Ct-based diagnosis of sarcopenia as a prognostic factor for postoperative mortality after elective open-heart surgery in older patients: a cohort-based systematic review and meta-analysis

Background

Cardiac open-heart surgery, which usually involves thoracotomy and cardiopulmonary bypass, is associated with a high incidence of postoperative mortality and adverse events. In recent years, sarcopenia, as a common condition in older patients, has been associated with an increased incidence of adverse prognosis.

Methods

We conducted a search of databases including PubMed, Embase, and Cochrane, with the search date up to January 1, 2024, to identify all studies related to elective cardiac open-heart surgery in older patients. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence.

Results

A total of 12 cohort studies were included in this meta-analysis for analysis. This meta-analysis revealed that patients with sarcopenia had a higher risk of postoperative mortality. Furthermore, the total length of hospital stay and ICU stay were longer after surgery. Moreover, there was a higher number of patients requiring further healthcare after discharge. Regarding postoperative complications, sarcopenia patients had an increased risk of developing renal failure and stroke.

Conclusion

Sarcopenia served as a tool to identify high-risk older patients undergoing elective cardiac open-heart surgery. By identifying this risk factor early on, healthcare professionals took targeted steps to improve perioperative function and made informed clinical decisions.Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42023426026.

Association of computed tomography-derived muscle mass and quality with delayed acquisition independent walking after cardiovascular surgery

BACKGROUND

In the context of cardiovascular surgery, the foremost concern lies in delayed functional recovery, as typified by the acquisition of independent walking after surgery, among older patients with decline in skeletal muscle mass and quality. Computed tomography (CT), which is typically employed for the preoperative assessment of pathological conditions in patients undergoing cardiovascular surgery, is also suitable for screening for potential decline in skeletal muscle mass and quality. The aim of this study was to examine the predictive capabilities of CT-derived parameters such as muscle mass and muscle quality for the delayed acquisition of independent walking in the postoperative period.

METHODS

This retrospective study enrolled consecutive Japanese patients who underwent elective cardiovascular surgery between May 2020 and January 2023. In total, 139 patients were included in the analyses. Based on the preoperative CT image, the psoas muscle volume index (PMVI) and psoas muscle attenuation (PMA) were calculated. Information on patient characteristics, including preoperative physical fitness such as handgrip strength/body mass index (GS/BMI), short physical performance battery (SPPB), and 6-min walking distance (6MWD), were obtained from the medical records. We defined delayed acquisition of independent walking after surgery as the inability to walk 100 m within 4 days after surgery.

RESULTS

The median age of the patients was 72 (interquartile: 64-78) years, and 74.8% (104/139) were men; 47.5% corresponded to the delayed group. The areas under the curves of SPPB, GS/BMI, 6MWD, PMVI, and PMA against delayed acquisition of independent walking after surgery were 0.68 [95% confidence interval (CI): 0.59 to 0.77], 0.72 (95% CI: 0.63 to 0.80), 0.73 (95% CI: 0.65 to 0.82), 0.69 (95% CI: 0.60 to 0.78), and 0.78 (95% CI: 0.70 to 0.85), respectively. In the multivariate logistic regression analysis, low PMA was significantly associated with delayed acquisition of independent walking even after adjustment for patient characteristics including physical fitness [model 1: SPPB (OR, 1.14; 95% CI: 1.03-1.25), model 2: GS/BMI (OR, 1.13; 95% CI: 1.03-1.25), and model 3: 6MWD (OR, 1.14; 95% CI: 1.03-1.25)], but PMVI was not.

CONCLUSIONS

Our study revealed a strong association between PMA, a marker of CT-derived muscle quality, and the postoperative delay in achieving independent walking in patients who underwent cardiovascular surgery. The technique to obtain information on muscle quality during the time period before surgery may be an option for timely therapeutic intervention in patients who may have delayed acquisition of independent walking after surgery.

Computed tomography -defined sarcopenia is associated with long-term survival among patients undergoing open thoracic aortic reconstruction

BACKGROUND AND OBJECTIVE

As markers of sarcopenia, psoas muscle areas and indexes measured from computed tomography images have been found to predict long-term mortality in cardiothoracic as well as other surgical cohorts. Our objective was to investigate the association between psoas muscle status, taking into account muscle density in addition to area, and survival among patients undergoing open thoracic aortic reconstruction.

METHODS

This was a retrospective registry study of a total of 451 patients treated with open surgery for thoracic aortic pathology. Psoas muscle area and density were measured from preoperative computed tomography images at the L3 and L4 lumbar levels. In addition, lean psoas muscle area was calculated by averaging sex-specific values of psoas muscle area and density. The association between mortality and psoas muscle status was analyzed with adjusted Cox-regression analysis.

