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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Bak M, Lee SH, Park SJ, Park J, Kim J, Kim D, Kim EK, Chang SA, Lee SC, Park SW. Perioperative Risk of Noncardiac Surgery in Patients With Asymptomatic Significant Aortic Stenosis: A 10-Year Retrospective Study. J Am Heart Assoc 2024; 13:e032675. [PMID: 38686895 PMCID: PMC11179948 DOI: 10.1161/jaha.123.032675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 03/25/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Aortic stenosis (AS) is a representative geriatric disease, and there is an anticipated rise in the number of patients requiring noncardiac surgeries in patients with AS. However, there is still a lack of research on the primary predictors of noncardiac perioperative complications in patients with asymptomatic significant AS. METHODS AND RESULTS Among the cohort of noncardiac surgeries under general anesthesia, with an intermediate to high risk of surgery from 2011 to 2019, at Samsung Medical Center, 221 patients were identified to have asymptomatic significant AS. First, to examine the impact of significant AS on perioperative adverse events, the occurrences of major adverse cardiovascular events and perioperative adverse cardiovascular events were compared between patients with asymptomatic significant AS and the control group. Second, to identify the factors influencing the perioperative adverse events in patients with asymptomatic significant AS, a least absolute shrinkage and selection operator regression model was used. There was no significant difference between the control group and the asymptomatic significant AS group in the event rate of major adverse cardiovascular events (4.6% at control group versus 5.5% at asymptomatic significant AS group; P=0.608) and perioperative adverse cardiovascular events (13.8% at control group versus 18.3% at asymptomatic significant AS group; P=0.130). Cardiac damage stage was a significant risk factor of major adverse cardiovascular events and perioperative adverse cardiovascular events. CONCLUSIONS There was no significant difference in major postoperative cardiovascular events between patients with asymptomatic significant AS and the control group. Advanced cardiac damage stage in significant AS is an important factor in perioperative risk of noncardiac surgery.
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Affiliation(s)
- Minjung Bak
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Seung-Hwa Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Jihoon Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Darae Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Sung-A Chang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Seung Woo Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
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Khan MJ, Eltayeb Y, Karmakar A, Malik R, Elsafi T. Successful Use of Ultrasound Guided Quadratus Lumborum Block Without General Anesthesia for Open Appendectomy in a Patient with Heart Failure with Reduced Ejection Fraction- A Case Report and Literature Review. Local Reg Anesth 2024; 17:9-17. [PMID: 38419671 PMCID: PMC10899805 DOI: 10.2147/lra.s438176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 12/29/2023] [Indexed: 03/02/2024] Open
Abstract
Background Patients diagnosed with Heart Failure with Reduced Ejection Fraction (HFrEF) are at high risk of perioperative cardiovascular complications. While it is important to focus on optimizing their cardiac function, it is also crucial to address and optimize any other modifiable risk factors that could potentially impact postoperative outcome. This also includes careful consideration of anesthetic techniques to suit the patient and facilitate the surgery. However, there is a scarcity of evidence regarding the safety of specific anesthetic approaches for heart failure patients. Case Presentation We describe the case of an adult patient in mid-50s, with a history of ischemic dilated cardiomyopathy with reduced Ejection Fraction (about 25%) who presented with acute gangrenous appendicitis and was scheduled for an open appendectomy. It was deemed to be a high-risk patient for general and spinal anesthesia. With the guidance of a multidisciplinary team, surgery was successfully performed using a quadratus lumborum block with standard monitoring. The patient was comfortable and hemodynamically stable throughout the procedure. The postoperative course was uneventful. Conclusion Quadratus Lumborum Block for open appendectomy can be a beneficial alternative anesthesia technique in high-risk patients that significantly lowers perioperative cardiovascular risk, maintains hemodynamics, enhances satisfaction, and shortens hospital stay.
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Affiliation(s)
- Muhammad Jaffar Khan
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Yasir Eltayeb
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Arunabha Karmakar
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Rohma Malik
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Tarig Elsafi
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar
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4
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Choi DY, Hayes D, Maidman SD, Dhaduk N, Jacobs JE, Shmukler A, Berger JS, Cuff G, Rehe D, Lee M, Donnino R, Smilowitz NR. Existing Nongated CT Coronary Calcium Predicts Operative Risk in Patients Undergoing Noncardiac Surgeries (ENCORES). Circulation 2023; 148:1154-1164. [PMID: 37732454 PMCID: PMC10592001 DOI: 10.1161/circulationaha.123.064398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 08/21/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Preoperative cardiovascular risk stratification before noncardiac surgery is a common clinical challenge. Coronary artery calcium scores from ECG-gated chest computed tomography (CT) imaging are associated with perioperative events. At the time of preoperative evaluation, many patients will not have had ECG-gated CT imaging, but will have had nongated chest CT studies performed for a variety of noncardiac indications. We evaluated relationships between coronary calcium severity estimated from previous nongated chest CT imaging and perioperative major clinical events (MCE) after noncardiac surgery. METHODS We retrospectively identified consecutive adults age ≥45 years who underwent in-hospital, major noncardiac surgery from 2016 to 2020 at a large academic health system composed of 4 acute care centers. All patients had nongated (contrast or noncontrast) chest CT imaging performed within 1 year before surgery. Coronary calcium in each vessel was retrospectively graded from absent to severe using a 0 to 3 scale (absent, mild, moderate, severe) by physicians blinded to clinical data. The estimated coronary calcium burden (ECCB) was computed as the sum of scores for each coronary artery (0 to 9 scale). A Revised Cardiac Risk Index was calculated for each patient. Perioperative MCE was defined as all-cause death or myocardial infarction within 30 days of surgery. RESULTS A total of 2554 patients (median age, 68 years; 49.7% women; median Revised Cardiac Risk Index, 1) were included. The median time interval from nongated chest CT imaging to noncardiac surgery was 15 days (interquartile range, 3-106 days). The median ECCB was 1 (interquartile range, 0-3). Perioperative MCE occurred in 136 (5.2%) patients. Higher ECCB values were associated with stepwise increases in perioperative MCE (0: 2.9%, 1-2: 3.7%, 3-5: 8.0%; 6-9: 12.6%, P<0.001). Addition of ECCB to a model with the Revised Cardiac Risk Index improved the C-statistic for MCE (from 0.675 to 0.712, P=0.018), with a net reclassification improvement of 0.428 (95% CI, 0.254-0.601, P<0.0001). An ECCB ≥3 was associated with 2-fold higher adjusted odds of MCE versus an ECCB <3 (adjusted odds ratio, 2.11 [95% CI, 1.42-3.12]). CONCLUSIONS Prevalence and severity of coronary calcium obtained from existing nongated chest CT imaging improve preoperative clinical risk stratification before noncardiac surgery.
