The patient with chronic heart failure undergoing surgery

Glucagon-like Receptor-1 agonists for obesity: Weight loss outcomes, tolerability, side effects, and risks

Background

This review investigates the side effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) like liraglutide, semaglutide, and tirzepatide, medications known for their efficacy in promoting weight loss among individuals with obesity. The rationale is rooted in understanding the balance between their therapeutic benefits and associated risks.

Methods

This was a comprehensive clinical review, including systematic reviews, meta-analyses, randomized controlled trials (RCTs), and cohort studies. Data were extracted from databases such as PubMed, Scopus, Embase, MEDLINE, and Google Scholar, focusing on the tolerability, severity, and risks of these medications.

Results

GLP-1RAs demonstrated significant weight loss outcomes. In clinical trials, liraglutide showed a placebo-corrected weight loss of around 5 %, semaglutide 12 %, and tirzepatide 18 %. Common side effects were predominantly gastrointestinal, including nausea, diarrhea, constipation, and vomiting. Rare serious adverse events included gallbladder disorders and acute pancreatitis. In, addition, multiple studies identify new risks associated with GLP-1RAs including increased aspiration risk during anesthesia due to delayed gastric emptying and challenges with bowel preparation for colonoscopies.

Conclusion

While GLP-1RAs are effective in managing obesity, their use is associated with gastrointestinal side effects and rare but serious adverse events. The findings underscore the importance of individualized dosing and thorough patient assessment. Continuous research and vigilant monitoring are essential to optimize their safe use. Further studies are needed to refine guidelines, particularly regarding new concerns such as delayed gastric emptying and its implications for anesthesia.

Heart failure diagnostic accuracy, intraoperative fluid management, and postoperative acute kidney injury: a single-centre prospective observational study

BACKGROUND

The accurate diagnosis of heart failure (HF) before major noncardiac surgery is frequently challenging. The impact of diagnostic accuracy for HF on intraoperative practice patterns and clinical outcomes remains unknown.

METHODS

We performed an observational study of adult patients undergoing major noncardiac surgery at an academic hospital from 2015 to 2019. A preoperative clinical diagnosis of HF was defined by keywords in the preoperative assessment or a diagnosis code. Medical records of patients with and without HF clinical diagnoses were reviewed by a multispecialty panel of physician experts to develop an adjudicated HF reference standard. The exposure of interest was an adjudicated diagnosis of heart failure. The primary outcome was volume of intraoperative fluid administered. The secondary outcome was postoperative acute kidney injury (AKI).

RESULTS

From 40 659 surgeries, a stratified subsample of 1018 patients were reviewed by a physician panel. Among patients with adjudicated diagnoses of HF, those without a clinical diagnosis (false negatives) more commonly had preserved left ventricular ejection fractions and fewer comorbidities. Compared with false negatives, an accurate diagnosis of HF (true positives) was associated with 470 ml (95% confidence interval: 120-830; P=0.009) lower intraoperative fluid administration and lower risk of AKI (adjusted odds ratio:0.39, 95% confidence interval 0.18-0.89). For patients without adjudicated diagnoses of HF, non-HF was not associated with differences in either fluids administered or AKI.

CONCLUSIONS

An accurate preoperative diagnosis of heart failure before noncardiac surgery is associated with reduced intraoperative fluid administration and less acute kidney injury. Targeted efforts to improve preoperative diagnostic accuracy for heart failure may improve perioperative outcomes.

Perioperative Management of Lower Limb Surgery in a Patient with Asymptomatic Left Ventricular Systolic Dysfunction: A Case Report

ABSTRACT

Heart failure poses significant challenges in perioperative settings, with an increasing prevalence in India. While much attention has been given to the management of symptomatic heart failure, there is a dearth of literature on asymptomatic left ventricular systolic dysfunction (ALVSD). In this case report, we present the successful perioperative management of a 35-year-old male with ALVSD and a low ejection fraction undergoing lower limb surgery under combined spinal epidural anesthesia. Our approach aimed to maintain hemodynamic stability, minimize myocardial overload, and mitigate the adverse effects of neuraxial blockade.

2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation

Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.

Chronic heart failure in patients undergoing major head and neck surgery: A hospital-based study

OBJECTIVE

To investigate the effects of chronic heart failure on various post-operative outcomes in head and neck cancer patients undergoing major cancer surgery.

STUDY DESIGN

For this retrospective cohort study of patients undergoing major head and neck cancer surgery, a sample of 10,002 patients between 2017 and 2019 were identified through the Nationwide Inpatient Sample.

