac surgery after TAVR.

Prognostic value of high-sensitivity cardiac troponin in non-cardiac surgical patients in intensive care units

Type II myocardial injury following surgical procedures is associated with adverse outcomes. The prognostic value of high-sensitivity cardiac troponin (hs-cTn) due to type II myocardial injury in surgical patients admitted to intensive care unit (ICU) remains unclear. The aim of this study was to assess prognostic value of hs-cTn in type II acute myocardial injury in non-cardiac surgical patients requiring post-operative ICU admission. Retrospective analysis of patients admitted to two level III ICUs following surgery and had hs-cTn measured on the day of ICU admission. Patients who had type I acute myocardial infarction (AMI) during their admission were excluded from the study. The primary outcome was hospital mortality. Secondary outcomes included ICU mortality, ICU length of stay (LOS) and hospital LOS. A total of 420 patients were included. On univariable analysis, higher hs-cTn was associated with increased hospital mortality (14.6% vs 6.3%, p = 0.008), ICU LOS (41.1 h, vs 25 h, p = 0.004) and hospital LOS (253 h vs 193 h, p = 0.02). On multivariable analysis, hs-cTn was not independently associated with increased risk of hospital mortality. However, in patients who had elective surgery, hs-cTn was associated with increased risk (OR 1.048; 95% CI 1.004-1.094; p = 0.031) of hospital mortality with area under the receiver operating characteristic curve of 0.753 (95% CI 0.598-0.908). In elective surgical patients, hs-cTn was associated with increased risk of mortality. Larger multicentre studies are required to confirm this association that may assist in risk stratification of elective surgical patients requiring ICU admission.

One-year Outcomes after Discharge from Noncardiac Surgery and Association between Predischarge Complications and Death after Discharge: Analysis of the VISION Prospective Cohort Study

BACKGROUND

In previous analyses, myocardial injury after noncardiac surgery, major bleeding, and sepsis were independently associated with most deaths in the 30 days after noncardiac surgery, but most of these deaths occurred during the index hospitalization for surgery. The authors set out to describe outcomes after discharge from hospital up to 1 yr after inpatient noncardiac surgery and associations between predischarge complications and postdischarge death up to 1 yr after surgery.

METHODS

This study was an analysis of patients discharged after inpatient noncardiac surgery in a large international prospective cohort study across 28 centers from 2007 to 2013 of patients aged 45 yr or older followed to 1 yr after surgery. The study estimated (1) the cumulative postdischarge incidence of death and other outcomes up to a year after surgery and (2) the adjusted time-varying associations between postdischarge death and predischarge complications including myocardial injury after noncardiac surgery, major bleeding, sepsis, infection without sepsis, stroke, congestive heart failure, clinically important atrial fibrillation or flutter, amputation, venous thromboembolism, and acute kidney injury managed with dialysis.

RESULTS

Among 38,898 patients discharged after surgery, the cumulative 1-yr incidence was 5.8% (95% CI, 5.5 to 6.0%) for all-cause death and 24.7% (95% CI, 24.2 to 25.1%) for all-cause hospital readmission. Predischarge complications were associated with 33.7% (95% CI, 27.2 to 40.2%) of deaths up to 30 days after discharge and 15.0% (95% CI, 12.0 to 17.9%) up to 1 yr. Most of the association with death was due to myocardial injury after noncardiac surgery (15.6% [95% CI, 9.3 to 21.9%] of deaths within 30 days, 6.4% [95% CI, 4.1 to 8.7%] within 1 yr), major bleeding (15.0% [95% CI, 8.3 to 21.7%] within 30 days, 4.7% [95% CI, 2.2 to 7.2%] within 1 yr), and sepsis (5.4% [95% CI, 2.2 to 8.6%] within 30 days, 2.1% [95% CI, 1.0 to 3.1%] within 1 yr).

CONCLUSIONS

One in 18 patients 45 yr old or older discharged after inpatient noncardiac surgery died within 1 yr, and one quarter were readmitted to the hospital. The risk of death associated with predischarge perioperative complications persists for weeks to months after discharge.

EDITOR’S PERSPECTIVE

[The role of cardiac biomarkers in perioperative risk evaluation of noncardiac surgery patients-A summary of the ESAIC guidelines 2023]

BACKGROUND

The recently published ESAIC guidelines highlight the clinical value of cardiac troponins (cTn) and B‑type natriuretic peptides (BNP) for risk assessment in patients undergoing noncardiac surgery.