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Affiliation(s)
- Daniel Y Choi
- Leon H. Charney Division of Cardiology (D.Y.C., D.H., S.D.M., N.D., J.S.B., R.D., N.R.S.), New York University Grossman School of Medicine, New York, NY
| | - Dena Hayes
- Leon H. Charney Division of Cardiology (D.Y.C., D.H., S.D.M., N.D., J.S.B., R.D., N.R.S.), New York University Grossman School of Medicine, New York, NY
| | - Samuel D Maidman
- Leon H. Charney Division of Cardiology (D.Y.C., D.H., S.D.M., N.D., J.S.B., R.D., N.R.S.), New York University Grossman School of Medicine, New York, NY
| | - Nehal Dhaduk
- Leon H. Charney Division of Cardiology (D.Y.C., D.H., S.D.M., N.D., J.S.B., R.D., N.R.S.), New York University Grossman School of Medicine, New York, NY
| | - Jill E Jacobs
- Department of Radiology (J.E.J., A.S., R.D.), New York University Grossman School of Medicine, New York, NY
| | - Anna Shmukler
- Department of Radiology (J.E.J., A.S., R.D.), New York University Grossman School of Medicine, New York, NY
| | - Jeffrey S Berger
- Leon H. Charney Division of Cardiology (D.Y.C., D.H., S.D.M., N.D., J.S.B., R.D., N.R.S.), New York University Grossman School of Medicine, New York, NY
- Department of Surgery (J.S.B.), New York University Grossman School of Medicine, New York, NY
| | - Germaine Cuff
- Department of Anesthesiology, Perioperative Care and Pain Medicine (G.C., D.R., M.L.), New York University Grossman School of Medicine, New York, NY
| | - David Rehe
- Department of Anesthesiology, Perioperative Care and Pain Medicine (G.C., D.R., M.L.), New York University Grossman School of Medicine, New York, NY
| | - Mitchell Lee
- Department of Anesthesiology, Perioperative Care and Pain Medicine (G.C., D.R., M.L.), New York University Grossman School of Medicine, New York, NY
| | - Robert Donnino
- Leon H. Charney Division of Cardiology (D.Y.C., D.H., S.D.M., N.D., J.S.B., R.D., N.R.S.), New York University Grossman School of Medicine, New York, NY
- Department of Radiology (J.E.J., A.S., R.D.), New York University Grossman School of Medicine, New York, NY
- Cardiology Division, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, New York, NY (R.D., N.R.S.)
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology (D.Y.C., D.H., S.D.M., N.D., J.S.B., R.D., N.R.S.), New York University Grossman School of Medicine, New York, NY
- Cardiology Division, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, New York, NY (R.D., N.R.S.)
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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Hiraoka E, Tanabe K, Izuta S, Kubota T, Kohsaka S, Kozuki A, Satomi K, Shiomi H, Shinke T, Nagai T, Manabe S, Mochizuki Y, Inohara T, Ota M, Kawaji T, Kondo Y, Shimada Y, Sotomi Y, Takaya T, Tada A, Taniguchi T, Nagao K, Nakazono K, Nakano Y, Nakayama K, Matsuo Y, Miyamoto T, Yazaki Y, Yahagi K, Yoshida T, Wakabayashi K, Ishii H, Ono M, Kishida A, Kimura T, Sakai T, Morino Y. JCS 2022 Guideline on Perioperative Cardiovascular Assessment and Management for Non-Cardiac Surgery. Circ J 2023; 87:1253-1337. [PMID: 37558469 DOI: 10.1253/circj.cj-22-0609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Tadao Kubota
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | | | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, International University of Health and Welfare Narita Hospital
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Taku Inohara
- Department of Cardiovascular Medicine, Keio University Graduate School of Medicine
| | - Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital
| | | | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital
| | - Yumiko Shimada
- JADECOM Academy NP·NDC Training Center, Japan Association for Development of Community Medicine
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomofumi Takaya
- Department of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital
| | - Kenichi Nakazono
- Department of Pharmacy, St. Marianna University Yokohama Seibu Hospital
| | | | | | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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Trivedi V, Ladha KS, Jivraj NK, Saskin R, Thorpe KE, Wijeysundera DN, Cuthbertson BH. Association between preoperative cardiac risk assessment and health care costs in major noncardiac surgery: a multicentre health economic analysis. Can J Anaesth 2023; 70:1340-1349. [PMID: 37430180 DOI: 10.1007/s12630-023-02519-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 07/12/2023] Open
Abstract
PURPOSE Patients with impaired functional capacity who undergo major surgery are at increased risk of postoperative morbidity including complications and increased length of stay. These outcomes have been associated with increased hospital and health system costs. We aimed to assess whether common preoperative risk indices are associated with postoperative cost. METHODS We conducted a health economic analysis focused on the subset of Measurement of Exercise Tolerance before Surgery (METS) study participants in Ontario, Canada. Participants were scheduled for major elective noncardiac surgery and underwent several preoperative assessments of cardiac risk, including physicians' subjective assessment, Duke Activity Status Index (DASI) questionnaire, peak oxygen consumption, and N-terminal pro-B-type natriuretic peptide concentration. Using linked health administrative data, postoperative costs were calculated for both one year and in-hospital. Using multiple regression models, we tested for association between the preoperative measures of cardiac risk and postoperative costs. RESULTS Our study included 487 patients (mean [standard deviation] age 68 [11] yr and 47.0% female) who underwent noncardiac surgery between 13 June 2013 and 8 March 2016. Overall, the median [interquartile range] cost incurred within one year postoperatively was CAD 27,587 [13,902-32,590], of which CAD 12,928 [10,253-12,810] were incurred in-hospital and CAD 14,497 [10,917-15,017] were incurred by 30 days. None of the four preoperative measures of cardiac risk assessment were associated with costs incurred in hospital or at one year postoperatively. This lack of strong association persisted in sensitivity analyses considering type of surgical procedure, burden of preoperative cost, and when costs were categorized as quantiles. CONCLUSION In patients undergoing major noncardiac surgery, common measures of functional capacity are not consistently associated with total postoperative cost. Until further data exist that differ from this analysis, clinicians and health care funders should not assume that preoperative measures of cardiac risk are associated with annual health care or hospital costs for such surgeries.