SETTING

Patients were selected as undergoing major head and neck cancer surgery, defined as laryngectomy, pharyngectomy, glossectomy, neck dissection, mandibulectomy, and maxillectomy, then separated based on pre-surgical diagnosis of chronic heart failure.

METHODS

The effects of pre-operative chronic heart failure on post-surgical outcomes in these patients were investigated by univariable and multivariable logistic regression using ICD-10 codes and SPSS.

RESULTS

A diagnosis of chronic heart failure was observed in 265 patients (2.6 %). Patients with chronic heart failure had more preexisting comorbidities when compared to patients without chronic heart failure (mean ± SD; 4 ± 1 vs. 2 ± 1). Multivariable logistic regression showed that chronic heart failure patients had significantly greater odds of dying during hospitalization (OR 2.86, 95 % CI 1.38-5.91) and experiencing non-routine discharge from admission (OR 1.89, 95 % CI 1.41-2.54) after undergoing major head and neck cancer surgery.

CONCLUSION

Chronic heart failure is associated with greater length of stay and hospital charges among head and neck cancer patients undergoing major head and neck cancer surgeries. Chronic heart failure patients have significantly greater rates of unfavorable post-operative outcomes, including death during hospitalization and non-routine discharge from admission.

External Validation of the Breast Cancer Surgery Risk Calculator (BCSRc): A Predictive Model for Postoperative Complications

BACKGROUND

The breast cancer surgical risk calculator (BCSRc) is a prognostic tool that determines a breast cancer patient's unique risk of acute complications following each possible surgical intervention. When used in the preoperative setting, it can help to stratify patients with an increased complication risk and enhance the patient-physician informed decision-making process. The objective of this study was to externally validate the four models used in the BCSRc on a large cohort of patients who underwent breast cancer surgery.

METHODS

The BCSRc was developed by using a retrospective cohort from the National Surgical Quality Improvement Program database from 2005 to 2018. Four models were built by using logistic regression methods to predict the following composite outcomes: overall, infectious, hematologic, and internal organ complications. This study obtained a new cohort of patients from the National Surgical Quality Improvement Program by utilizing participant user files from 2019 to 2020. The area under the curve, brier score, and Hosmer-Lemeshow goodness of fit test measured model performance, accuracy, and calibration, respectively.

RESULTS

A total of 192,095 patients met inclusion criteria in the development of the BCSRc, and the validation cohort included 60,144 women. The area under the curve during external validation for each model was approximately 0.70. Accuracy, or Brier scores, were all between 0.04 and 0.003. Model calibration using the Hosmer-Lemeshow statistic found all p-values > 0.05. All of these model coefficients will be updated on the web-based BCSRc platform: www.breastcalc.org .

CONCLUSIONS

The BCSRc continues to show excellent external-validation measures. Collectively, this prognostic tool can enhance the decision-making process, help stratify patients with an increased complication risk, and improve expectant management.

Mechanical thrombectomy in patients with heart failure: the Italian registry of Endovascular Treatment in Acute Stroke

BACKGROUND

Heart failure (HF) is the second most important cardiac risk factor for stroke after atrial fibrillation (AF). Few data are available on mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients with HF.

METHODS

The source of data is the multicentre Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS). All AIS patients ≥ 18 years receiving MT were categorised in two groups: HF and no-HF. Baseline clinical and neuroradiological findings on admission were analysed.

RESULTS

Of 8924 patients, 642 (7.2%) had HF. Compared to the no-HF group, HF patients had higher prevalence of cardiovascular risk factors. Rate of complete recanalisation (TICI 2b-3) was 76.9% in HF vs 78.1% in no-HF group (p = 0.481). Rate of symptomatic intracerebral haemorrhage at 24-h non-contrast computed tomography (NCCT) was 7.6% in HF vs 8.3% in no-HF patients (p = 0.520). At 3 months, 36.4% of HF patients and 48.2% of no-HF patients (p < 0.001) had mRS 0-2, and mortality was, respectively, 30.7% and 18.5% (p < 0.001). In multivariate logistic regression, HF was independently associated with mortality at 3 months (OR 1.53, 1.24-1.88 95% CI, p < 0.001). In multivariate ordinal regression, HF patients had a probability of transitioning to a higher mRS level of 1.23 (1.05-1.44 95% CI, p = 0.012). The propensity score analysis of two groups matched for age, sex, and NIHSS at admission yielded the same results.

CONCLUSION

MT is safe and effective in HF patients with AIS. Patients with HF and AIS suffered from higher 3-month mortality and unfavourable outcome regardless of acute treatments.

