Pre-operative cardiac optimisation: a directed review

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.

Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association

Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.

Are Octogenarians at Higher Risk of Complications After Elective Lumbar Spinal Fusion Surgery? Analysis of a Cohort of 7880 Patients From the Kaiser Permanente Spine Registry

STUDY DESIGN

A retrospective cohort study with chart review.

OBJECTIVE

To determine if there is a difference in risk of adverse outcomes following elective posterior instrumented lumbar spinal fusions for patients aged 80 years and above compared with patients aged 50 to 79 years.

SUMMARY OF BACKGROUND DATA

Patients aged 80 years and above are undergoing elective lumbar spinal fusion surgery in increasing numbers. There are conflicting data on the risks of intraoperative and postoperative complications in these patients.

MATERIALS AND METHODS

Patients aged 80 years and above were compared with 50 to 79 years (reference group) using time-dependent multivariable Cox proportional hazards regression with a competing risk of death for longitudinal outcomes and multivariable logistic regression for binary outcomes. Outcome measures used were: (1) intraoperative complications (durotomy), (2) postoperative complications: 30-day outcomes (pneumonia); 90-day outcomes (deep vein thrombosis, pulmonary embolism, emergency room visits, readmission, reoperations, and mortality); and two-year outcomes (reoperations and mortality).

RESULTS

The cohort consisted of 7880 patients who underwent primary elective posterior instrumented lumbar spinal fusion (L1-S1) for degenerative disk disease or spondylolisthesis. This was subdivided into 596 patients were aged 80 years and above and 7284 patients aged 50 to 79. After adjustment, patients aged 80 years and above had a higher likelihood of durotomy [odds ratio (OR)=1.43, 95% confidence interval (CI)=1.02-2.02] and 30-day pneumonia (OR=1.81, 95% CI=1.01-3.23). However, there was a lower risk of reoperation within two years of the index procedure (hazard ratio=0.69, 95% CI=0.48-0.99). No differences were observed for mortality, readmissions, emergency room visits, pulmonary embolism, or deep vein thrombosis.

CONCLUSIONS

In a cohort of 7880 elective posterior instrumented lumbar fusion patients for degenerative disk disease or spondylolisthesis, we did not observe any significant risks of adverse events between patients aged 80 years and above and those aged 50 to 79 except for higher durotomies and 30-day pneumonia in the former. We believe octogenarians can safely undergo lumbar fusions, but proper preoperative screening is necessary to reduce the risks of 30-day pneumonia.

Focused Cardiac Ultrasound Training for Non-cardiologists: An Overview and Recommendations for a Lower Middle-Income Country

Poor outcomes among the critically ill in low- and middle-income countries (LMICs) have been attributed in part to the challenge of diagnostic delays caused by lack of skilled personnel. Focused cardiac ultrasound (FoCUS) by non-cardiologists may mitigate the shortage of echocardiography experts to perform emergency echocardiography at the point of care in these settings. It is however crucial that FoCUS training for non-cardiologists in LMICs be based on robust evidence to support training delivery if diagnostic accuracy is to be assured.

Anaesthetic Approach to Enhanced Recovery after Surgery for Kidney Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) protocols are designed to reduce medical complications, the length of hospital stays (LoS), and healthcare costs. ERAS is considered safe and effective for kidney transplant (KTx) surgery. KTx recipients are often frail with multiple comorbidities. As these patients follow an extensive diagnostic pathway preoperatively, the ERAS protocol can ideally be implemented at this stage. Small singular changes in a long perioperative pathway can result in significant positive outcomes. We have investigated the current evidence for an ERAS pathway related to anaesthetic considerations in renal transplant surgery for adult recipients.

Elevated preoperative suPAR is a strong and independent risk marker for postoperative complications in patients undergoing major noncardiac surgery (SPARSE)

BACKGROUND

Patients undergoing major surgery are often at risk of developing postoperative complications. We investigated whether a preoperative marker of chronic inflammation, soluble urokinase plasminogen activator receptor, can aid in identifying patients at high risk for postoperative complications, morbidity, and mortality.

METHODS

In this prospective observational study (ClinicalTrials.gov identifier: NCT03851965), EDTA blood was collected from consecutive adult White patients scheduled for major noncardiac surgery with expected duration ≥2 hours under general anesthesia. Inclusion criteria were age ≥18 years and American Society of Anesthesiologists physical status I to IV. Plasma soluble urokinase plasminogen activator receptor levels were determined using the suPARnostic quick triage lateral flow assay. The primary endpoint was postoperative complications defined as presence of any complication and/or admission to intensive care unit and/or mortality within the first 90 postoperative days.