RESULTS

The median age of the study population was 63 (interquartile range (IQR): 53-70) years. The majority were male (74.7%, n = 337) and underwent elective procedures (58.1% n = 262). Surgery of the ascending aorta was carried out in 90% of the patients, and 15% (n = 67) had concomitant coronary artery bypass surgery. Aortic dissection was present in 34.6% (n = 156) patients. Median follow-up time was 4.3 years (IQR: 2.2-7.4). During the follow-up, 106 patients (23.5%) died, with 55.7% of deaths occurring within the first four postoperative weeks. Psoas muscle parameters were not associated with perioperative mortality, but significant independent associations with long-term mortality were observed for psoas muscle area, density, and lean psoas muscle area with hazard ratios (HRs) of 0.63 (95% confidence interval (CI): 0.45-0.88), 0.62 (95% CI: 0.46-0.83), and 0.47 (95% CI: 0.32-0.69), respectively (all per 1-SD increase).

CONCLUSIONS

Psoas muscle sarcopenia status is associated with long-term mortality after open thoracic aortic surgery.

Impact of Frailty in Patients Undergoing Minimally Invasive Mitral Valve Surgery

OBJECTIVE

Psoas muscle size is a reliable marker of sarcopenia and frailty that correlates with adverse outcomes after cardiac surgery. However, its use in mitral and minimally invasive cardiac surgery is lacking. We sought to determine whether frailty, as measured by psoas muscle index, increases surgical risk for minimally invasive mitral valve surgery.

METHODS

Patients undergoing isolated minimally invasive mitral surgery via right minithoracotomy were identified. Patients who underwent maze, tricuspid intervention, and those who were emergent were excluded. Total psoas muscle area was calculated using the average cross-sectional area at the L3 vertebra on computed tomography scan and indexed to body surface area. Sarcopenia was defined as <25th gender-specific percentile. Patients were stratified by sarcopenia status and outcomes compared.

RESULTS

Of 287 total patients, 192 patients met inclusion criteria. Sarcopenic patients were 6 years older (66 vs 60 years, P = 0.01), had lower preoperative albumin levels (4.0 vs 4.3 g/dL, P < 0.001), and had higher Society of Thoracic Surgeons risk of morbidity/mortality (13.1% vs 9.0%, P = 0.003). Operative major morbidity or mortality was 6.4% versus 5.5% (P = 0.824), while the 1-year mortality rate was 2.1% versus 0% (P = 0.08). After risk adjustment, psoas index did not predict operative morbidity or mortality. However, sarcopenia was associated with higher odds of readmission (odds ratio = 0.74, P = 0.02).

CONCLUSIONS

Contrary to other cardiac operations, for patients undergoing isolated minimally invasive mitral valve surgery, sarcopenia was not associated with increased perioperative risk except for higher readmission rates. Minimally invasive surgical approaches should be strongly considered as the approach of choice in frail patients.

Impact of sarcopenia on outcomes in surgical patients: a systematic review and meta-analysis

BACKGROUND

Surgeons have historically used age as a preoperative predictor of postoperative outcomes. Sarcopenia, the loss of skeletal muscle mass due to disease or biological age, has been proposed as a more accurate risk predictor. The prognostic value of sarcopenia assessment in surgical patients remains poorly understood. Therefore, the authors aimed to synthesize the available literature and investigate the impact of sarcopenia on perioperative and postoperative outcomes across all surgical specialties.

METHODS

The authors systematically assessed the prognostic value of sarcopenia on postoperative outcomes by conducting a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching the PubMed/MEDLINE and EMBASE databases from inception to 1st October 2022. Their primary outcomes were complication occurrence, mortality, length of operation and hospital stay, discharge to home, and postdischarge survival rate at 1, 3, and 5 years. Subgroup analysis was performed by stratifying complications according to the Clavien-Dindo classification system. Sensitivity analysis was performed by focusing on studies with an oncological, cardiovascular, emergency, or transplant surgery population and on those of higher quality or prospective study design.