Day-surgery adult patients with obesity and obstructive sleep apnea: Current controversies and concerns

Obesity and obstructive sleep apnea are considered independent risk factors that can adversely affect perioperative outcomes. A combination of these two conditions in the ambulatory surgery patient can pose significant challenges for the anesthesiologist. Nevertheless, these patients should not routinely be denied access to ambulatory surgery. Instead, patients should be appropriately optimized. Anesthesiologists and surgeons must work together to implement fast-track anesthetic and surgical techniques that will ensure successful ambulatory outcomes.

Different Types of Intraoperative Hypotension and their Association with Post-Anesthesia Care Unit Recovery

Background

The underlying causative mechanism leading to intraoperative hypotension (IOH) may vary depending on the stage of anesthesia and surgery, resulting in different types of IOH. Consequently, the incidence, severity, and postoperative complications associated with IOH types may differ. This study explores the association between IOH types and post-anesthesia care unit (PACU) recovery, with a focus on duration and complications.

Methods

From May 2022 to December 2022, we included 4776 consecutive surgical patients aged ≥18 who underwent elective surgery with planned overnight stays at Acibadem Altunizade Hospital and received general anesthesia. Post-induction hypotension (pIOH) was defined as a decrease in blood pressure during the first 20 minutes after anesthesia induction, while maintenance intraoperative hypotension (mIOH) referred to a decrease in blood pressure occurring after the 20th minute following induction, with or without preceding pIOH.

Results

Among the included patients, 22.13% experienced IOH, with a higher prevalence observed among females. Patients with mIOH exhibited higher rates of bleeding, transfusions, hypothermia, longer stays in the PACU, and increased oxygen requirements. The duration of anesthesia did not increase the likelihood of IOH. Multivariate logistic regression analysis revealed that ephedrine usage, hypothermia, the need for additional analgesics, nausea, and vomiting were factors associated with longer PACU duration. Older patients (≥65), patients with ASA≥2 status, those undergoing major surgery, experiencing unexpected bleeding, and exhibiting hypothermia at the end of anesthesia had a higher likelihood of requiring vasopressor support.

Conclusions

Patients experiencing hypotension, particularly during the maintenance of anesthesia, are more prone to complications in the PACU and require closer monitoring and treatment. Although less common, mIOH has a more significant impact on outcomes compared to other factors affecting PACU recovery. The impact of mIOH on PACU duration should not be overlooked in favor of other factors.

Registration

Clinicaltrials.gov identifier: NCT05671783.

Preoperative clinical diagnostic accuracy of heart failure among patients undergoing major noncardiac surgery: a single-centre prospective observational analysis

Background

Reliable diagnosis of heart failure during preoperative evaluation is important for perioperative management and long-term care. We aimed to quantify preoperative heart failure diagnostic accuracy and explore characteristics of patients with heart failure misdiagnoses.

Methods

We performed an observational cohort study of adults undergoing major noncardiac surgery at an academic hospital between 2015 and 2019. A preoperative clinical diagnosis of heart failure was defined using keywords from the history and clinical examination or administrative documentation. Across stratified subsamples of cases with and without clinically diagnosed heart failure, health records were intensively reviewed by an expert panel to develop an adjudicated heart failure reference standard using diagnostic criteria congruent with consensus guidelines. We calculated agreement among experts, and analysed performance of clinically diagnosed heart failure compared with the adjudicated reference standard.

Results

Across 40 555 major noncardiac procedures, a stratified subsample of 511 patients was reviewed by the expert panel. The prevalence of heart failure was 9.1% based on clinically diagnosed compared with 13.3% (95% confidence interval [CI], 10.3-16.2%) estimated by the expert panel. Overall agreement and inter-rater reliability (kappa) among heart failure experts were 95% and 0.79, respectively. Based upon expert adjudication, heart failure was clinically diagnosed with an accuracy of 92.8% (90.6-95.1%), sensitivity 57.4% (53.1-61.7%), specificity 98.3% (97.1-99.4%), positive predictive value 83.5% (80.3-86.8%), and negative predictive value 93.8% (91.7-95.9%).

Conclusions

Limitations exist to the preoperative clinical diagnosis of heart failure, with nearly half of cases undiagnosed preoperatively. Considering the risks of undiagnosed heart failure, efforts to improve preoperative heart failure diagnoses are warranted.