RESULTS

Preoperative soluble urokinase plasminogen activator receptor had an odds ratio of 1.50 (95% confidence interval: 1.24-1.82) for every ng/mL increase. When including age, sex, American Society of Anesthesiologists score, C-reactive protein, and grouped soluble urokinase plasminogen activator receptor in multivariate analysis, patients with soluble urokinase plasminogen activator receptor between 5.5 and 10 ng/mL had an odds ratio of 11.2 (confidence interval: 3.1-40.8) and patients with soluble urokinase plasminogen activator receptor >10 ng/mL had an odds ratio of 19.9 (95% confidence interval: 4.3-92.9) compared to patients with soluble urokinase plasminogen activator receptor ≤5.5 ng/mL, respectively. Receiver operating characteristic analysis of soluble urokinase plasminogen activator receptor showed an area under the curve of 0.82 (confidence interval: 0.72-0.91). Receiver operating characteristic analysis combining age, sex, C-reactive protein levels, and American Society of Anesthesiologists score and had an area under the curve of 0.71 (95% confidence interval: 0.61-0.82). Adding soluble urokinase plasminogen activator receptor to this model increased the area under the curve to 0.83 (95% confidence interval: 0.74-0.92) (P = .033).

CONCLUSION

Preoperative soluble urokinase plasminogen activator receptor provided strong and independent predictive value on postoperative complications in White patients undergoing major noncardiac surgery.

Role of Cardiac Biomarkers in Epidemiology and Risk Outcomes

BACKGROUND

The use of biomarkers associated with cardiovascular disease (CVD) is established for diagnostic purposes. Cardiac troponins, as specific markers of myocardial injury, and natriuretic peptides, reflecting myocardial dilation, are routinely used for diagnosis in clinical practice. In addition, a substantial body of research has shed light on the ability of biomarkers to reflect the risk of future major cardiovascular events. Among biomarkers, troponin and members of the natriuretic peptide family have been investigated extensively in the general population, in those at higher risk, and in patients with known CVD. Both biomarkers have been shown to contribute substantially to statistical models describing cardiovascular risk, in addition to and independently of important clinical characteristics. The more precise identification of individuals at risk by appropriate use of biomarkers might lead to an earlier initiation of preventive therapies and potentially avoid significant events.

CONTENT

We summarize the current evidence concerning risk prediction using cardiac biomarkers at different stages in the development of CVD and provide examples of observational studies and large-scale clinical trials testing such application. Beyond the focus on troponin and natriuretic peptides, we also discuss other important and emerging biomarkers in the field with potential for such application, including growth differentiation factor-15, soluble ST2 (alias for IL1RL1 [interleukin 1 receptor like 1), and galectin-3.

SUMMARY

Incorporating biomarkers in risk prediction models might allow more precise identification of individuals at risk. Among the various biomarkers, cardiac troponin appears to be the most promising for prediction of future cardiovascular events in a wide variety of patient populations.

The risk factors for delayed recovery in patients with cardiopulmonary bypass: Why should we care?

Cardiopulmonary bypass (CPB) is very commonly performed among the cardiovascular surgeries, and delayed recovery (DR) is a kind of serious complications in patients with CPB. It is necessary to assess the risk factors for DR in patients with CPB, to provide evidence into the management of CPB patients.Patients undergoing CPB in our hospital from January 2018 to March 2020 were included. Cases that consciousness has not recovered 12 hours after anesthesia were considered as DR. The preoperative and intraoperative variables of CPB patients were collected and analyzed. Logistic regressions were conducted to analyze the potential influencing factor.A total of 756 CPB patients were included, and the incidence of DR was 9.79%. There were significant differences on the age, aspartate aminotransferase (AST), glutamic pvruvic transaminase (ALT), blood urea nitrogen (BUN), and serum creatinine (SCr) between patients with and without DR (all P < .05); there were no significant differences in the types of surgical procedure (all P > .05); there were significant differences on the duration of CPB, duration of aortic cross clamp (ACC), duration of surgery, minimum nasopharyngeal temperature, and transfusion of packed red blood cells between patients with and without DR (all P < .05). Logistic regression analysis indicated that duration of CPB ≥132 minutes (odds ratio [OR] 4.12, 1.02-8.33), BUN ≥9 mmol/L (OR 4.05, 1.37-8.41), infusion of red blood cell suspension (OR 3.93, 1.25-7.63), duration of surgery ≥350 minutes (OR 3.17, 1.24-5.20), age ≥6 (OR 3.01, 1.38-6.84) were the independent risk factors for DR in patients with CPB (all P < .05).Extra attention and care are needed for those CPB patients with duration of CPB ≥132 minutes, BUN ≥9 mmol/L, infusion of red blood cell suspension, duration of surgery ≥350 minutes, and age ≥60.