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Affiliation(s)
- Vatsal Trivedi
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Naheed K Jivraj
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Refik Saskin
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Kevin E Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Brian H Cuthbertson
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON, M4N 3M5, Canada.
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8
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Meyer JR, Earnest RE, Johnson BM, Steffensmeier AM, Vyas DA, Laughlin RT. Implementation of a Multidisciplinary Preoperative Protocol for Geriatric Hip Fractures Improves Time to Surgery at a Level III Trauma Center. Geriatr Orthop Surg Rehabil 2023; 14:21514593231181991. [PMID: 37325698 PMCID: PMC10262602 DOI: 10.1177/21514593231181991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/29/2023] [Accepted: 05/29/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Hip fractures are common among the elderly, and delays in time to surgery (TTS) and length of stay (LOS) are known to increase mortality risk in these patients. Preoperative multidisciplinary protocols for hip fracture management are effective at larger trauma hospitals. The purpose of this study is to evaluate the effect of a similar multidisciplinary preoperative protocol for geriatric hip fracture patients at our Level III trauma center. Materials and Methods In this single-center retrospective study, patients aged 65 and older who were admitted from March 2016 to December 2018 (pre-protocol group, Cohort #1, n = 247) and from August 2021 to September 2022 (post-protocol group, Cohort #2, n = 169) were included. Demographic information, TTS, and LOS were obtained and compared using Student's t-test and Chi-square testing. Results There was a significant decrease in TTS in Cohort #2 compared to Cohort #1 (P < .001). There was a significant increase in LOS in Cohort #2 compared to Cohort #1 (P < .05), but when comparing a subset of Cohort #2 (Subgroup 2B, patients admitted from May to September 2022 when the effects of COVID-19 were likely dissipated) to Cohort #1, there was no significant difference in LOS (P = .13). For patients admitted to skilled nursing facilities (SNF), LOS in Cohort #2 was significantly longer than in Cohort #1 (P = .001). Discussion In general, Level III hospitals have fewer perioperative resources compared to larger Level I hospitals. Despite this fact, this multidisciplinary preoperative protocol effectively reduced TTS which improves mortality risk in elderly patients. LOS is a multifactorial variable, and we believe the COVID-19 pandemic was a significant confounder that reduced available SNF beds in our area which prolonged the average LOS in Cohort #2. Conclusion A multidisciplinary preoperative protocol for geriatric hip fracture management can improve efficiency of getting patients to surgery at Level III trauma centers.
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Affiliation(s)
- Jacob R. Meyer
- Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ryan E. Earnest
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brian M. Johnson
- Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew M. Steffensmeier
- Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Dheer A. Vyas
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard T. Laughlin
- Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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9
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Statman BJ. Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery: Part 2. Anesth Prog 2023; 70:37-48. [PMID: 36995961 PMCID: PMC10069535 DOI: 10.2344/anpr-70-01-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/27/2023] [Indexed: 03/31/2023] Open
Abstract
Part 1 of "Perioperative Management of Oral Antithrombotics in Dentistry and Oral Surgery" covered the physiological process of hemostasis and the pharmacology of both traditional and novel oral antiplatelets and anticoagulants. Part 2 of this review discusses various factors that are considered when developing a perioperative management plan for patients on oral antithrombotic therapy in consultation with dental professionals and managing physicians. Additionally included are how thrombotic and thromboembolic risks are assessed as well as how patient- and procedure-specific bleeding risks are evaluated. Special attention is given to the bleeding risks associated with procedures encountered when providing sedation and general anesthesia within the office-based dental environment.
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10
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Kim EK, Choi HM, Lee JH, Han DW, Lee HS, Choi EY. Practical role of preoperative echocardiography in low-risk non-cardiac surgery. Front Cardiovasc Med 2023; 10:1088496. [PMID: 36755797 PMCID: PMC9899884 DOI: 10.3389/fcvm.2023.1088496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/02/2023] [Indexed: 01/24/2023] Open
Abstract
Background Due to increased needs to reduce non-fatal as well as fatal cardiac events, preoperative echocardiography remains part of routine clinical practice in many hospitals. Data on the role of preoperative echocardiography in low-risk non-cardiac surgery (NCS) other than ambulatory surgeries do not exist. We aimed to investigate the role of preoperative echocardiography in predicting postoperative adverse cardiovascular events (CVEs) in asymptomatic patients undergoing low-risk NCS. Methods The study population was derived from a retrospective cohort of 1,264 patients who underwent elective low-risk surgery at three tertiary hospitals from June 1, 2021, to June 30, 2021. Breast, distal bone, thyroid, and transurethral surgeries were included. Preoperative examination data including electrocardiography, chest radiography, and echocardiography were collected. The primary outcome was a composite of postoperative adverse CVEs including all-cause death, myocardial infarction, cerebrovascular events, newly diagnosed or acutely decompensated heart failure (HF), lethal arrhythmia such as sustained ventricular tachycardia/fibrillation, and new-onset atrial fibrillation within 30 days after the index surgery. Results Preoperative echocardiography was performed in 503 patients (39.8%), most frequently in patients with breast surgery (73.5%), followed by transurethral (37.7%), distal bone (21.6%), and thyroid surgeries (11.9%). Abnormal findings were observed in 5.0% of patients with preoperative echocardiography. Postoperative adverse CVEs occurred in 10 (0.79%) patients. Although a history of previous HF was an independent predictor of postoperative CVE occurrence (adjusted odds ratio, aOR: 17.98; 95% confidence interval, CI: 1.21-266.71, P = 0.036), preoperative echocardiography did not significantly predict CVE in multivariate analysis (P = 0.097). However, in patients who underwent preoperative echocardiography, the presence of abnormal echocardiographic findings was independently associated with development of CVE after NCS (aOR: 23.93; 95% CI: 1.2.28-250.76, P = 0.008). In particular, the presence of wall motion abnormality was a strong predictor of postoperative adverse CVE. Conclusion In real-world clinical practice, preoperative echocardiography was performed in substantial number of patients with potential cardiac risk even in low-risk NCS, and abnormal findings were independently associated with postoperative CVE. Future studies should identify patients undergoing low-risk NCS for whom preoperative echocardiography would be helpful to predict adverse CVE.