Graded Epidural Anesthesia for Non-cardiac Surgery in the Prone Position in a Patient With Low Ejection Fraction

Ischemic heart disease (IHD), also known as coronary artery disease, occurs due to the blockage of coronary arteries which reduces the blood supply of the myocardium. The main goal of the anesthetic management of IHD patients undergoing non-cardiac surgery is to maintain the balance between myocardial oxygen supply and demand. Here, we report the anesthetic management of an IHD patient with a low ejection fraction who was posted for percutaneous nephrolithotomy in the prone position. We opted for graded epidural anesthesia with a low dose of a local anesthetic drug and opioid. Graded epidural anesthesia is a safe alternative over general anesthesia for patients with IHD and low ejection fraction as it reduces stress response to surgery, provides good postoperative analgesia, and avoids myocardial depressant drugs and coagulation responses.

Congestive Heart Failure Is Associated With Worse Outcomes in Patients With Ischemic Colitis: A Nationwide Study

INTRODUCTION

Ischemic colitis (IC) results from compromised blood flow to the colon. Risk factors include atrial fibrillation (A.Fib), peripheral artery disease (PAD), coronary artery disease (CAD), and congestive heart failure (CHF). However, few studies compared the mortality rate and colectomy between patients with IC with CHF and IC alone.

OBJECTIVE

We aim to investigate the possibility of worse outcomes in patients with IC and CHF compared to IC alone.

METHODOLOGY

Using the National Inpatient Sample database from 2016 to 2019, we obtained baseline demographic data, total hospital charge, rate of colectomy, length of hospital stay (LOS), and in-hospital mortality. Data were compared using a t-test and chi-squared. Odds ratios for comorbidities including A.Fib, CAD, PAD, end-stage renal disease, chronic obstructive pulmonary disease, hyperlipidemia, hypertension, diabetes, and cirrhosis were calculated.

RESULTS

106,705 patients with IC were identified, among which 15,220 patients also had CHF. IC patients with CHF had a longer LOS (6.6 days vs 4.4 days; P<0.0001), higher total hospital charge ($71,359 vs $45,176; P<0.0001), higher mortality rate (8.5% vs 2.9%; P<0.0001), and higher colectomy rate (9.2% vs 5.9%; P<0.0001).

CONCLUSION

CHF is associated with poor outcomes in patients with IC. Our study showed an increased risk of mortality and colectomy compared to patients with IC alone. The findings suggest it may be warranted to have a heightened clinical suspicion of IC in patients with CHF who present with bleeding per rectum.

Successful use of ultrasound-guided peripheral nerve block for lower limb surgery in a patient with heart failure with reduced ejection fraction: a case report

The number of patients with heart failure with reduced ejection fraction (HFrEF) is increasing. These patients have a reduced cardiorespiratory reserve. Therefore, preoperative evaluation is essential to determine the best type of anaesthesia to use in patients with HFrEF. A 70-year-old man with HFrEF was scheduled to undergo debridement of skin necrosis due to thrombotic occlusion of the right common iliac artery. He had undergone wound dressing changes under local anaesthesia every other day for several months, and treatment for heart failure was on-going. A sciatic nerve and fascia iliaca compartment block was performed under ultrasound guidance because of the patient’s cardiopulmonary function. After confirming adequate sensory blockage, surgery was performed without any haemodynamic instability or complications. Thereafter, debridement was performed twice more using the same block technique, and a skin autograft was also successfully performed. We successfully performed an ultrasound-guided sciatic nerve and fascia iliaca compartment block in a patient with HFrEF who was scheduled to undergo lower limb surgery. Peripheral nerve block is an alternative option for patients with HFrEF.

Bleeding risk in patients with cardiac disease from ischaemic stroke reperfusion therapy: an update

Background

Intravenous tissue plasminogen activator (rtPA) and arterial endovascular therapy (ET) rapidly restore cerebral perfusion in eligible patients who had an acute ischaemic stroke (AIS). It is unknown whether patients who had an AIS with premorbid cardiac disease respond differently to reperfusion therapies than those without. These patients may have risk factors that worsen outcomes or may represent those who would most benefit from reperfusion therapy.

Objective

To determine whether patients who had an AIS with the most frequently encountered pre-existing cardiac conditions, atrial fibrillation (AF), heart failure (HF), left ventricular assist devices (LVADs), or taking anticoagulation for cardiac indications, are at increased risk for poor outcome, such as symptomatic intracranial haemorrhage (sICH), after reperfusion therapy.

Results

Although AF is an independent risk factor for poor poststroke outcomes, intravenous rtPA is not associated with increased risk of sICH for those not on anticoagulants. Likewise, HF is independently associated with mortality post stroke, yet these patients benefit from reperfusion therapies without increased rates of sICH. Patients with LVADs or who are on anticoagulation should not be given IV rtPA; however, ET remains a viable option in those who meet criteria, even patients with LVAD.