RESULTS

A total of 294 studies comprising 97 643 patients, of which 33 070 had sarcopenia, were included in our analysis. Sarcopenia was associated with significantly poorer postoperative outcomes, including greater mortality, complication occurrence, length of hospital stay, and lower rates of discharge to home (all P <0.00001). A significantly lower survival rate in patients with sarcopenia was noted at 1, 3, and 5 years (all P <0.00001) after surgery. Subgroup analysis confirmed higher rates of complications and mortality in oncological (both P <0.00001), cardiovascular (both P <0.00001), and emergency ( P =0.03 and P =0.04, respectively) patients with sarcopenia. In the transplant surgery cohort, mortality was significantly higher in patients with sarcopenia ( P <0.00001). Among all patients undergoing surgery for inflammatory bowel disease, the frequency of complications was significantly increased among sarcopenic patients ( P =0.007). Sensitivity analysis based on higher quality studies and prospective studies showed that sarcopenia remained a significant predictor of mortality and complication occurrence (all P <0.00001).

CONCLUSION

Sarcopenia is a significant predictor of poorer outcomes in surgical patients. Preoperative assessment of sarcopenia can help surgeons identify patients at risk, critically balance eligibility, and refine perioperative management. Large-scale studies are required to further validate the importance of sarcopenia as a prognostic indicator of perioperative risk, especially in surgical subspecialties.

Impact of sarcopenia on early and mid-term outcomes of surgery for acute type A aortic dissection in octogenarians

OBJECTIVE

To determine the association between sarcopenia and surgical outcomes in octogenarians with acute type A aortic dissection.

METHODS

We enrolled 72 octogenarians who had undergone type A aortic dissection surgery between April 2013 and March 2019. The psoas muscle index, an indexed area of the psoas muscle at the L3 level on preoperative computed tomography, was obtained as an indicator of sarcopenia. The study participants were divided into sarcopenia and non-sarcopenia groups based on the mean psoas muscle index. The postoperative outcomes were compared between the groups.

RESULTS

The median age was 84 years (interquartile range 82-87 years), and 13 patients were male. The mean psoas muscle index was 3.53 ± 0.97 cm2/m2. Except for sex, no significant differences were observed in patients' baseline characteristics and operative data between the two groups. The 30-day mortality rates in the sarcopenia and non-sarcopenia groups were 14% and 8%, respectively (P = 0.71), and postoperative morbidity was similar in both groups. Postoperative all-cause mortality was significantly higher in the sarcopenia group (log-rank P = 0.038), especially in patients aged 85 years or older (log-rank P < 0.01). The sarcopenia group had a lower home discharge rate than the non-sarcopenia group (21% vs. 54%, P < 0.01), and home discharge was associated with longer survival (log-rank P = 0.015).

CONCLUSIONS

All-cause mortality after emergency surgery for acute type A aortic dissection was significantly higher in octogenarians with sarcopenia than in those without, especially in patients aged 85 years or older.

Impact of sarcopenia on long-term survival after cardiac surgery for end-stage renal disease patients

BACKGROUND

The long-term mortality of end-stage renal disease (ESRD) patients is still unsatisfactory. Therefore, long-term risk assessments in ESRD patients undergoing cardiac surgery are needed. Recently, sarcopenia is major concern in cardiac surgery because of its association with poor long-term survival. However, the impact of sarcopenia on the long-term survival of ESRD patients undergoing cardiac surgery is not well understood.

METHODS

Eighty-two ESRD patients who underwent elective cardiac surgery were enrolled. Sarcopenia was identified based on noncontrast abdominal computed tomography. The impact of preoperative and intraoperative factors on long-term survival was investigated.

RESULTS

Forty-three patients (52%) were diagnosed with sarcopenia. The in-hospital mortality rate was 4.9%. The 5-year overall survival rate was 48%. The multivariate analyses revealed that STS score ≥ 4 (odds ratio, 6.0; confidence interval, 2.5-14.7; p < 0.01) and presence of sarcopenia (odds ratio, 2.4; confidence interval, 1.3-4.5; p  =  0.03) were independent risk factors for overall survival. The 5-year survival rates of low-risk (Society of Thoracic Surgeons score of < 4) patients without sarcopenia, low-risk with sarcopenia, more than intermediate-risk (Society of Thoracic Surgeons score of ≥ 4) without sarcopenia, and more than intermediate-risk with sarcopenia groups were 80%, 51%, 50%, and 26%, respectively.

CONCLUSIONS

Among the ESRD patients, the low risk without sarcopenia group showed an excellent long-term survival, in contrast to more than intermediate-risk patients with sarcopenia, who can expect poor long-term survival. Preoperative assessment of sarcopenia in addition to the surgical risk score can be useful in developing a therapeutic strategy.