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Affiliation(s)
- Eun Kyoung Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hong-Mi Choi
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Woo Han
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eui-Young Choi
- Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea,*Correspondence: Eui-Young Choi,
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11
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Gennari AG, Grünig H, Benz DC, Skawran S, Maurer A, Abukwaik AMA, Rossi A, Gebhard C, Buechel RR, Messerli M. Low-dose CT from myocardial perfusion SPECT/CT allows the detection of anemia in preoperative patients. J Nucl Cardiol 2022; 29:3236-3247. [PMID: 35175556 PMCID: PMC9834113 DOI: 10.1007/s12350-021-02899-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/14/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND To assess whether low-dose CT for attenuation correction of myocardial perfusion single-photon emission computed tomography (SPECT) allows for identification of anemic patients and grading anemia severity. METHODS AND RESULTS Patients who underwent a preoperative blood-test and low-dose CT scan, as a part of a cardiac SPECT exam, between 01 January 2015 and 31 December 2017 were enrolled in this retrospective study. Hemoglobin (Hb) levels and hematocrit were derived from clinical records. CT images were visually assessed (qualitative analysis) for the detection of inter-ventricular septum sign (IVSS) and aortic rim sign (ARS) and quantitative analysis were performed. The diagnostic accuracy for detecting anemia was compared using Hb values as the standard of reference. A total of 229 patients were included (110 with anemia; 57 mild; 46 moderate; 7 severe). The AUC of IVSS and ARS were 0.830 and 0.669, respectively (p<0.0001). The quantitative analysis outperformed ARS and IVSS; (AUC of 0.893, p=0.29). The optimal anemia cut-off using Youden index was 4.5 HU. CONCLUSION Quantitative analysis derived from low-dose CT images, as a part of cardiac SPECT exams, have a diagnostic accuracy similar to that of hematocrit for the detection of anemia and may allow discriminating different anemia severities.
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Affiliation(s)
- Antonio G Gennari
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Hannes Grünig
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Dominik C Benz
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Stephan Skawran
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Alexander Maurer
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Ahmad M A Abukwaik
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Michael Messerli
- Department of Nuclear Medicine, University Hospital Zurich/University of Zurich, Ramistrasse 100, 8091, Zurich, Switzerland.
- University of Zurich, Zurich, Switzerland.
- Maastricht UMC+, Heart and Vascular Center, Maastricht, The Netherlands.
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12
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Cheng XS, VanWagner LB, Costa SP, Axelrod DA, Bangalore S, Norman SP, Herzog C, Lentine KL. Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association: Endorsed by the American Society of Transplantation. Circulation 2022; 146:e299-e324. [PMID: 36252095 PMCID: PMC10124159 DOI: 10.1161/cir.0000000000001104] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Coronary heart disease is an important source of mortality and morbidity among kidney transplantation and liver transplantation candidates and recipients and is driven by traditional and nontraditional risk factors related to end-stage organ disease. In this scientific statement, we review evidence from the past decade related to coronary heart disease screening and management for kidney and liver transplantation candidates. Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has not been demonstrated to improve outcomes but is common in practice. Risk stratification algorithms based on the presence or absence of clinical risk factors and physical performance have been proposed, but a high proportion of candidates still meet criteria for screening tests. We suggest new approaches to pretransplantation evaluation grounded on the presence or absence of known coronary heart disease and cardiac symptoms and emphasize multidisciplinary engagement, including involvement of a dedicated cardiologist. Noninvasive functional screening methods such as stress echocardiography and myocardial perfusion scintigraphy have limited accuracy, and newer noninvasive modalities, especially cardiac computed tomography-based tests, are promising alternatives. Emerging evidence such as results of the 2020 International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease trial emphasizes the vital importance of guideline-directed medical therapy in managing diagnosed coronary heart disease and further questions the value of revascularization among asymptomatic kidney transplantation candidates. Optimizing strategies to disseminate and implement best practices for medical management in the broader end-stage organ disease population should be prioritized to improve cardiovascular outcomes in these populations.
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Affiliation(s)
| | | | | | | | | | | | - Charles Herzog
- Hennepin Healthcare/University of Minnesota, Minneapolis, MN
| | - Krista L. Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
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13
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Lee C, Columbo JA, Stone DH, Creager MA, Henkin S. Preoperative evaluation and perioperative management of patients undergoing major vascular surgery. Vasc Med 2022; 27:496-512. [PMID: 36214163 PMCID: PMC9551317 DOI: 10.1177/1358863x221122552] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients undergoing major vascular surgery have an increased risk of perioperative major adverse cardiovascular events (MACE). Accordingly, in this population, it is of particular importance to appropriately risk stratify patients' risk for these complications and optimize risk factors prior to surgical intervention. Comorbidities that portend a higher risk of perioperative MACE include coronary artery disease, heart failure, left-sided valvular heart disease, and significant arrhythmic burden. In this review, we provide a current approach to risk stratification prior to major vascular surgery and describe the strengths and weaknesses of different cardiac risk indices; discuss the role of noninvasive and invasive cardiac testing; and review perioperative pharmacotherapies.
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Affiliation(s)
| | | | | | | | - Stanislav Henkin
- Stanislav Henkin, Heart and Vascular
Center, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at
Dartmouth, Lebanon, NH 03756, USA.