Conclusion

There is no evidence of an increased risk for sICH after intravenous rtPA or ET for those with AF or HF. Intravenous rtPA should not be given to patients on anticoagulation or with LVADs, but ET should be offered to them when eligible. Whenever possible, future AIS reperfusion research should include patients with premorbid cardiac disease as they are frequently excluded, representing a gap in evidence.

New-Onset Cancer in the HF Population: Epidemiology, Pathophysiology, and Clinical Management

PURPOSE OF REVIEW

Oncological treatments are known to induce cardiac toxicity, but the impact of new-onset cancer in patients with pre-existing HF remains unknown. This review focuses on the epidemiology, pathophysiological mechanisms, and clinical implications of HF patients who develop malignancies.

RECENT FINDINGS

Novel findings suggest that HF and cancer, beside common risk factors, are deeply linked by shared pathophysiological mechanisms. In particular, HF itself may enhance carcinogenesis by producing pro-inflammatory cytokines, and it has been suggested that neurohormonal activation, commonly associated with the failing heart, might play a pivotal role in promoting neoplastic transformation. The risk of malignancies seems to be higher in HF patients compared to the general population, probably due to shared risk factors and common pathophysiological pathways. Additionally, management of these patients represents a challenge for clinicians, considering that the co-existence of these diseases significantly worsens patients' prognosis and negatively affects therapeutic options for both diseases.

Surgical Predictive Model for Breast Cancer Patients Assessing Acute Postoperative Complications: The Breast Cancer Surgery Risk Calculator

BACKGROUND

Prognostic tools, such as risk calculators, improve the patient-physician informed decision-making process. These tools are limited for breast cancer patients when assessing surgical complication risk preoperatively.

OBJECTIVE

In this study, we aimed to assess predictors associated with acute postoperative complications for breast cancer patients and then develop a predictive model that calculates a complication probability using patient risk factors.

METHODS

We performed a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2017. Women diagnosed with ductal carcinoma in situ or invasive breast cancer who underwent either breast conservation or mastectomy procedures were included in this predictive modeling scheme. Four models were built using logistic regression methods to predict the following composite outcomes: overall, infectious, hematologic, and internal organ complications. Model performance, accuracy and calibration measures during internal/external validation included area under the curve, Brier score, and Hosmer-Lemeshow statistic, respectively.

RESULTS

A total of 163,613 women met the inclusion criteria. The area under the curve for each model was as follows: overall, 0.70; infectious, 0.67; hematologic, 0.84; and internal organ, 0.74. Brier scores were all between 0.04 and 0.003. Model calibration using the Hosmer-Lemeshow statistic found all p-values to be > 0.05. Using model coefficients, individualized risk can be calculated on the web-based Breast Cancer Surgery Risk Calculator (BCSRc) platform ( www.breastcalc.org ).

CONCLUSION

We developed an internally and externally validated risk calculator that estimates a breast cancer patient's unique risk of acute complications following each surgical intervention. Preoperative use of the BCSRc can potentially help stratify patients with an increased complication risk and improve expectations during the decision-making process.

30-Day Postoperative Outcomes Following Transcervical Zenker's Diverticulectomy in the Elderly: Analysis of the NSQIP Database

OBJECTIVE

To compare the effect of patient factors, including age, on 30-day postoperative outcomes and complications for patients undergoing transcervical Zenker's diverticulectomy.

STUDY DESIGN

Retrospective cross-sectional analysis.

SETTING

American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database.

METHODS

Patients who underwent open Zenker's diverticulectomy (Current Procedural Terminology code 43130) were queried via the NSQIP (2006-2018). Outcomes analyzed include patient demographics, medical comorbidities, admission type, operative characteristics, length of admission, postoperative complication, readmission, and reoperation.

RESULTS

A total of 614 patients were identified. Mean age at time of surgery was 71.1 years, with 13.4% older than 85 years. Outpatient procedures were performed in 29.8%. Postoperative complications occurred in 6.7%, with reoperation and readmission rates of 6.4% and 7.2%, respectively. A mortality rate of 0.3% was observed. Only smoking status (odds ratio, 2.94; P = .008) and history of congestive heart failure (odds ratio, 10.00; P = .014) were shown to have a significant effect on postoperative complications.

CONCLUSION

Smoking status confers a high risk for postoperative complication. Age was not an independent risk factor associated with adverse outcomes following open diverticulectomy, suggesting this procedure can be safely performed in patients with advanced age.

Cancer Risk in the Heart Failure Population: Epidemiology, Mechanisms, and Clinical Implications

PURPOSE OF REVIEW

Along with population aging, the incidence of both heart failure (HF) and cancer is increasing. However, little is known about new-onset cancer in HF patients. This review aims at showing recent discoveries concerning this subset of patients.