Sarcopenia Adversely Affects Outcomes following Cardiac Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Sarcopenia is a degenerative condition characterised by the loss of skeletal muscle mass and strength. Its impact on cardiac surgery outcomes remains poorly investigated. This meta-analysis aims to provide a comprehensive synthesis of the available evidence to determine the effect of sarcopenia on cardiac surgery outcomes.

METHODS

A systematic review and meta-analysis followed PRISMA guidelines from inception to April 2023 in EMBASE, MEDLINE, Cochrane database, and Google Scholar. Twelve studies involving 2717 patients undergoing cardiac surgery were included. Primary outcomes were early and late mortality; secondary outcomes included surgical time, infection rates, and functional outcomes. Statistical analyses were performed using appropriate methods.

RESULTS

Sarcopenic patients (906 patients) had a significantly higher risk of early mortality (OR: 2.40, 95% CI: 1.44 to 3.99, p = 0.0007) and late mortality (OR: 2.65, 95% CI: 1.57 to 4.48, p = 0.0003) compared to non-sarcopenic patients (1811 patients). There were no significant differences in overall surgical time or infection rates. However, sarcopenic patients had longer ICU stays, higher rates of renal dialysis, care home discharge, and longer intubation times.

CONCLUSION

Sarcopenia significantly increases the risk of early and late mortality following cardiac surgery, and sarcopenic patients also experience poorer functional outcomes.

Impact of muscle loss in children with hematologic malignancies undergoing allogeneic hematopoietic cell transplantation

The widespread recognition of the concept of sarcopenia, or muscle loss, has impacted the prognosis of patients undergoing high-intensity treatments. We focused on the effect of muscle loss on the prognosis of pediatric patients with hematologic diseases. A total of 65 patients with hematologic malignancies who underwent allogeneic HCT once were investigated. The change in cross-sectional psoas muscle area (PMA) measured on computed tomography (CT) images was expressed as the muscle loss index (MLI), which was calculated by dividing the pre-HCT PMA by the baseline PMA. In this study, patients with MLI values less than 0.85 were classified into the muscle loss group. Muscle loss was observed in 27 patients (41.5%). Patients who experienced muscle loss were older than those who did not. Muscle loss was an independent predictor of higher non-relapse mortality (NRM) (p = 0.012) and inferior overall survival (OS) (p = 0.045) at 5 years. Multivariate analysis showed that muscle loss was an independent risk factor for higher NRM (p = 0.046), and inferior EFS (p = 0.048). Muscle loss observed pre-HCT may be a predictor of increased NRM, poor OS and EFS in pediatric patients with hematologic malignancies undergoing allogeneic HCT.

Psoas muscle size, possible sarcopenia and frailty, and long-term survival in elderly patients after isolated surgical aortic valve replacement for aortic stenosis

Purpose

This study investigated the use of psoas muscle area index (PAI) as an indicator of mortality risk in relation to survival in elderly patients after isolated surgical aortic valve replacement (SAVR) for aortic valve stenosis (AS).

Methods

Between January 2005 and March 2015, 140 patients with AS, aged ≥ 70 years, and with preoperative abdominal computed tomography scans, underwent elective, primary, isolated SAVR. PAI showed the ratio of the psoas muscle cross-sectional area at the fourth lumbar vertebral level to body surface area, and PAI less than the gender-specific lowest 20th percentile we called “low PAI” for the purposes of this study. Patients were classified as low PAI (n = 29) or normal PAI (n = 111).

Results

The mean age in the low-PAI group was significantly older than in the normal-PAI group (81.0 vs. 77.3 years; p = 0.001). The mean follow-up was 4.25 years. The low-PAI group had a lower survival rate than the normal-PAI group at 1 year (89.7 ± 5.7% vs. 96.3 ± 1.8%), at 3 years (71.6 ± 9.3% vs. 91.5 ± 2.7%), and overall (53.0 ± 13.4% vs. 76.0 ± 5.6%; p = 0.039). The prognostic factors of mortality included low PAI (hazard ratio 2.95; 95% confidence interval 1.084–8.079; p = 0.034).

Conclusions

PAI was associated with reduced overall survival after isolated SAVR in elderly people. PAI measurement may help to predict patient risks.