OBJECTIVE

Summary of the ESAIC guideline recommendations.

MATERIAL AND METHODS

The evidence for the recommendations was extracted from studies that investigated the perioperative role of cTn and BNP as prognostic factors, for risk prediction and for therapeutic guidance. To collate this evidence 12 relevant endpoints as well as risk benefit analyses of systematic screening were considered to issue the strength of the recommendations.

RESULTS

The body of evidence for these guidelines was based on 115 studies. The evidence varied significantly across the 12 predefined endpoints. Additionally, there was a gradient in evidence for the use of cTn and BNP as prognostic factors, for risk prediction and for therapeutic guidance. The guidelines issue a weak recommendation for the use of preoperative, postoperative and combined measurement of cTn as well as for preoperative BNP measurement to assess the prognosis. For risk prediction a weak recommendation was formulated for combined and postoperative cTn and preoperative BNP measurements. No recommendation could be given for the evidence on biomarkers as data were very limited.

CONCLUSION

Both cTn and BNP can be used as prognostic factors or to predict the risk for selected endpoints. Therapeutic interventions should not be guided by cardiac biomarker levels.

Refractory hypotension and coronary artery spasm induced by antipsychotic drugs: A challenging case and treatment consideration: A case report and literature review

RATIONALE

Coronary artery spasms may result from supply-demand mismatch due to hypotension. Norepinephrine is more effective in ameliorating antipsychotic-induced refractory hypotension.

PATIENT CONCERNS

Postoperative difficult-to-correct hypoperfusion occurs in patients with comorbid depression and coronary spasm; the use of norepinephrine and epinephrine for rapidly raising blood pressure needs to be considered.

DIAGNOSES

Electrocardiogram is an auxiliary tool and Digital Substraction Angiography is the gold standard for the diagnosis.

INTERVENTIONS

Surgery and correct choice of raising blood pressure are the main treatment methods.

OUTCOMES

Hypotension induced by the use of antipsychotics after angiography is difficult to correct with dobutamine, and the above scenario is relatively rare in the clinic, where norepinephrine could be a potential therapeutic option.

LESSONS

Based on the lessons learnt from this case, caution must be exercised when dealing with patients on multiple antipsychotics during the perioperative period, while pressor-boosting medications should not be limited to conventional drugs such as dopamine. Norepinephrine may be more effective in dealing with difficult-to-correct hypoperfusion.

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.

Sarcopenic Obesity as a Risk Factor for Cardiovascular Disease: An Underrecognized Clinical Entity

Sarcopenic obesity (SO) is a chronic condition and an emerging health challenge, in view of the growing elderly population and the obesity epidemic. Due to a lack of awareness among treating doctors and the non-specific nauture of the associated symptoms, SO remains grossly underdiagnosed. There is no consensus yet on a standard definition or diagnostic criteria for SO, which limits the estimation of the global prevalence of this condition. It has been linked to numerous metabolic derangements, cardiovascular disease (CVD) and mortality. The treatment of SO is multimodal and requires expertise across multiple specialties. While dietary modifications and exercise regimens have shown a potential therapeutic benefit, there is currently no proven pharmacological management for SO. However, numerous drugs and the role of bariatric surgery are still under trial, and have great scope for further research. This article covers the available literature regarding the definition, diagnostic criteria, and prevalence of SO, with available evidence linking it to CVD, metabolic disease and mortality, and an overview of current directives on management.

Association between inflammation-based prognostic markers and mortality of non-cardiac surgery

BACKGROUND

To evaluate the association between inflammation and nutrition-based biomarkers and postoperative outcomes after non-cardiac surgery.

METHODS

Between January 2011 and June 2019, a total of 102,052 patients undergoing non-cardiac surgery were evaluated, with C-reactive protein (CRP), albumin, and complete blood count (CBC) measured within six months before surgery. We assessed their CRP-to-albumin ratio (CAR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and modified Glasgow Prognostic Score (mGPS). We determined the best cut-off values by using the receiver operating characteristic (ROC) curves. Patients were divided into high and low groups according to the estimated threshold, and we compared the one-year mortality.