Preoperative Point-of-Care Assessment of Left Ventricular Systolic Dysfunction With Transthoracic Echocardiography

BACKGROUND

Left ventricular (LV) systolic dysfunction is an acknowledged perioperative risk factor and should be identified before surgery. Conventional echocardiographic assessment of LV ejection fraction (LVEF) obtained by biplane LV volumes is the gold standard to detect LV systolic dysfunction. However, this modality needs extensive training and is time consuming. Hence, a feasible point-of-care screening method for this purpose is warranted. The aim of this study was to evaluate 3 point-of-care echocardiographic methods for identification of LV systolic dysfunction in comparison with biplane LVEF.

METHODS

One hundred elective surgical patients, with a mean age of 63 ± 12 years and body mass index of 27 ± 4 kg/m2, were consecutively enrolled in this prospective observational study. Transthoracic echocardiography was conducted 1-2 hours before surgery. LVEF was obtained by automatic two-dimensional (2D) biplane ejection fraction (EF) software. We evaluated if Tissue Doppler Imaging peak systolic myocardial velocities (TDISm), anatomic M-mode E-point septal separation (EPSS), and conventional M-mode mitral annular plane systolic excursion (MAPSE) could discriminate LV systolic dysfunction (LVEF <50%) by calculating accuracy, efficiency, correlation, positive (PPV) respective negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC) for each point-of-care method.

RESULTS

LVEF<50% was identified in 22% (21 of 94) of patients. To discriminate an LVEF <50%, AUROC for TDISm (mean <8 cm/s) was 0.73 (95% confidence interval [CI], 0.62-0.84; P < .001), with a PPV of 47% and an NPV of 90%. EPSS with a cutoff value of >6 mm had an AUROC 0.89 (95% CI, 0.80-0.98; P < .001), with a PPV of 67% and an NPV of 96%. MAPSE (mean <12 mm) had an AUROC 0.80 (95% CI, 0.70-0.90; P < 0.001) with a PPV of 57% and an NPV of 98%.

CONCLUSIONS

All 3 point-of-care methods performed reasonably well to discriminate patients with LVEF <50%. The clinician may choose the most suitable method according to praxis and observer experience.

The association between preoperative length of hospital stay and deep sternal wound infection: A scoping review

BACKGROUND

Deep sternal wound infection (DSWI) is a serious complication of cardiac surgery, associated with a significantly longer hospital stay, an increased mortality, and an almost doubling of treatment costs. The preoperative length of hospital stay has been suggested in a small number of studies as a modifiable risk factor yet is not included in surgical site infection prevention guidelines. The aim of this scoping review was to review the existing evidence on the association between preoperative length of hospital stay and DSWI, and to identify established risk factors for DSWI.

METHODS

A literature search of six electronic databases yielded 2297 results. Titles concerning risk factors for DSWI, sternal or surgical wound infection, or poststernotomy complications were included. Abstracts relating to preoperative length of stay as a risk factor for DSWI proceeded to full article review. Articles regarding paediatric surgery, DSWI management or unavailable in English were excluded.

RESULTS

The review identified 11 observational cohort studies. DSWI prevalence was between 0.9% and 6.8%. Preoperative length of stay ranged from 0-15.5 days and was found to be associated with DSWI in all studies. Preoperative length of stay and DSWI were inconsistently defined. Other risk factors for DSWI included diabetes, obesity, respiratory disease, heart failure, renal impairment, complex surgery, and reoperation (p < 0.05).

CONCLUSION

In this scoping review, an association between preoperative length of stay and the development of DSWI following cardiac surgery was identified. Thus, preoperative length of stay as a modifiable risk factor for DSWI should be considered for inclusion in cardiothoracic surgical infection prevention guidelines.

Perioperative management and anaesthetic considerations in pelvic exenterations using Delphi methodology: results from the PelvEx Collaborative

BACKGROUND

The multidisciplinary perioperative and anaesthetic management of patients undergoing pelvic exenteration is essential for good surgical outcomes. No clear guidelines have been established, and there is wide variation in clinical practice internationally. This consensus statement consolidates clinical experience and best practice collectively, and systematically addresses key domains in the perioperative and anaesthetic management.

METHODS

The modified Delphi methodology was used to achieve consensus from the PelvEx Collaborative. The process included one round of online questionnaire involving controlled feedback and structured participant response, two rounds of editing, and one round of web-based voting. It was held from December 2019 to February 2020. Consensus was defined as more than 80 per cent agreement, whereas less than 80 per cent agreement indicated low consensus.

RESULTS

The final consensus document contained 47 voted statements, across six key domains of perioperative and anaesthetic management in pelvic exenteration, comprising preoperative assessment and preparation, anaesthetic considerations, perioperative management, anticipating possible massive haemorrhage, stress response and postoperative critical care, and pain management. Consensus recommendations were developed, based on consensus agreement achieved on 34 statements.