Current Clinical Implications of Frailty and Sarcopenia in Vascular Surgery: A Comprehensive Review of the Literature and Consideration of Perioperative Management

Frailty is a well-known geriatric syndrome of impaired physiological reserve and increased vulnerability to stressors. Sarcopenia is also used as a parameter of physical impairment characterized by muscle weakness. As population aging has become more prominent in recent years, both modalities are now regarded as clinically important prognostic tools defined by multidimensional factors that may affect clinical outcomes in various clinical settings. A preoperative surgical risk analysis is mandatory to predict clinical and surgical outcomes in all surgical practices, particularly in high-risk surgical patients. In vascular surgical settings, frailty and sarcopenia have been accepted as useful prognostic tools to evaluate patient characteristics before surgery, as these may predict perioperative clinical and surgical outcomes. Although minimally invasive surgical approaches, such as endovascular therapy, and hybrid approaches have been universally developed, achieving good vascular surgical outcomes for high-risk cohorts remains to be challenge due to the increasing prevalence of elderly patients and multiple preoperative co-morbidities in addition to frailty and sarcopenia. Therefore, to further improve clinical and surgical outcomes, these preoperative geriatric prognostic factors will be of great importance and interest in vascular surgical settings for both physicians and surgeons.

Paradigm shift in gastrointestinal surgery − combating sarcopenia with prehabilitation: Multimodal review of clinical and scientific data

A growing body of evidence has demonstrated the prognostic significance of sarcopenia in surgical patients as an independent predictor of postoperative complications and outcomes. These included an increased risk of total complications, major complications, re-admissions, infections, severe infections, 30 d mortality, longer hospital stay and increased hospitalization expenditures. A program to enhance recovery after surgery was meant to address these complications; however, compliance to the program since its introduction has been less than ideal. Over the last decade, the concept of prehabilitation, or “pre-surgery rehabilitation”, has been discussed. The presurgical period represents a window of opportunity to boost and optimize the health of an individual, providing a compensatory “buffer” for the imminent reduction in physiological reserve post-surgery. Initial results have been promising. We review the literature to critically review the utility of prehabilitation, not just in the clinical realm, but also in the scientific realm, with a resource management point-of-view.

Preoperative sarcopenia is associated with late mortality after off-pump coronary artery bypass grafting

OBJECTIVES

We investigated the association between sarcopenia (a marker of frailty) and outcomes after coronary artery bypass grafting (CABG).

METHODS

This study included 304 patients who underwent elective isolated off-pump CABG at our hospital between October 2008 and August 2013. Psoas muscle area was measured on preoperative computed tomography scans. Sarcopenia was defined as the lowest sex-specific quartile of the psoas muscle area index (the psoas muscle area normalized for height). Patients were categorized into a sarcopenia group (76 patients) and a non-sarcopenia group (228 patients). Patients in the sarcopenia group were older and showed a lower body mass index, lower serum haemoglobin and albumin levels and lower prevalence of dyslipidaemia but higher prevalence of renal dysfunction and peripheral artery disease. The mean follow-up period was 4.5 ± 2.3 years.

RESULTS

The cut-off values for sarcopenia were psoas muscle area index 215 and 142 mm2/m2 in men and women, respectively. No intergroup difference was observed in the in-hospital mortality and morbidity rates. After risk adjustment using inverse probability weighting analysis, late mortality rates were significantly higher in the sarcopenia group than in the non-sarcopenia group (P = 0.022). Multivariable analysis showed that preoperative sarcopenia was an independent predictor of late mortality (hazard ratio 4.25, 95% confidence interval 2.18-8.28; P < 0.001). Preoperative sarcopenia was not associated with major adverse cardiac and cerebrovascular events during follow-up.

CONCLUSIONS

Preoperative sarcopenia (assessed by psoas muscle area index) was associated with late mortality after CABG and effectively predicts postoperative prognosis.

Systematic review and meta-analysis of lean mass and mortality: Rationale and study description

Objectives

Muscle mass is one of the key components in defining sarcopenia and is known to be important for locomotion and body homeostasis. Lean mass is commonly used as a surrogate of muscle mass and has been shown to be associated with increased mortality. However, the relationship of lean mass with mortality may be affected by different clinical conditions, modalities used, cut-off point to define low or normal lean mass, and even types of cancer among cancer patients. Thus, we aim to perform a comprehensive meta-analysis of lean mass with mortality by considering all these factors.

Methods

Systematic search was done in PubMed, Cochrane Library and Embase for articles related to lean mass and mortality. Lean mass measured by dual X-ray absorptiometry, bioelectrical impedance analysis, and computerized tomography were included.

Results

The number of relevant studies has increased continuously since 2002. A total of 188 studies with 98 468 people were included in the meta-analysis. The association of lean mass with mortality was most studied in cancer patients, followed by people with renal diseases, liver diseases, elderly, people with cardiovascular disease, lung diseases, and other diseases. The meta-analysis can be further conducted in subgroups based on measurement modalities, site of measurements, definition of low lean mass adopted, and types of cancer for studies conducted in cancer patients.