RESULTS

The one-year mortality of the entire sample was 4.2%. ROC analysis revealed areas under the curve of 0.796, 0.743, 0.670, and 0.708 for CAR, NLR, PLR, and mGPS, respectively. According to the estimated threshold, high CAR, NLR, PLR, and mGPS were associated with increased one-year mortality (1.7% vs. 11.7%, hazard ratio [HR]: 2.38, 95% CI [2.05, 2.76], P < 0.001 for CAR; 2.2% vs. 10.3%, HR: 1.81, 95% CI [1.62, 2.03], P < 0.001 for NLR; 2.6% vs. 10.5%, HR: 1.86, 95% CI [1.73, 2.01], P < 0.001 for PLR; and 2.3% vs. 16.3%, HR: 2.37, 95% CI [2.07, 2.72], P < 0.001 for mGPS).

CONCLUSIONS

Preoperative CAR, NRL, PLR, and mGPS were associated with postoperative mortality. Our findings may be helpful in predicting mortality after non-cardiac surgery.

Tight perioperative blood pressure management to reduce complications: a randomised feasibility trial

OBJECTIVE

Evaluate the feasibility of a trial of perioperative hypotension and serious complications.

DESIGN

A patient and assessor-blinded randomised feasibility trial.

SETTING

We included patients in a tertiary university hospital.

PARTICIPANTS

We enrolled 80 adults scheduled for major non-cardiac surgery.

INTERVENTIONS

In patients randomised to tight blood pressure control, intraoperative mean arterial pressure (MAP) was targeted to ≥85 mm Hg maintained with norepinephrine infusion, and restarting chronic antihypertensive medications was delayed until the third postoperative day. In the reference group, intraoperative blood pressure was managed per routine and antihypertensive medications were restarted immediately after surgery.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our first co-primary outcome was the fraction of time when intraoperative MAP was >85 mm Hg, intraoperative area (time integral) of MAP >85 mm Hg and MAP <65 mm Hg. The second co-primary outcome was time until antihypertensive medications were restarted after surgery. Secondary outcomes were time-weighted average intraoperative MAP, cumulative minimum MAP for 10 min, average postoperative systolic blood pressure (SBP) and mean of the lowest three postoperative SBPs.

RESULTS

Forty patients in each group were analysed. The median for intraoperative area of MAP >85 mm Hg was 1303 (772-2419) mm Hg*min in routine blood pressure (BP) cases and 2425 (1926-3545) mm Hg*min in tight BP control. The area for intraoperative MAP <65 mm Hg was 7 (0-40) mm Hg*min with routine BP management, and 0 (0-0) mm Hg*min with tight BP control. The fraction of time with MAP >85 mm Hg was 0.52 (0.25) and 0.87 (0.15). Antihypertensive medications were restarted 2 (1-3) days later in tight BP control cases. However, postoperative SBPs were similar.

CONCLUSIONS

Tight BP management markedly increased intraoperative MAP and reduced the amount of hypotension. In contrast, delaying chronic antihypertensive medications had little effect on postoperative SBP. The full trial appears feasible and remains necessary but should not include postoperative antihypertensive management.

TRIAL REGISTRATION

NCT04789733.

Diagnostic and prognostic value of cardiac stress testing before major noncardiac surgery-A cohort study

OBJECTIVE

To assess the incremental contribution of preoperative stress test results toward a diagnosis of obstructive coronary artery disease (CAD), prediction of mortality, or prediction of perioperative myocardial infarction in patients considering noncardiac, nonophthalmologic surgery.

DESIGN, SETTING, PARTICIPANTS

A retrospective cohort study of visits to a preoperative risk assessment and optimization clinic in a large health system between 2008 and 2018.

MEASUREMENTS

To assess diagnostic information of preoperative stress testing, we used the Begg and Greenes method to calculate test characteristics adjusted for referral bias, with a gold standard of angiography. To assess prognostic information, we first created multiply-imputed logistic regression models to predict 90-day mortality and perioperative myocardial infarction (MI), starting with two tools commonly used to assess perioperative cardiac risk, Revised Cardiac Risk Index (RCRI) and Myocardial Infarction or Cardiac Arrest (MICA). We then added stress test results and compared the discrimination for models with and without stress test results.

MAIN RESULTS

Among 136,935 visits by patients without an existing diagnosis of CAD, the decision to obtain preoperative stress testing identified around 4.0% of likely new diagnoses. Stress testing increased the likelihood of CAD (likelihood ratio: 1.31), but for over 99% of patients, stress testing should not change a decision on whether to proceed to angiography. In 117,445 visits with subsequent noncardiac surgery, stress test results failed to improve predictions of either perioperative MI or 90-day mortality. Reweighting the models and adding hemoglobin improved the prediction of both outcomes.