RECENT FINDINGS

Not only cancer and HF share similar risk factors but also HF itself can stimulate cancer development. Some cytokines produced by the failing heart induce mild inflammation promoting carcinogenesis, as it has been recently suggested by an experimental model of HF in mice. The incidence of new-onset cancer is higher in HF patients compared to the general population, and it significantly worsens their prognosis. Moreover, the management of HF patients developing new-onset cancer is challenging, especially due to the limited therapeutic options for patients affected by both cancer and HF and the higher risk of cardiotoxicity from anticancer drugs.

Selective Spinal Anesthesia in a Patient with Low Ejection Fraction Who Underwent Emergent Below-Knee Amputation in a Resource-Constrained Setting

Patients with congestive heart failure have a high risk of perioperative major adverse cardiac events and death. The major perioperative goal of management in patients with low ejection fraction is maintaining hemodynamic stability. Evidence is scarce on the safety of a certain anesthetic technique for patients with heart failure. In this report, we present a 48-year-old man with ischemic dilated cardiomyopathy and low-output congestive heart failure (estimated ejection fraction of 27%) who underwent emergent below-knee amputation under selective spinal anesthesia without any apparent complications. We believe that selective spinal anesthesia can be a useful alternative anesthetic technique in patients with low ejection fraction undergoing emergent lower limb surgery. We showed evidence-based and customized anesthetic management of a high-risk patient with the available equipment and resources. This report will hopefully show the contextual challenges of the perioperative care of critically ill patients in resource-constrained settings.

Survival curve identifies critical period for postoperative mortality in cardiac patients undergoing emergency general surgery

The number of non-cardiac major surgeries carried out has significantly increased in recent years to around 200 million procedures carried out annually. Approximately 30% of patients submitted to non-cardiac surgery present some form of cardiovascular comorbidity. In emergency situations, with less surgery planning time and greater clinical severity, the risks become even more significant. The aim of this study is to determine the incidence and clinical outcomes in patients with cardiovascular disease submitted to non-cardiac surgical procedures in a single cardiovascular referral center. This is a prospective cohort study of patients with cardiovascular disease submitted to non-cardiovascular surgery. All procedures were carried out by the same surgeon, between January 2006 and January 2018. 240 patients included were elderly, 154 were male (64%), 8 patients presented two diagnoses. Of the resulting 248 procedures carried out, 230 were emergency (92.8%). From the data obtained it was possible to estimate the day from which the occurrence of mortality is less probable in the postoperative phase. Our research evaluated the epidemiological profile of the surgeries and we were able to estimate the survival and delimit the period of greatest risk of mortality in these patients. The high rate of acute mesenteric ischemia was notable, a serious and frequently fatal condition.

Factors Contributing to Extended Hospital Length of Stay in Emergency General Surgery†

BACKGROUND

Emergency general surgery (EGS) is a field characterized by disproportionately high costs, post-operative mortality, and complications. We attempted to identify independent factors predictive of an increased postoperative length of stay (LOS), a key contributor to economic burden and worse outcomes.

METHODS

The ACS-NSQIP database was queried for data from2005 to 2017. Current procedural terminology (CPT) codes were used to identify the most commonly performed EGS procedures: appendectomy, bowel resection, colectomy, and cholecystectomy. Cohorts above and below 75^th percentile LOS were determined, compared by preoperative variables, and evaluated with univariate and multivariate logistic regression to quantify risk.

RESULTS

Of 267,495 cases, 70,703 cases were above the 75^th percentile for LOS. A larger proportion of patients in the extended LOS group were 41 years or older (88.6% vs 45.7%). More Blacks (10.3% vs 6.7%) were observed in the extended LOS group. Age, race, cardiopulmonary, hepatic, and renal disease, diabetes, recent weight loss, steroid use, and sepsis history were significant factors on multivariate analysis but varied in terms of risk proportion by procedure. Age (61+), Black race, hypertension, sepsis, and cancer were significant for all 4 procedures.

CONCLUSIONS

Several factors are independently associated with extended LOS for those undergoing the most common EGS procedures. Five of these were associated with an increased LOS for all four procedures. These included, age (61+), hypertension, sepsis, cancer, and Black race.