Twitter: @stanhenkin
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14
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Mohammad Ismail A, Forssten MP, Bass GA, Trivedi DJ, Ekestubbe L, Ioannidis I, Duffy CC, Peden CJ, Mohseni S. Mode of anesthesia is not associated with outcomes following emergency hip fracture surgery: a population-level cohort study. Trauma Surg Acute Care Open 2022; 7:e000957. [PMID: 36148316 PMCID: PMC9486374 DOI: 10.1136/tsaco-2022-000957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/31/2022] [Indexed: 11/05/2022] Open
Abstract
Background Hip fractures often occur in frail patients with several comorbidities. In those undergoing emergency surgery, determining the optimal anesthesia modality may be challenging, with equipoise concerning outcomes following either spinal or general anesthesia. In this study, we investigated the association between mode of anesthesia and postoperative morbidity and mortality with subgroup analyses. Methods This is a retrospective study using all consecutive adult patients who underwent emergency hip fracture surgery in Orebro County, Sweden, between 2013 and 2017. Patients were extracted from the Swedish National Hip Fracture Registry, and their electronic medical records were reviewed. The association between the type of anesthesia and 30-day and 90-day postoperative mortality, as well as in-hospital severe complications (Clavien-Dindo classification ≥3a), was analyzed using Poisson regression models with robust SEs, while the association with 1-year mortality was analyzed using Cox proportional hazards models. All analyses were adjusted for potential confounders. Results A total of 2437 hip fracture cases were included in the study, of whom 60% received spinal anesthesia. There was no statistically significant difference in the risk of 30-day postoperative mortality (adjusted incident rate ratio (IRR) (95% CI): 0.99 (0.72 to 1.36), p=0.952), 90-day postoperative mortality (adjusted IRR (95% CI): 0.88 (0.70 to 1.11), p=0.281), 1-year postoperative mortality (adjusted HR (95% CI): 0.98 (0.83 to 1.15), p=0.773), or in-hospital severe complications (adjusted IRR (95% CI): 1.24 (0.85 to 1.82), p=0.273), when comparing general and spinal anesthesia. Conclusions Mode of anesthesia during emergency hip fracture surgery was not associated with an increased risk of postoperative mortality or in-hospital severe complications in the study population or any of the investigated subgroups. Level of evidence: Therapeutic/Care Management, level III
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Affiliation(s)
- Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Gary Alan Bass
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dhanisha Jayesh Trivedi
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Lovisa Ekestubbe
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Ioannis Ioannidis
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Caoimhe C Duffy
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carol J Peden
- Department of Clinical Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA.,Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
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15
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Ibekwe SO, Potluri V, Palvadi R, Best GT. Use of Point-of-Care Ultrasound and Focus-Assessed Transthoracic Echocardiography to Diagnose Acute Right Heart Failure Due to Fat Emboli in a Parturient. Cureus 2022; 14:e28585. [PMID: 36185894 PMCID: PMC9521511 DOI: 10.7759/cureus.28585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2022] [Indexed: 11/17/2022] Open
Abstract
Fat embolism syndrome (FES), causing right heart dysfunction, is a rare disease that is often difficult to diagnose with imaging modalities such as computed tomography (CT). FES is the clinical presentation that follows the entry of fat globules into the systemic circulation, which typically results in respiratory failure, scattered petechiae, cardiovascular collapse, and neurological sequelae. It is mostly observed in the cases of orthopedic trauma but may occur in any circumstance where fat can enter the circulatory system. In this case report, the authors describe an atypical presentation of FES in a 24-week parturient. The use of bedside point-of-care ultrasonography (POCUS) and the focus-assessed transthoracic echocardiography (FATE) protocol aided in the prompt diagnosis of right heart failure and helped to confirm the diagnosis of FES with more advanced imaging technology.
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16
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Dovzhanskiy DI, Bischoff MS, Jäckel P, Boeckler D. [Diagnosis and Management of Perioperative Myocardial Ischemia after Elective Aortic Aneurysm Surgery]. Zentralbl Chir 2022. [PMID: 35915925 DOI: 10.1055/a-1880-1586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Perioperative myocardial ischemia (PMI) is a serious postoperative complication. Aortic operations represent an especially high-risk surgery concerning cardiac complications. This aim of this study was to analyse the clinical features of PMI after elective aortic aneurysm surgery. PATIENTS AND METHODS This study is a retrospective analysis of 863 patients who underwent elective aortic aneurysm surgery between 2005 and 2012 in the Department of Vascular and Endovascular Surgery of Heidelberg University Hospital with regard to PMI. The PMI diagnosis was based on a positive serum troponin diagnostic test. We evaluated the clinical course, time point of the diagnosis and features of diagnostics to characterise PMI. Moreover, we analysed the treatment options and management of the patients' discharge. RESULTS Thirty-one patients (3.6% of 863) with PMI after elective aortic aneurysm surgery were identified. Of these, 21 patients (67.7%) underwent open surgery and 10 patients (32.3%) received endovascular treatment. PMI was diagnosed in 24 patients (77%) during the first 3 days. More than half of these patients (16/31) were clinically asymptomatic. Electrocardiogram did not show pathological findings in 24 cases (77.4%). The first troponin measurement was not elevated in eight patients (25.8%). Drug therapy alone was used in 17 cases (54.8%) of PMI, coronary catheterisation was performed in 12 patients (38.7%) and two patients (6.5%) received aortocoronary bypass. Fourteen patients (45.1%) were discharged home and another 14 patients (44.1%) were transferred to another hospital or to a rehabilitation institution. Two patients died because of multi-organ failure. CONCLUSION PMI is not a rare complication after elective aortic surgery. The diagnosis of PMI can be challenging because of occult symptoms especially in a perioperative setting. Due to the potentially serious consequences, cardiac enzyme diagnostics should be initiated immediately if there is suspicion of PMI or routinely in defined at-risk patients after aortic surgery.
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Affiliation(s)
- Dmitriy I Dovzhanskiy
- Department of Vascular and Endovascular Surgery, Heidelberg University, Heidelberg, Deutschland
| | - Moritz S Bischoff
- Department of Vascular and Endovascular Surgery, Heidelberg University, Heidelberg, Deutschland
| | - Petra Jäckel
- Department of Vascular and Endovascular Surgery, Heidelberg University, Heidelberg, Deutschland
| | - Dittmar Boeckler
- Department of Vascular and Endovascular Surgery, Heidelberg University, Heidelberg, Deutschland
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17
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Starke H, von Dossow V, Karsten J. Intraoperative Circulatory Support in Lung Transplantation: Current Trend and Its Evidence. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071005. [PMID: 35888094 PMCID: PMC9322250 DOI: 10.3390/life12071005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/02/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022]
Abstract
Lung transplantation has a high risk of haemodynamic complications in a highly vulnerable patient population. The effects on the cardiovascular system of the various underlying end-stage lung diseases also contribute to this risk. Following a literature review and based on our own experience, this review article summarises the current trends and their evidence for intraoperative circulatory support in lung transplantation. Identifiable and partly modifiable risk factors are mentioned and corresponding strategies for treatment are discussed. The approach of first identifying risk factors and then developing an adjusted strategy is presented as the ERSAS (early risk stratification and strategy) concept. Typical haemodynamic complications discussed here include right ventricular failure, diastolic dysfunction caused by left ventricular deconditioning, and reperfusion injury to the transplanted lung. Pre- and intra-operatively detectable risk factors for the occurrence of haemodynamic complications are rare, and the therapeutic strategies applied differ considerably between centres. However, all the mentioned risk factors and treatment strategies can be integrated into clinical treatment algorithms and can influence patient outcome in terms of both mortality and morbidity.