CONCLUSIONS

Cardiac stress testing before noncardiac, nonophthalmologic surgery does not improve predictions of either perioperative mortality or myocardial infarction. Very few patients considering noncardiac, nonophthalmologic surgery have a pretest probability of CAD in a range where stress testing could usefully select patients for angiography. Better use of existing patient data could improve predictions of perioperative adverse events without additional patient testing.

Personalized multimodal prehabilitation reduces cardiopulmonary complications after pancreatoduodenectomy: results of a propensity score matching analysis

BACKGROUND

The purpose of prehabilitation is to improve postoperative outcomes by increasing patients' resilience against the stress of surgery. This study investigates the effect of personalized multimodal prehabilitation on patients undergoing pancreatoduodenectomy.

METHODS

Included patients were screened for six modifiable risk factors: (1) low physical fitness, (2) malnutrition, (3) low mental resilience, (4) anemia and hyperglycemia, (5) frailty, and (6) substance abuse. Interventions were performed as needed. Using 1:1 propensity score matching (PSM), patients were compared to a historical cohort.

RESULTS

From 120 patients, 77 (64.2%) performed a cardiopulmonary exercise test to assess their physical fitness and provide them with a preoperative training advice. Furthermore, 88 (73.3%) patients received nutritional support, 15 (12.5%) mental support, 17 (14.2%) iron supplementation to correct for iron deficiency, 18 (15%) regulation support for hyperglycemia, 14 (11.7%) a comprehensive geriatric assessment, and 19 (15.8%) substance abuse support. Of all patients, 63% required ≥2 prehabilitation interventions. Fewer cardiopulmonary complications were observed in the prehabilitation cohort (9.2% versus 23.3%; p = 0.002). In surgical outcomes and length of stay no differences were observed.

CONCLUSION

Our prehabilitation program is effective in detecting risk factors in patients; most patients required multiple interventions. Consequently, a reduction in cardiopulmonary complications was observed.

Vasopressors to treat postoperative hypotension after adult noncardiac, non-obstetric surgery: a systematic review

BACKGROUND

Postoperative hypotension is common after major surgery and is associated with patient harm. Vasopressors are commonly used to treat hypotension without clear evidence of benefit. We conducted a systematic review to better understand the use, impact, and rationale for vasopressor administration after noncardiac, non-obstetric surgery in adults.

METHODS

We conducted a prospectively registered systematic review. Cochrane CENTRAL, EMBASE, MEDBASE, and MEDLINE were searched for RCTs and cohort studies of adult patients receiving vasopressors after noncardiac, non-obstetric surgery. Study quality was critically appraised by two investigators. Findings from the review were synthesised, but formal meta-analysis was not performed because of significant variability in study populations and outcomes.

RESULTS

A total of 3201 articles were screened, of which seven RCTs, two prospective cohort studies, and 15 retrospective cohort studies were included in the analysis (24 in total). One study was graded as high quality, two as moderate quality, and the remaining 21 as low quality. Sixteen studies relied on clinical assessment alone to decide on therapeutic interventions. Vasodilation was the most common suggested physiological disturbance. The median proportion of patients receiving vasopressors was 42% (interquartile range: 11.5-74.7%). Norepinephrine was the most common vasopressor used.

CONCLUSIONS

The evidence supporting the use of vasopressors to treat postoperative hypotension is limited. Future research should focus on whether vasodilatation or other physiological disturbance is driving postoperative hypotension to allow rational decision-making.

Late Mortality After Myocardial Injury in Critical Care Non-Cardiac Surgery Patients Using Machine Learning Analysis