Cardiogenic Shock in Perioperative and Intraoperative Settings: A Team Approach

Cardiogenic shock (CS) is a multifactorial disease process with high morbidity and mortality. When it occurs in a peri- or intraoperative setting, factors such as surgery, anesthesia, and post-surgical physiology can negatively affect patient outcomes. Since patient needs often escalate during CS-from medications to mechanical support to palliative care-this disease demands a multidisciplinary approach that encompasses all aspects of medical delivery. Preliminary studies have indicated that a multidisciplinary team approach to CS results in earlier diagnosis and treatment and improves patient outcomes. Here we discuss various management strategies for CS from an anesthesiology, surgery, and critical care perspective.

Transcatheter and Surgical Aortic Valve Replacement Outcomes for Patients with Chronic Heart Failure

OBJECTIVES

To determine in-hospital outcomes and assess high-risk groups among chronic heart failure (CHF) patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR).

DESIGN

A retrospective analysis of the Nationwide Inpatient Sample database from January 2012 to September 2015 was performed.

SETTING

Hospitals across the United States that offer TAVRs or SAVRs.

PARTICIPANTS

Adults with a diagnosis of CHF and AS.

INTERVENTIONS

The patients underwent either TAVR or SAVR.

MEASUREMENTS AND MAIN RESULTS

Totals of 5,871 and 4,008 CHF patients underwent TAVR and SAVR, respectively. TAVR patients were significantly older, more were female, and had a higher comorbidity burden. No significant differences in in-hospital mortality were noted between TAVR and SAVR. However, mean length of stay was significantly longer by 3.5 days in the SAVR group, as was the mean total cost. With the exception of complete heart block, permanent pacemaker implantation, and vascular complications, the majority of postoperative events were higher among the SAVR group. Multivariate regression analysis identified postoperative cardiac, respiratory and renal complications as significant predictors of in-hospital mortality for both groups. Additionally, age ≥75 years and vascular complications were significant predictors of mortality for patients undergoing TAVR.

CONCLUSIONS

Among CHF patients with symptomatic AS, TAVR had similar in-hospital mortality rate compared with SAVR despite higher comorbidity burden. TAVR patients are at a lower risk of cardiovascular, respiratory, and renal complications and might lead to reduced length of hospital stay and cost. Hence, TAVR may be a safer option in this population.

Appraisal of Cardiac Ejection Fraction With Liver Disease Severity: Implication in Post-Liver Transplantation Mortality

BACKGROUND AND AIMS

Enhanced sympathetic nervous activation and peripheral vasodilation in end-stage liver disease (ESLD) may limit the importance of left ventricular ejection fraction (LVEF) as an influential prognosticator. We sought to understand the LVEF and cardiac dimensions in ESLD patients in order to define the LVEF threshold to predict all-cause mortality after liver transplantation (LT).

APPROACH AND RESULTS

Data were collected prospectively from the Asan LT Registry between 2008 and 2016, and outcomes were retrospectively reviewed. LVEF, end-diastolic volume index (EDVI), and end-diastolic elastance (Eed) were measured by preoperative echocardiography. Of 2,799 patients, 452 (16.2%) had LVEF ≤ 60%, with 29 (1.0%) having LVEF < 55% and 269 (9.6%) had LVEF ≥ 70%. Over a median of 5.4-year follow-up, 329 (11.8%) patients died: 104 (3.7%) died within 90 days. LVEF (range, 30%-81%) was directly proportionate to Model for End-stage Liver Disease (MELD) scores, an index of liver disease severity, in survivors but showed a fixed flat-line pattern in nonsurvivors (interaction P = 0.004 between groups), with lower EDVI (P = 0.013) and higher Eed (P = 0.001) in the MELD ≥ 20 group. Patients with LVEF ≤ 60% had higher 90-day (13% vs. 7.4%; log rank, P = 0.03) and median 5.4-year (26.7% vs. 16.2%; log rank, P = 0.003) mortality rates in the MELD ≥ 20 group, respectively, compared to those with LVEF > 60%. Specifically, in the MELD > 35 group, median 5.4-year mortality rate was 53.3% in patients with LVEF ≤ 60% versus 24% in those with LVEF > 60% (log rank P < 0.001). By contrast, mortality rates of LVEF ≤ 60% and > 60% were similar in the MELD < 20 group (log rank P = 0.817).

CONCLUSIONS

LVEF ≤ 60% is strongly associated with higher post-LT mortality rates in the MELD ≥ 20 group, indicating the need to appraise both LVEF and liver disease severity simultaneously. Enhanced diastolic elastance with low EDVI provides insights into pathogenesis of low LVEF in nonsurvivors with MELD ≥ 20.

Heart Failure in Ischemic Stroke

Background and Purpose—

Heart failure (HF) in patients with acute ischemic stroke constitutes the source of various detrimental pathophysiologic mechanisms including prothrombotic and proinflammatory states, worsening of cerebral tissue oxygenation, and hemodynamic impairment. In addition, HF might affect the safety and efficacy of the acute recanalization stroke therapies.