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Affiliation(s)
- Henning Starke
- Institute of Anaesthesiology, Heart and Diabetes Centre NRW, Bad Oeynhausen, Ruhr University Bochum, 44801 Bochum, Germany;
| | - Vera von Dossow
- Institute of Anaesthesiology, Heart and Diabetes Centre NRW, Bad Oeynhausen, Ruhr University Bochum, 44801 Bochum, Germany;
- Correspondence: ; Tel.: +49-(0)-5731-97-1128; Fax: +49-(0)-5731-97-2196
| | - Jan Karsten
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany;
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18
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Ibrahim KD, Tragesser LA, Soans R, Haddad A, Eddy VJ, McComb J, Keane MG, Whitman IR. Impact of Racial Disparities in Preoperative Cardiovascular Evaluation and Surgical Outcomes in Patients Undergoing Metabolic and Bariatric Surgery: A Retrospective Cohort Analysis. J Am Heart Assoc 2022; 11:e024499. [PMID: 35624077 PMCID: PMC9238690 DOI: 10.1161/jaha.121.024499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background We investigated preoperative referral patterns, rates of cardiovascular testing, surgical wait times, and postoperative outcomes in White versus Black, Hispanic, or other racial or ethnic groups of patients undergoing metabolic and bariatric surgery. Methods and Results This was a single center retrospective cohort analysis of 797 consecutive patients undergoing metabolic and bariatric surgery from January 2014 to December 2018; 86% (n=682) were Black, Hispanic, or other racial or ethnic groups. White versus Black, Hispanic, or other racial or ethnic groups had similar baseline comorbidities and were referred for preoperative cardiovascular evaluation in similar proportion (65% versus 68%, P=0.529). Black, Hispanic, or other racial or ethnic groups of patients were less likely to undergo preoperative cardiovascular testing (unadjusted odds ratio [OR], 0.56; 95% CI, 0.33–0.95; P=0.031; adjusted for Revised Cardiac Risk Index OR, 0.59; 95% CI, 0.35–0.996; P=0.049). White patients had a shorter wait time for surgery (unadjusted hazard ratio [HR], 0.7; 95% CI, 0.58–0.87; P=0.001; adjusted HR, 0.7; 95% CI, 0.56–0.95; P=0.018). Reduction in body mass index at 6 months was greater in White patients (12.9 kg/m2 versus 12.0 kg/m2, P=0.0289), but equivalent at 1 year (14.9 kg/m2 versus 14.3 kg/m2, P=0.330). Conclusions White versus Black, Hispanic, or other racial or ethnic groups of patients were referred for preoperative cardiovascular evaluation in similar proportion. White patients underwent more preoperative cardiac testing yet had a shorter wait time for surgery. Early weight loss was greater in White patients, but equivalent between groups at 12 months.
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Affiliation(s)
- Kaitlyn D Ibrahim
- Lewis Katz School of Medicine at Temple University Philadelphia PA.,Division of Cardiology Temple University Hospital Philadelphia PA.,Main Line Health Broomall PA
| | | | - Rohit Soans
- Lewis Katz School of Medicine at Temple University Philadelphia PA.,Division of Bariatric Surgery Temple University Hospital Philadelphia PA
| | - Abdullah Haddad
- Lewis Katz School of Medicine at Temple University Philadelphia PA.,Division of Cardiology Temple University Hospital Philadelphia PA
| | - Vikram J Eddy
- Lewis Katz School of Medicine at Temple University Philadelphia PA.,Division of Bariatric Surgery Temple University Hospital Philadelphia PA
| | - Joseph McComb
- Lewis Katz School of Medicine at Temple University Philadelphia PA.,Division of Anesthesiology Temple University Hospital Philadelphia PA
| | - Martin G Keane
- Lewis Katz School of Medicine at Temple University Philadelphia PA.,Division of Cardiology Temple University Hospital Philadelphia PA
| | - Isaac R Whitman
- Lewis Katz School of Medicine at Temple University Philadelphia PA.,Division of Cardiology Temple University Hospital Philadelphia PA
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19
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Oh AR, Park J, Lee JH, Kim H, Yang K, Choi JH, Ahn J, Sung JD, Lee SH. Association Between Perioperative Adverse Cardiac Events and Mortality During One-Year Follow-Up After Noncardiac Surgery. J Am Heart Assoc 2022; 11:e024325. [PMID: 35411778 PMCID: PMC9238468 DOI: 10.1161/jaha.121.024325] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Cardiac complications are associated with perioperative mortality, but perioperative adverse cardiac events (PACEs) that are associated with long‐term mortality have not been clearly defined. We identified PACE as a composite of myocardial infarction, coronary revascularization, congestive heart failure, arrhythmic attack, acute pulmonary embolism, cardiac arrest, or stroke during the 30‐day postoperative period and we compared mortality according to PACE occurrence. Methods and Results From January 2011 to June 2019, a total of 203 787 consecutive adult patients underwent noncardiac surgery at our institution. After excluding those with 30‐day mortality, mortality during a 1‐year follow‐up was compared. Machine learning with the extreme gradient boosting algorithm was also used to evaluate whether PACE was associated with 1‐year mortality. After excluding 1203 patients with 30‐day mortality, 202 584 patients were divided into 7994 (3.9%) patients with PACE and 194 590 (96.1%) without PACE. After an adjustment, the mortality was higher in the PACE group (2.1% versus 7.7%; hazard ratio [HR], 1.90; 95% CI, 1.74–2.09; P<0.001). Results were similar for 7839 pairs of propensity‐score‐matched patients (4.9% versus 7.9%; HR, 1.64; 95% CI, 1.44–1.87; P<0.001). PACE was significantly associated with mortality in the extreme gradient boostingmodel. Conclusions PACE as a composite outcome was associated with 1‐year mortality. Further studies are needed for PACE to be accepted as an end point in clinical studies of noncardiac surgery.