Myocardial injury after noncardiac surgery (MINS) increases mortality within 30 days. We aimed to evaluate the long-term impact of myocardial injury in a large cohort of patients admitted to intensive care after noncardiac surgery. All patients who stayed, at least, overnight with measurement of high-sensitive cardiac troponin were included. Clinical characteristics and occurrence of MINS were assessed between patients who died and survivors using chi-square test and Student t test. Variables with p <0.01 in the univariate model were included in the Cox regression model to identify predictor variables. Survival decision tree (SDT), a machine learning model, was also used to find the predictors and their correlations. We included 2,230 patients with mean age of 63.8±16.3 years, with most (55.6%) being women. The prevalence of MINS was 9.4% (209 patients) and there were 556 deaths (24.9%) in a median follow-up of 6.7 years. Univariate analysis showed variables associated with late mortality, namely: MINS, arterial hypertension, previous myocardial infarction, atrial fibrillation, dementia, urgent surgery, peripheral artery disease (PAD), chronic health status, and age. These variables were included in the Cox regression model and SDT. The predictor variables of all-cause death were MINS (hazard ratio [HR] 2.21; 95% confidence interval [CI] 1.77 to 2.76), previous myocardial infarction (HR 1.47; 95% CI 1.14 to 1.89); urgent surgery (HR 1.24; 95% CI 1.01 to 1.52), PAD (HR 1.83; 95% CI 1.23 to 2.73), dementia (HR 2.54; 95% CI 1.86 to 3.46) and age (HR 1.05; 95% CI 1.04 to 1.06). SDT had the same predictors, except PAD. In conclusion, increased high-sensitive troponin levels in patients who underwent noncardiac surgery raised the risk of short and late mortality.

The Impact of Perioperative Morbidities, Lack of Discharge Aspirin, and Lack of Discharge Statin on Long Term Survival Following EVAR

OBJECTIVE

Adverse perioperative events and discharge medications both have the potential to impact survival following endovascular abdominal aortic aneurysm repair (EVAR). We hypothesize that variables such as blood loss, reoperation in the same hospital admission, and lack of discharge statin/aspirin have significant effect on long term survival following EVAR. Similarly, other perioperative morbidities, are hypothesized to affect long term mortality. Quantifying the mortality effect of perioperative events and treatment emphasizes to physicians the critical nature of preoperative optimization, case planning, operative execution and postoperative patient management.

METHODS

All EVAR in the Vascular Quality Initiative between 2003 and 2021 were queried. Exclusions were: ruptured/symptomatic aneurysm; concomitant renal artery or supra-renal intervention at the time of EVAR; conversion to open aneurysm repair at the time of initial operation; and undocumented mortality status at the 5 year mark postoperatively. 18,710 patients met inclusion criteria. Multivariable Cox regression time dependent analysis was performed to investigate the strength of mortality association of the exposure variables. Standard demographic variables and pre-existing major co-morbidities were included in the regression analysis to account for disproportionate, deleterious co-variables amongst those experiencing the various morbidities. Kaplan-Meier survival analysis was performed to provide survival curves for the key variables.

RESULTS

Mean follow up was 5.99 years and 5-year survival for included patients was 69.2%. Cox regression revealed increased long term mortality to be associated with the following perioperative events: reoperation during the index hospital admission (HR 1.21, P = .034), perioperative leg ischemia (HR 1.34, P = .014), perioperative acute renal insufficiency (HR 1.24, P = .013), perioperative myocardial infarction (HR 1.87, P < .001), perioperative intestinal ischemia (HR 2.13, P < .001), perioperative respiratory failure (HR 2.15, P < .001), lack of discharge aspirin (HR 1.26, P < .001), and lack of discharge statin (HR 1.26, P < .001). The following pre-existing co-morbidities correlated with increased long term mortality (P < .001 for all) : body mass index under 20 kg/m2, hypertension, diabetes, coronary artery disease, reported history congestive heart failure, chronic obstructive pulmonary disease, peripheral artery disease, advancing age, baseline renal insufficiency and left ventricular ejection fraction less than 50%. Females were more likely to have EBL >300 mL, reoperation, perioperative MI, limb ischemia and acute renal insufficiency than males (P < .01 for all). Female sex trended but was not associated with increased long term mortality risk (HR 1.06, 95% CI .995-1.14, P = .072).

CONCLUSIONS

Survival after EVAR is improved with optimal operative planning to facilitate evading the need for reoperation and ensuring patients without contra-indication are discharged with aspirin and statin medications. Females and patients with pre-existing co-morbidity are at particularly higher risk for perioperative limb ischemia, renal insufficiency, intestinal ischemia and myocardial ischemia necessitating appropriate preparation and preventative measures.

Intraoperative hypotension in noncardiac surgery patients with chronic beta-blocker therapy: A matched cohort analysis

STUDY OBJECTIVE

To explore the incidence of intraoperative hypotension in patients with chronic beta-blocker therapy, expressed as time spent, area and time-weighted average under predefined mean arterial pressure thresholds.