Conclusions

This series of meta-analysis provided insight and evidence on the relationship between lean mass and mortality in all directions, which may be useful for further study and guideline development.

Presence of sarcopenia does not affect the clinical results of balloon kyphoplasty for acute osteoporotic vertebral fracture

Sarcopenia has been associated with poor clinical outcomes in several diseases. Herein, the clinical results of balloon kyphoplasty (BKP) for acute osteoporotic vertebral fracture (OVF) treatment were assessed and compared between sarcopenia and non-sarcopenia patients. Sixty patients who underwent BKP for treatment of acute OVF with poor prognostic factors between April 2016 and September 2017 and were assessed for sarcopenia were enrolled. Clinical results (back pain on visual analogue scale [VAS]; short-form [SF] 36; vertebral deformity; activities of daily living levels; and incidence of adjacent vertebral fractures) were compared between the two groups at 6 months post-BKP. Data analysis revealed that back pain on VAS, SF-36 scores, and vertebral deformity improved from baseline to 6 months after BKP. Thirty-nine patients (65.0%) were diagnosed with sarcopenia and demonstrated a lower body mass index (21.2 vs. 23.3 kg/m², p = 0.02), skeletal muscle mass index (5.32 vs. 6.55 kg/m², p < 0.01), hand-grip strength (14.7 vs. 19.2 kg, p = 0.01), and bone mineral density of the femoral neck (0.57 vs. 0.76 g/cm², p < 0.01) than those of patients without sarcopenia. However, no significant differences were observed in the clinical results between these groups. Therefore, BKP's clinical results for the treatment of acute OVF are not associated with sarcopenia.

Sarcopenia in open heart surgery patients: A cohort study

Background

Sarcopenia is a condition characterized by loss of muscle mass, muscle strength, or physical performance. It has been reported that cardiac surgery causes systemic inflammatory response, which leads to sarcopenia. In addition, open-heart surgery (OHS) has been associated with length of hospital stay, prolonged mechanical ventilation, and postoperative pulmonary complications. However, very few studies have explored the association of sarcopenia with OHS. Thus, this study explores the prevalence of sarcopenia in OHS patients as well as their relationship.

Methods

This cohort study included 160 patients; it was designed to assess sarcopenia during preoperative OHS and before patient discharge from the hospital. Sarcopenia was defined according to Asian Working Group for Sarcopenia (AWGS) criteria as low muscle mass plus low muscle strength and/or slow gait speed. Participants were requested to perform exercises to test their handgrip strength, gait speed, and bioelectrical impedance. In addition, their medical history (e.g., duration of hospitalization and mechanical ventilation) was recorded.

Results

The prevalence of sarcopenia during preoperative OHS was 26.9%, with affected men comprising 11.9% and affected women comprising 15% of the total sample. Participants with sarcopenia had a significantly lower body mass index (BMI) than those without. Further, patients who had longer stays in the hospital and prolonged mechanical ventilation time showed significantly higher rates of developing sarcopenia. During postoperative OHS, the incidence of sarcopenia rose by 20.92%, increasing the total prevalence of sarcopenia to 46.41%. Moreover, advanced age emerged as one of the most significant risk factors of sarcopenia. Participants in the age group >55 years had an increased risk of sarcopenia (odds ratio [OR]: 3.90). It was also found that patients with a low BMI (<23 kg∗m⁻²) and a history of diabetes mellitus (DM) had an increased risk of sarcopenia (ORs: 2.11 and 1.47, respectively). Moreover, longer hospital stays and mechanical ventilation times were important risk factors (ORs: 1.58 and 2.07, respectively).

Conclusion

The prevalence of sarcopenia was observed to be high during postoperative OHS. Participants with sarcopenia who underwent OHS had a history of DM, longer length of hospital stays, and prolonged mechanical ventilation times, compared with patients without sarcopenia.

Clinical trial registration number

TCTR20190509003.

Risk of Psoas Muscle Atrophy After Endovascular Aneurysm Repair Assessed by Cross-Sectional Psoas Muscle Area

PURPOSE

We evaluated possible association of decreased psoas muscle area (PMA) after endovascular aneurysm repair (EVAR) by measuring the area of muscle in computed tomographic (CT) images.

MATERIALS AND METHODS

We retrospectively reviewed CT images of 201 consecutive patients who underwent EVAR at our institution between April 1, 2015, and November 9, 2018, and compared them with images of 75 consecutive patients with no history of EVAR, who served as controls and underwent thoracic endovascular aortic repair (TEVAR) during the same period. We investigated EVAR and possible associated factors that might be potential predictors of decrease in PMA.