Methods—

Patients treated with intravenous recombinant tissue-type plasminogen activator or mechanical recanalization at a universitary stroke center were included into a prospective registry. Patients received cardiological evaluation, including echocardiography, during acute care. Functional outcome was assessed after 90 days by structured telephone interviews. Safety and efficacy of intravenous thrombolysis and mechanical thrombectomy were investigated among patients with HF and compared with patients with normal cardiac function after propensity score matching.

Results—

One thousand two hundred nine patients were included. HF was present in 378 patients (31%) and an independent predictor of unfavorable functional outcome. Recanalization rates were equal among patients with HF after intravenous thrombolysis and after mechanical recanalization or combined treatment. The rate of secondary intracranial hemorrhage was not different (7% versus 8%; P =0.909 after thrombolysis and 15% versus 20%, P =0.364 after mechanical recanalization or combined therapy). Early mortality within 48 hours after admission was equal (<1.5% in both groups).

Conclusions—

In this real-world cohort of patients with stroke, HF was an independent predictor of unfavorable functional long-term outcome, while the safety and efficacy of intravenous thrombolysis and mechanical recanalization appeared unaffected.

Anesthetic Agents Isoflurane and Propofol Decrease Maximal Ca2+-Activated Force and Thus Contractility in the Failing Myocardium

In the normal heart, frequently used anesthetics such as isoflurane and propofol can reduce inotropy. However, the impact of these agents on the failing myocardium is unclear. Here, we examined whether and how isoflurane and propofol influence cardiac contractility in intact cardiac muscles from rats treated with monocrotaline to induce heart failure. We measured force and intracellular Ca²⁺ ([Ca^{2 +}]_i) in trabeculae from the right ventricles of the rats in the absence or presence of propofol or isoflurane. At low to moderate concentrations, both propofol and isoflurane dose-dependently depressed cardiac force generation in failing trabeculae without altering [Ca²⁺]_i At high doses, propofol (but not isoflurane) also decreased amplitude of [Ca²⁺]_i transients. During steady-state activation, both propofol and isoflurane impaired maximal Ca²⁺-activated force (F_max) while increasing the amount of [Ca²⁺]_i required for 50% of maximal activation (Ca₅₀). These events occurred without apparent change in the Hill coefficient, suggesting no impairment of cooperativity. Exposing these same muscles to the anesthetics after fiber skinning resulted in a similar decrement in F_max and rise in Ca₅₀ but no change in the myofibrillar ATPase-Ca²⁺ relationship. Thus, our study demonstrates that challenging the failing myocardium with commonly used anesthetic agents such as propofol and isoflurane leads to reduced force development as a result of lowered myofilament responsiveness to Ca²⁺ SIGNIFICANCE STATEMENT: Commonly used anesthetics such as isoflurane and propofol can impair myocardial contractility in subjects with heart failure by lowering myofilament responsiveness to Ca²⁺. High doses of propofol can also reduce the overall amplitude of the intracellular Ca²⁺ transient. These findings may have important implications for the safety and quality of intra- and perioperative care of patients with heart failure and other cardiac disorders.

Trending Towards Safer Breast Cancer Surgeries? Examining Acute Complication Rates from A 13-Year NSQIP Analysis

As breast cancer surgery continues to evolve, this study highlights the acute complication rates and predisposing risks following partial mastectomy (PM), mastectomy(M), mastectomy with muscular flap reconstruction (M + MF), mastectomy with implant reconstruction (M + I), and oncoplastic surgery (OPS). Data was collected from the American College of Surgeons NSQIP database (2005⁻2017). Complication rate and trend analyses were performed along with an assessment of odds ratios for predisposing risk factors using adjusted linear regression. 226,899 patients met the inclusion criteria. Complication rates have steadily increased in all mastectomy groups (p < 0.05). Cumulative complication rates between surgical categories were significantly different in each complication cluster (all p < 0.0001). Overall complication rates were: PM: 2.25%, OPS: 3.2%, M: 6.56%, M + MF: 13.04% and M + I: 5.68%. The most common predictive risk factors were mastectomy, increasing operative time, ASA class, BMI, smoking, recent weight loss, history of CHF, COPD and bleeding disorders (all p < 0.001). Patients who were non-diabetic, younger (age < 60) and treated as an outpatient all had protective OR for an acute complication (p < 0.0001). This study provides data comparing nationwide acute complication rates following different breast cancer surgeries. These can be used to inform patients during surgical decision making.