DESIGN

Retrospective analysis of a prospective observational cohort registry.

SETTING

Patients ≥60 years undergoing intermediate- to high-risk noncardiac surgery with routine postoperative troponin measurements on the first three days after surgery.

PATIENTS

1468 matched sets of patients (1:1 ratio with replacement) with and without chronic beta-blocker treatment.

INTERVENTIONS

None.

MEASUREMENTS

The primary outcome was the exposure to intraoperative hypotension in beta-blocker users vs. non-users. Time spent, area and time-weighted average under predefined mean arterial pressure thresholds (55-75 mmHg) were calculated to express the duration and severity of exposure. Secondary outcomes included incidence of postoperative myocardial injury and thirty-day mortality, myocardial infarction (MI) and stroke. Furthermore, analyses for patient subgroup and beta-blocker subtype were conducted.

MAIN RESULTS

In patients with chronic beta-blocker therapy, no increased exposure to intraoperative hypotension was observed for all characteristics and thresholds calculated (all P > .05). Beta-blocker users had lower heart rate before, during and after surgery (70 vs. 74, 61 vs. 65 and 68 vs. 74 bpm, all P < .001, respectively). Postoperative myocardial injury (13.6% vs. 11.6%, P = .269) and thirty-day mortality (2.5% vs. 1.4%, P = .055), MI (1.4% vs. 1.5%, P = .944) and stroke (1.0% vs 0.7%, P =  .474) rates were comparable. The results were consistent in subtype and subgroup analyses.

CONCLUSIONS

In this matched cohort analysis, chronic beta-blocker therapy was not associated with increased exposure to intraoperative hypotension in patients undergoing intermediate- to high-risk noncardiac surgery. Furthermore, differences in patient subgroups and postoperative adverse cardiovascular events as a function of treatment regimen could not be demonstrated.

Myocardial injury and long-term oncological outcomes in patients undergoing surgery for colorectal cancer

PURPOSE

Myocardial injury after noncardiac surgery (MINS) is associated with increased mortality and postoperative complications. In patients with colorectal cancer (CRC), postoperative complications are a risk factor for cancer recurrence and disease-free survival. This study investigates the association between MINS and long-term oncological outcomes in patients with CRC in an ERAS setting.

METHODS

This retrospective cohort study was conducted at Zealand University Hospital, Denmark, between June 2015 and July 2017. Patients undergoing CRC surgery were included if troponin was measured twice after surgery. Outcomes were all-cause mortality, recurrence, and disease-free survival within five years of surgery.

RESULTS

Among 586 patients, 42 suffered MINS. After five years, 36% of patients with MINS and 26% without MINS had died, p = 0.15. When adjusted for sex, age and UICC, the hazard ratio (aHR) for 1-year all-cause mortality, recurrence, and disease-free survival were 2.40 [0.93-6.22], 1.47 [0.19-11.29], and 2.25 [0.95-5.32] for patients with MINS compared with those without, respectively. Further adjusting for ASA status, performance status, smoking, and laparotomies, the aHR for 3- and 5-year all-cause mortality were 1.05 [0.51-2.15] and 1.11 [0.62-1.99], respectively. Similarly, the aHR for 3- and 5-year recurrence were 1.38 [0.46-4.51], and 1.49 [0.56-3.98] and for 3- and 5-year disease-free survival the aHR were 1.19 [0.63-2.23], and 1.19 [0.70-2.03].

CONCLUSION

In absolute numbers, we found no difference in all-cause mortality and recurrence in patients with and without MINS. In adjusted Cox regression analyses, the hazard was increased for all-cause mortality, recurrence, and disease-free survival in patients with MINS without reaching statistical significance.

Myocardial injury after non-cardiac surgery and per operative fibrin metabolism in patients undergoing hip-fracture surgery: an observational study