RESULTS

Those patients with a history of EVAR demonstrated significantly greater mean decrease in PMA than those with a history of TEVAR after the repair procedure (mean 6.25% (8.5); P < 0.001; odds ratio [OR], 3.63; 95% confidence interval [CI] 1.90-6.90).

CONCLUSION

Although EVAR is a less stressful procedure than other major abdominal surgeries, we identified it as an independent predictor of decreased area of the psoas muscle. Thus, our results might encourage post-procedural evaluation of frailty associated with psoas muscle function and prescription of appropriate rehabilitation interventions after EVAR to help prevent deterioration of patients' abilities.

Skeletal muscle quality affects patient outcomes in acute type A aortic dissection

OBJECTIVES

Although skeletal muscle quantity is linked to surgical outcomes, quality remains unexamined. In this study, we evaluated whether skeletal muscle quality and quantity could predict surgical outcomes in acute type A aortic dissection (ATAAD).

METHODS

Skeletal muscle quality and quantity were evaluated using computed tomography (CT) values and the psoas muscle mass index, respectively. From May 2004 to December 2017, 324 ATAAD patients underwent aortic replacement after CT scans and psoas muscle mass index measurements. Patients were grouped into intramuscular fat (IMF; n = 55) and non-IMF (n = 269) deposition groups.

RESULTS

The mean ages of the patients were 72.3 ± 9.7 and 66.8 ± 12.1 years (P = 0.002), and hospital mortality rates were 3.6% (2/55) and 7.4% (20/269; P = 0.393) for IMF and non-IMF deposition groups, respectively. IMF deposition was a risk factor for a deterioration in activities of daily living at discharge by multivariable analysis [odds ratio 0.33, 95% confidence interval (CI) 0.16-0.69; P = 0.003]. The mean follow-up was 43.9 ± 36.8 months. The 5-year survival was significantly worse for the IMF deposition group (IMF 73.8% vs non-IMF 88.2%; P = 0.010). The multivariable Cox proportional hazard analysis showed that IMF deposition significantly predicted poor survival (hazard ratio 3.26, 95% CI 1.47-7.24; P = 0.004), unlike psoas muscle mass index and age.

CONCLUSIONS

Skeletal muscle quality, defined by IMF deposition, was an independent predictor of overall survival and postoperative activities of daily living dependence risk in patients undergoing surgery for ATAAD. Thus, IMF deposition may be an additional risk factor for estimating late outcomes of ATAAD surgery.

The psoas muscle index as a predictor of mortality and morbidity of geriatric trauma patients: experience of a major trauma center in Kobe

PURPOSE

An association between the prognoses of trauma and sarcopenia has not been well documented. The purpose of this study was to compare the outcomes of elderly Japanese trauma patients with sarcopenia and those without sarcopenia.

METHODS

The medical records of patients aged ≧ 65 years old and Injury Severity Scores above 15 treated for trauma between 2010 and 2017 were reviewed, retrospectively. We measured the psoas muscle index (PMI), defined as the psoas muscle area at the third lumbar vertebra level divided by the body surface area. Patients of each gender with a PMI less than the lower interquartile range were included in the sarcopenia group. A questionnaire was mailed to the patients or their families to collect data on 1-year mortality and activities of daily living.

RESULTS

There were 405 patients included in this study: 304 in the non-sarcopenia group (Group NS) and 101 in the sarcopenia group (Group S). Mortality was significantly higher in Group S than in Group NS (NS; 7.9% vs. S; 15.8%, OR, 2.20; 95% CI, 1.12-4.32; p = 0.027). Only 175 of the questionnaires were completed and the responses did not reveal any significant differences between the groups.

CONCLUSIONS

Sarcopenia as defined by the PMI may be used as an indicator for mortality risk for geriatric trauma patients.

Sarcopenia assessed by the quantity and quality of skeletal muscle is a prognostic factor for patients undergoing cardiac surgery

PURPOSE

Sarcopenia was assessed as a prognostic factor for patients undergoing cardiac surgery by evaluating the quantity and quality of skeletal muscle.

METHODS

Sarcopenia was assessed by perioperative abdominal computed tomography using the total psoas muscle index (TPI) and intra-muscular adipose tissue content (IMAC). Patients were classified into high- (HT, n = 143) and low- (LT, n = 63) TPI groups and low- (LI, n = 122) and high- (HI, n = 84) IMAC groups.