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Affiliation(s)
- Ah Ran Oh
- Department of Anesthesiology and Pain Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea.,Department of Anesthesiology and Pain Medicine Kangwon National University Hospital Chuncheon Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea.,Department of Biomedical Sciences Ajou University Graduate School of Medicine Suwon Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Hara Kim
- Department of Anesthesiology and Pain Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Kwangmo Yang
- Department of Biomedical Sciences Ajou University Graduate School of Medicine Suwon Korea.,Center for Health Promotion Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Jin-Ho Choi
- Department of Emergency Medicine Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Joonghyun Ahn
- Statistics and Data Center Research Institute for Future Medicine Samsung Medical Center Seoul Korea
| | - Ji Dong Sung
- Rehabilitation & Prevention Center Heart Vascular Stroke Institute Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea
| | - Seung-Hwa Lee
- Rehabilitation & Prevention Center Heart Vascular Stroke Institute Samsung Medical CenterSungkyunkwan University School of Medicine Seoul Korea.,Department of Biomedical Engineering Seoul National University College of Medicine Seoul Korea
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20
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Lean Management Approach for Reengineering the Hospital Cardiology Consultation Process: A Report from AORN "A. Cardarelli" of Naples. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084475. [PMID: 35457344 PMCID: PMC9026877 DOI: 10.3390/ijerph19084475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 02/06/2023]
Abstract
Background: Consultations with specialists are essential for safe and high-quality care for all patients. Cardiology consultations, due to a progressive increase in cardiology comorbidities, are becoming more common in hospitals prior to any type of treatment. The appropriateness and correctness of the request, the waiting time for delivery and the duration of the visit are just a few of the elements that can affect the quality of the process. Methods: In this work, a Lean approach and Telemedicine are used to optimize the cardiology consultancy process provided by the Cardiology Unit of “Antonio Cardarelli” Hospital of Naples (Italy), the largest hospital in the southern Italy. Results: The application of corrective actions, with the introduction of portable devices and telemedicine, led to a reduction in the percentage of waiting for counseling from 29.6% to 18.3% and an increase in the number of patients treated. Conclusions: The peculiarity of the study is to apply an innovative methodology such as Lean Thinking in optimizing the cardiology consultancy process, currently little studied in literature, with benefits for both patients and medical staff.
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21
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Xiao J, Yong JN, Ng CH, Syn N, Lim WH, Tan DJH, Tan EY, Huang D, Wong RC, Chew NWS, Tan EXX, Noureddin M, Siddiqui MS, Muthiah MD. A Meta-Analysis and Systematic Review on the Global Prevalence, Risk Factors, and Outcomes of Coronary Artery Disease in Liver Transplantation Recipients. Liver Transpl 2022; 28:689-699. [PMID: 34626045 DOI: 10.1002/lt.26331] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022]
Abstract
The shift in the changing etiology of cirrhosis requiring liver transplantation (LT) has resulted in an increasing prevalence of coronary artery disease (CAD) that can potentially impact post-LT outcomes. This systematic review and meta-analysis evaluates the prevalence of CAD, risk factors, and outcomes of patients diagnosed with CAD before LT. MEDLINE and EMBASE were searched for articles describing CAD in pre-LT patients. Meta-analysis of proportions using the generalized linear mix model was conducted to analyze the pooled prevalence of CAD in pre-LT patients. Associated risk factors for CAD in pre-LT patients and outcomes were evaluated in conventional pairwise meta-analysis. A total of 39 studies were included. The pooled prevalence of patients diagnosed with CAD before LT was 15.9% (95% CI, 9.8%-24.7%). Age, male sex, diabetes mellitus, hypertension, hyperlipidemia, smoking, nonalcoholic steatohepatitis, hepatitis B virus, and hepatocellular carcinoma were significantly associated with CAD. Patients from high-income countries especially North America, Europe, and South America, with the associated risk factors were at increased risk for CAD before LT. CAD before LT was associated with an increased odds of overall mortality (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.4-1.4; P = 0.01) and cardiac-related mortality (OR, 1.2; 95% CI, 1.1-1.3; P = 0.03). A total of 48.7% of included articles considered the presence of cardiovascular risk factors for CAD screening. However, 10.3% of the studies screened for CAD in pre-LT patients via invasive coronary angiography only, without stress testing or risk stratification. This study demonstrates the high prevalence of CAD in pre-LT patients, associated risk factors, and outcomes. There is heterogeneity among guidelines and practice in screening for pre-LT CAD, and more studies are needed to establish consensus.
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Affiliation(s)
- Jieling Xiao
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - En Ying Tan
- Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Daniel Huang
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Raymond C Wong
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Nicholas W S Chew
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Eunice Xiang Xuan Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Mazen Noureddin
- Cedars-Sinai Fatty Liver Program, Division of Digestive and Liver Diseases, Department of Medicine, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
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22
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Nasrallah AA, Dakik HA, Abou Heidar NF, Najdi JA, Nasrallah OG, Mansour M, Tamim H, Hajj AE. Major adverse cardiovascular events following partial nephrectomy: a procedure-specific risk index. Ther Adv Urol 2022; 14:17562872221084847. [PMID: 35321052 PMCID: PMC8935558 DOI: 10.1177/17562872221084847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 02/15/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction: Partial nephrectomy (PN) is associated with a non-negligible risk of postoperative cardiovascular morbidity and mortality. Identification of high-risk patients may enable optimization of perioperative management and consideration of alternative approaches. The authors aim to develop a procedure-specific cardiovascular risk index for PN patients and compare its performance to the widely used revised cardiac risk index (RCRI) and AUB-HAS2 cardiovascular risk index. Methods: The cohort was derived from the American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) database. The primary outcome was the incidence of major adverse cardiovascular events (MACE), defined as 30-day postoperative incidence of myocardial infarction, stroke, or mortality. A multivariate logistic regression model was constructed; performance and calibration were evaluated using an ROC analysis and the Hosmer–Lemeshow test and compared to the RCRI and the AUB-HAS2 index. Results: In a cohort of 4795 patients, MACE occurred in 52 (1.1%) patients. A univariate analysis yielded 13 eligible variables for entry into the multivariate model. The final PN-A4CH model utilized six variables: Age ⩾75 years, ASA class >2, Anemia, surgical Approach, Creatinine >1.5, and history of Heart disease. Index ROC analysis provided a C-statistic of 0.81, calibration R2 was 0.99, and sensitivity was 85%. In comparison, the RCRI and AUB-HAS2 C-statistics were 0.59 and 0.68, respectively. Conclusion: This study proposes a novel procedure-specific cardiovascular risk index. The PN-A4CH index demonstrated good predictive ability and excellent calibration using a large national database and may enable further individualization of patient care and optimization of patient selection.