Myocardial injury after non-cardiac surgery (MINS) is associated with a 2-3-fold increased risk of subsequent major cardiovascular events and postoperative mortality. The pathological mechanism behind MINS is not fully uncovered. We hypothesized that patients with MINS following hip fracture surgery would have an altered haemostatic balance pre- and postoperative compared with patients without MINS. This was investigated in a prospective single-centre observational study including patients consecutively. The outcomes were changes in thrombin generation, fibrinogen/fibrin turnover, tissue plasminogen activator, plasminogen activator inhibitor-1 and fibrin structure measurements in patients developing MINS and patients who did not. Outcomes were measured preoperatively and two hours postoperatively. Seventy-two patients were included whereof 26 (36%) patients developed MINS. D-dimer delta values were significantly higher in patients developing MINS than in patients who did not (p = 0.01). After adjusting for age, sex, smoking, alcohol abuse, atrial fibrillation, anticoagulant medication preoperative CRP, preoperative creatinine and duration of surgery, the association remained significant (p = 0.04). There were no significant changes in thrombin generation, in markers of fibrinogen/fibrin turnover besides D-dimer, or in fibrin structure measurements pre- and postoperatively between patients with and without MINS. As such, a relationship between the coagulative and fibrinolytic activity and MINS cannot be ruled out in patients with MINS after hip fracture surgery. Registration: The study was an observational sub-study to a multicentre randomised clinical trial registered at ClinicalTrials.gov (NCT02344797).

Machine learning to predict myocardial injury and death after non-cardiac surgery

Myocardial injury due to ischaemia within 30 days of non-cardiac surgery is prognostically relevant. We aimed to determine the discrimination, calibration, accuracy, sensitivity and specificity of single-layer and multiple-layer neural networks for myocardial injury and death within 30 postoperative days. We analysed data from 24,589 participants in the Vascular Events in Non-cardiac Surgery Patients Cohort Evaluation study. Validation was performed on a randomly selected subset of the study population. Discrimination for myocardial injury by single-layer vs. multiple-layer models generated areas (95%CI) under the receiver operating characteristic curve of: 0.70 (0.69-0.72) vs. 0.71 (0.70-0.73) with variables available before surgical referral, p < 0.001; 0.73 (0.72-0.75) vs. 0.75 (0.74-0.76) with additional variables available on admission, but before surgery, p < 0.001; and 0.76 (0.75-0.77) vs. 0.77 (0.76-0.78) with the addition of subsequent variables, p < 0.001. Discrimination for death by single-layer vs. multiple-layer models generated areas (95%CI) under the receiver operating characteristic curve of: 0.71 (0.66-0.76) vs. 0.74 (0.71-0.77) with variables available before surgical referral, p = 0.04; 0.78 (0.73-0.82) vs. 0.83 (0.79-0.86) with additional variables available on admission but before surgery, p = 0.01; and 0.87 (0.83-0.89) vs. 0.87 (0.85-0.90) with the addition of subsequent variables, p = 0.52. The accuracy of the multiple-layer model for myocardial injury and death with all variables was 70% and 89%, respectively.

Development and validation of a prediction model to predict major adverse cardiovascular events in elderly patients undergoing noncardiac surgery: A retrospective cohort study

BACKGROUND AND AIMS

Current existing predictive tools have limitations in predicting major adverse cardiovascular events (MACEs) in elderly patients. We will build a new prediction model to predict MACEs in elderly patients undergoing noncardiac surgery by using traditional statistical methods and machine learning algorithms.

METHODS

MACEs were defined as acute myocardial infarction (AMI), ischemic stroke, heart failure and death within 30 days after surgery. Clinical data from 45,102 elderly patients (≥65 years old), who underwent noncardiac surgery from two independent cohorts, were used to develop and validate the prediction models. A traditional logistic regression and five machine learning models (decision tree, random forest, LGBM, AdaBoost, and XGBoost) were compared by the area under the receiver operating characteristic curve (AUC). In the traditional prediction model, the calibration was assessed using the calibration curve and the patients' net benefit was measured by decision curve analysis (DCA).

RESULTS

Among 45,102 elderly patients, 346 (0.76%) developed MACEs. The AUC of this traditional model was 0.800 (95% CI, 0.708-0.831) in the internal validation set, and 0.768 (95% CI, 0.702-0.835) in the external validation set. In the best machine learning prediction model-AdaBoost model, the AUC in the internal and external validation set was 0.778 and 0.732, respectively. Besides, for the traditional prediction model, the calibration curve of model performance accurately predicted the risk of MACEs (Hosmer and Lemeshow, p = 0.573), the DCA results showed that the nomogram had a high net benefit for predicting postoperative MACEs.

CONCLUSIONS

This prediction model based on the traditional method could accurately predict the risk of MACEs after noncardiac surgery in elderly patients.