CONCLUSION

The perioperative and anaesthetic management of patients undergoing pelvic exenteration is best accomplished by a dedicated multidisciplinary team with relevant domain expertise in the setting of a specialized tertiary unit. This consensus statement has addressed key domains within the framework of current perioperative and anaesthetic management among patients undergoing pelvic exenteration, with an international perspective, to guide clinical practice, and has outlined areas for future clinical research.

Pre-operative transthoracic echocardiography in ambulatory surgery-A cross-sectional study

BACKGROUND

Cardiac disease and aberrations in central volume status are risk factors for perioperative complications, and should be identified prior to surgery. This study investigated the benefit of transthoracic echocardiography (TTE) for pre-operative identification of cardiac disease and hypovolemia in ambulatory surgery.

METHODS

Ninety-six patients, with a mean age of 63.5 ± 12.2 years and body mass index of 27.0 ± 4.3 kg/m² , scheduled for ambulatory surgery (breast, thyroid, and minor gastrointestinal), were consecutively enrolled in this prospective observational study. Pre-operative comprehensive TTE was performed in order to assess heart failure (HF), asymptomatic left ventricular dysfunction, valvular disease, and aberrations in central volume status.

RESULTS

Pre-operative TTE identified a total of 28 cases of HF, 13 cases of HF with reduced or moderately reduced, ejection fraction (EF), and 15 cases of HF with preserved EF. Furthermore, 46 cases of asymptomatic left ventricular (LV) dysfunction were identified. 44/96 patients were hypovolemic, 16 of whom in severe hypovolemia. Seven cases of previously unknown obstructive valvular or myocardial disease and six cases of right ventricular systolic dysfunction were identified. A total of 24% (23/96) were classified as potential critical hemodynamic findings. The number needed (NNT) to treat for pre-operative TTE in order to find one critical finding was 4.2.

CONCLUSION

In this ambulatory surgical cohort, a high prevalence of pre-operative LV dysfunction and aberrations in volume status was observed. The results demonstrate that pre-operative TTE contributed valuable hemodynamic information. The standard pre-operative assessment for this cohort might need to be revised.

Peri-operative ventricular bigeminy and cardiomyopathy in elective surgery

Premature ventricular contractions are common in the general population and are often seen during general anaesthesia. A high frequency of premature ventricular contractions may be associated with underlying left ventricular dysfunction. Premature ventricular contraction-induced cardiomyopathy is a rare disease and requires cardiologist input into peri-operative management. Medical and interventional management strategies may completely reverse the disease process. A 19-year-old man was scheduled for removal of tibial metalwork, due to chronic pain, and ventricular bigeminy was noted in the anaesthetic room before induction of anaesthesia. Surgery was postponed and he was later diagnosed with premature ventricular contraction-induced cardiomyopathy. Ventricular bigeminy noted before induction of anaesthesia may not always be benign.

Peri-operative cardiac biomarker screening: a narrative review

Peri-operative risk estimation has traditionally focused on assessing the likelihood of postoperative morbidity and mortality using pre-operative functional assessment. Although this strategy is currently recommended by most major society guidelines, contemporary evidence suggests that cardiac biomarker measurement has important advantages over pre-operative functional assessment. These advantages include superior predictive discrimination and inclusion of the postoperative course in risk estimation. In this review, we provide an overview of the evidence supporting the peri-operative utilisation, compare risk estimation methods and discuss which patients may benefit most from cardiac biomarker screening. We also discuss protocols for biomarker screening and management of patients with abnormal results.

A comparison of four risk models for the prediction of cardiovascular complications in patients with a history of atrial fibrillation undergoing non-cardiac surgery

It is unclear how best to predict peri-operative cardiovascular risk in patients with atrial fibrillation undergoing non-cardiac surgery. This study examined the accuracy of the revised cardiac risk index and three atrial fibrillation thrombo-embolic risk models for predicting 30-day cardiovascular events after non-cardiac surgery in patients with a pre-operative history of atrial fibrillation. We conducted a prospective cohort study in 28 centres from 2007 to 2013 of 40,004 patients ≥ 45 years of age undergoing inpatient non-cardiac surgery who were followed until 30 days after surgery for cardiovascular events (defined as myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death). The 2088 patients with a pre-operative history of atrial fibrillation were at higher risk of peri-operative cardiovascular events compared with the 34,830 patients without a history of atrial fibrillation (29% vs. 13%, respectively, adjusted odds ratio 1.30 (95%CI 1.17-1.45). Compared with the revised cardiac risk index (c-index 0.60), all atrial fibrillation thrombo-embolic risk scores were significantly better at predicting peri-operative cardiovascular events: CHADS₂ (c-index 0.62); CHA₂ DS₂ -VASc (c-index 0.63); and R₂ CHADS₂ (c-index 0.65), respectively. Although the three thrombo-embolic risk prediction models were significantly better than the revised cardiac risk index for prediction of peri-operative cardiovascular events, none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri-operative risk prediction model.