RESULTS

There were significantly more complications in the LT and HI groups than in the HT and LI groups. (HT 15.4% vs. LT 30.2%, P = 0.014) (LI 11.5% vs. HI 31.1%, P < 0.001). There were more respiratory complications in the LT group (HT 0% vs. LT 6.3%, P = 0.002) and more surgical site infections in the HI group than in the LI group (LI 0.8% vs. HI 7.1%, P = 0.014). A multivariable analysis showed that low TPI and high IMAC significantly predicted more major complications than other combinations (odds ratio [OR] 2.375; 95% confidence interval [CI] 1.152-5.783; P = 0.036, OR 3.973; 95% CI 1.737-9.088; P = 0.001).

CONCLUSIONS

Sarcopenia is a risk factor for complications. The quantity and quality of muscle must be assessed to predict operative outcomes.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000027077.

Effects of sarcopenia on functional improvement over the first year after cardiac surgery: a cohort study

Background:

Sarcopenia is linked with poor postoperative outcomes.

Aims:

To evaluate the effects of sarcopenia on first-year functional changes after cardiac surgery.

Methods:

In this prospective cohort study, functional changes (physical activity levels in metabolic equivalent hours/week, 6-minute walking distance in metres, and grip strength in kg) from preoperative baseline to 1, 3, 6 and 12 months postoperatively were compared in adult patients with and without sarcopenia undergoing cardiac surgery at a tertiary medical centre. Presurgical sarcopenia was defined as low muscle mass plus either low strength or poor physical performance (i.e. reduced gait speed). Secondary outcomes (length of hospital stay and 1-year mortality) were compared between sarcopenia and non-sarcopenia groups.

Results:

Sarcopenia presented in 27.7% ( n=67) of 242 participants. Participants with sarcopenia were significantly older, predominantly women, and had lower body mass index and higher cardiac surgery risk (measured by the EuroSCORE II) than those without sarcopenia. For both groups, physical activity levels, walking distance and grip strength steadily improved over the year following cardiac surgery. Independent of EuroSCORE II, changes in physical activity levels, walking distance and grip strength did not differ significantly between the sarcopenia and non-sarcopenia groups 1, 3, 6 and 12 months after surgery. Nevertheless, the sarcopenia group had a significantly longer length of hospital stay than the non-sarcopenia group (19.4 vs. 15.3 days; β=2.9, P=0.02) but 1-year mortality (3.4 vs. 3.9% for non-sarcopenia group) was comparable.

Conclusions:

Despite a longer length of hospital stay for the sarcopenia group, sarcopenia was not a restriction for cardiac surgery given their comparable functional improvement and mortality 1 year following surgery.

Psoas Muscle Size Predicts Risk-Adjusted Outcomes After Surgical Aortic Valve Replacement

BACKGROUND

Frailty is an important predictor of outcomes after cardiac surgery, but utility is limited by difficult assessment and quantification. We hypothesize that sarcopenia defined as psoas muscle cross-sectional area is a useful predictor of surgical aortic valve replacement outcomes in moderate to high-risk patients.

METHODS

Moderate to high risk patients (predicted risk of mortality greater than 3%) who underwent surgical aortic valve replacement with or without coronary artery bypass were extracted from an institutional database (2009 to 2016). Psoas index was calculated as the cross-sectional area of the psoas muscle at the L4 vertebral level normalized to body surface area. Patients were stratified by sarcopenia status, defined as less than 25th sex-specific percentile. Multivariable regression analysis identified risk-adjusted associations with psoas index using The Society of Thoracic Surgeons predicted risk scores.

RESULTS

Of the 240 patients included, the median predicted risk of mortality was 6%, median age 80 years, and 40% were female. Patients with (33.3%) and without (66.7%) sarcopenia had equivalent baseline risk (median predicted risk of mortality 5.7% versus 6.0%, p = 0.29). Patients with sarcopenia had higher 1-year mortality (31.9% versus 16.9% p = 0.03). Psoas index significantly predicted risk-adjusted 1-year mortality (odds ratio 0.84, p = 0.02) and long-term mortality (hazard ratio 0.92, p = 0.04), as well as risk-adjusted major morbidity, prolonged ventilation, length of stay, discharge to a facility, and hospital cost. Finally, psoas index measurements were highly reproducible (Pearson correlation coefficient 0.944).

CONCLUSIONS

Psoas index is an easily obtained and reproducible measure of frailty that predicts risk-adjusted resource utilization, morbidity, and long-term mortality. Psoas index may improve procedural selection and risk adjustment in high-risk patients with aortic valve disease.