Impact of surgical complications on hospital costs and revenues: retrospective database study of Medicare claims

Aim: To compare the length of stay, hospital costs and hospital revenues for Medicare patients with and without a subset of potentially preventable postoperative complications after major noncardiac surgery. Materials & methods: Retrospective data analysis using the Medicare Standard Analytical Files, Limited Data Set, 5% inpatient claims files for years 2016-2020. Results: In 74,103 claims selected for analysis, 71,467 claims had no complications and 2636 had one or more complications of interest. Claims with complications had significantly longer length of hospital stay (12.41 vs 3.95 days, p < 0.01), increased payments to the provider ($34,664 vs $16,641, p < 0.01) and substantially higher estimates of provider cost ($39,357 vs $16,158, p < 0.01) compared with claims without complications. This results on average in a negative difference between payments and costs for patients with complications compared with a positive difference for claims without complications (-$4693 vs $483, p < 0.01). Results were consistent across three different cost estimation methods used in the study. Conclusion: Compared with patients without postoperative complications, patients developing complications stay longer in the hospital and incur increased costs that outpace the increase in received payments. Complications are therefore costly to providers and payers, may negatively impact hospital profitability, and decrease the quality of life of patients. Quality initiatives aimed at reducing complications can be immensely valuable for both improving patient outcomes and hospital finances.

Effects of remote ischaemic preconditioning on myocardial injury after major abdominal surgery in patients at high risk for cardiovascular adverse events in China (RIPC-MAS): protocol for a randomised, sham-controlled, observer-blinded trial

INTRODUCTION

Myocardial injury after non-cardiac surgery (MINS) caused by an ischaemic mechanism is common and is associated with adverse short-term and long-term prognoses. However, MINS is a recent concept, and few studies have prospectively used it as a primary outcome. Remote ischaemic preconditioning (RIPC) is a non-invasive procedure that induces innate cardioprotection and may reduce MINS.

METHODS AND ANALYSIS

This is a multicentre, randomised, sham-controlled, observer-blinded trial. Patients with a high clinical risk of cardiovascular events who are scheduled to undergo major abdominal surgery will be enrolled. A total of 766 participants will be randomised (1:1 ratio) to receive RIPC or control treatment before anaesthesia. RIPC will comprise four cycles of cuff inflation for 5 min to 200 mm Hg and deflation for 5 min. In the controls, an identical-looking cuff will be placed around the arm but will not be actually inflated. The primary outcome will be MINS, defined as at least one postoperative cardiac troponin (cTn) concentration above the 99th percentile upper reference limit of the cTn assay as a result of a presumed ischaemic mechanism. This trial will test the concentration of high-sensitivity cardiac troponin T (hs-cTnT). The secondary outcomes will be hs-cTnT levels reaching/above the prognostically important thresholds, peak hs-cTnT and total hs-cTnT release during the initial 3 days after surgery, length of hospital stay after surgery, length of stay in the intensive care unit, myocardial infarction, major adverse cardiovascular events, cardiac-related death, all-cause death within 30 days, 6 months, 1 year and 2 years after surgery, and postoperative complications and adverse events within 30 days after surgery.

ETHICS AND DISSEMINATION

This study protocol (version 5.0 on 7 April 2023) was approved by the Ethics Committee of Sixth Affiliated Hospital of Sun Yat-sen University. The findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05733208.

Handoffs and the challenges to implementing teamwork training in the perioperative environment

Perioperative handoffs are high-risk events for miscommunications and poor care coordination, which cause patient harm. Extensive research and several interventions have sought to overcome the challenges to perioperative handoff quality and safety, but few efforts have focused on teamwork training. Evidence shows that team training decreases surgical morbidity and mortality, and there remains a significant opportunity to implement teamwork training in the perioperative environment. Current perioperative handoff interventions face significant difficulty with adherence which raises concerns about the sustainability of their impact. In this perspective article, we explain why teamwork is critical to safe and reliable perioperative handoffs and discuss implementation challenges to the five core components of teamwork training programs in the perioperative environment. We outline evidence-based best practices imperative for training success and acknowledge the obstacles to implementing those best practices. Explicitly identifying and discussing these obstacles is critical to designing and implementing teamwork training programs fit for the perioperative environment. Teamwork training will equip providers with the foundational teamwork competencies needed to effectively participate in handoffs and utilize handoff interventions. This will improve team effectiveness, adherence to current perioperative handoff interventions, and ultimately, patient safety.