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Affiliation(s)
- Ali A. Nasrallah
- Division of Urology, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Habib A. Dakik
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nassib F. Abou Heidar
- Division of Urology, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jad A. Najdi
- Division of Urology, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Oussama G. Nasrallah
- Division of Urology, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mazen Mansour
- Division of Urology, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Tamim
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Albert El Hajj
- Division of Urology, Department of Surgery, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El-Solh, 1107 2020 Beirut, Lebanon
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23
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Hu JR, Sugeng L. Routine Cardiac Stress Testing in Potential Kidney Transplant Candidates Is Only Appropriate in Symptomatic Individuals: CON. KIDNEY360 2022; 3:2013-2016. [PMID: 36591343 PMCID: PMC9802547 DOI: 10.34067/kid.0007162021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/20/2021] [Indexed: 01/12/2023]
Affiliation(s)
- Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lissa Sugeng
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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24
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Takeuchi K, Hayashida M, Kudoh O, Niimi N, Kataoka K, Kakemizu-Watanabe M, Yamamoto M, Hara A, Kawagoe I, Yamaguchi K. Continuing versus withholding angiotensin receptor blocker (ARB)/calcium channel blocker (CCB) combination tablets during perioperative periods in patients undergoing minor surgery: a single-blinded randomized controlled trial. J Anesth 2022; 36:374-382. [PMID: 35247102 PMCID: PMC9156462 DOI: 10.1007/s00540-022-03053-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/20/2022] [Indexed: 11/30/2022]
Abstract
Purpose This trial was conducted to compare effects of continuing versus withholding single-pill combination tablets consisting of angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs) on perioperative hemodynamics and clinical outcomes. Methods Patients undergoing minor abdominal or urological surgery (n = 106) were randomly assigned to Group C, in which ARB/CCB combination tablets were continued until surgery, or Group W, in which they were withheld within 24 h of surgery. Perioperative hemodynamics and clinical outcomes were compared between the Groups. Results The incidence of hypotension during anesthesia requiring repeated treatment with vasoconstrictors was higher in Group C than Group W (p = 0.0052). Blood pressure during anesthesia was generally lower in Group C than Group W (p < 0.05) despite significantly more doses of ephedrine and phenylephrine administrated in Group C (p = 0.0246 and p = 0.0327, respectively). The incidence of postoperative hypertension did not differ between Groups (p = 0.3793). Estimated glomerular filtration rate (eGFR) on the preoperative day did not differ between Groups (p = 0.7045), while eGFR was slightly lower in Group C than Group W on the first and third postoperative days (p = 0.0400 and p = 0.0088, respectively), although clinically relevant acute kidney injury did not develop. Conclusions Continuing ARB/CCB combination tablets preoperatively in patients undergoing minor surgery increased the incidence of hypotension during anesthesia, increased requirements of vasoconstrictors to treat hypotension, and might deteriorate postoperative renal function, albeit slightly. These results suggest that withholding ARB/CCB tablets preoperatively is preferable to continuing them. Clinical trial registration This trial is registered with the Japan Registry of Clinical Trials (jRCT) at Japanese Ministry of Health, Labour, and Welfare (Trial ID: jRCT1031190027).
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Affiliation(s)
- Kazuyo Takeuchi
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Masakazu Hayashida
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Osamu Kudoh
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Naoko Niimi
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kumi Kataoka
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Maho Kakemizu-Watanabe
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Makiko Yamamoto
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Atsuko Hara
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Izumi Kawagoe
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Keisuke Yamaguchi
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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25
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Moster M, Bolliger D. Perioperative Guidelines on Antiplatelet and Anticoagulant Agents: 2022 Update. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00511-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Abstract
Purpose of Review
Multiple guidelines and recommendations have been written to address the perioperative management of antiplatelet and anticoagulant drugs. In this review, we evaluated the recent guidelines in non-cardiac, cardiac, and regional anesthesia. Furthermore, we focused on unresolved problems and novel approaches for optimized perioperative management.
Recent Findings
Vitamin K antagonists should be stopped 3 to 5 days before surgery. Preoperative laboratory testing is recommended. Bridging therapy does not decrease the perioperative thromboembolic risk and might increase perioperative bleeding risk. In patients on direct-acting oral anticoagulants (DOAC), a discontinuation interval of 24 and 48 h in those scheduled for surgery with low and high bleeding risk, respectively, has been shown to be saved. Several guidelines for regional anesthesia recommend a conservative interruption interval of 72 h for DOACs before neuraxial anesthesia. Finally, aspirin is commonly continued in the perioperative period, whereas potent P2Y12 receptor inhibitors should be stopped, drug-specifically, 3 to 7 days before surgery.
Summary
Many guidelines have been published from various societies. Their applicability is limited in emergent or urgent surgery, where novel approaches might be helpful. However, their evidence is commonly based on small series, case reports, or expert opinions.
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26
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Jha S. Decision-Making Dilemma in Preoperative Cardiac Evaluation: Should We Turn the Page or Close the Book? Cureus 2022; 14:e21151. [PMID: 35165601 PMCID: PMC8831317 DOI: 10.7759/cureus.21151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 11/06/2022] Open
Abstract
Coronary artery disease is one of the most dreadful and life-threatening diseases out of all cardiac diseases. The diagnosis and management of coronary artery disease comprise stepwise approaches. All these approaches are mostly guideline-driven. While the majority of the time, guidelines help us take the most appropriate care, exceptions do exist. For example, patients may have unusual risk factors and abnormal test results; however, they do not fit into the guideline algorithm to proceed further. This case report of a 68-year-old male patient depicts a true example of such a situation. He presented to the cardiologist's office for pre-operative cardiac evaluation for urological surgery. In view of associated risk factors, an exercise stress test was done, which showed critical abnormalities. As per the pre-operative cardiac assessment guidelines, the patient did not meet the criteria for further testing. However, a clinician's strong judgment and persistent negotiation superseded those barriers. Given critical abnormalities of the exercise stress test, the patient underwent cardiac catheterization. He was found to have triple vessel disease on cardiac catheterization. The scheduled surgery was withheld, and the patient underwent a coronary artery bypass graft. This life-threatening condition could have been easily missed if only the guidelines were to be followed. While guidelines cover a significant portion of the bell curve, this case report represents the importance of not missing the tail ends of the curve. It enhances the importance of thinking out of the box based on clinical training and expertise.
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Ding Q, Trickey AW, Mudumbai S, Kamal RN, Sears ED, Harris AHS. Prevalence and Factors Associated With Low-Value Preoperative Testing for Patients Undergoing Carpal Tunnel Release at an Academic Medical Center. Hand (N Y) 2022; 17:28-34. [PMID: 32100568 PMCID: PMC8721789 DOI: 10.1177/1558944720906498] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Routine preoperative screening tests before low-risk surgery cannot be justified if the risks to patients are not outweighed by benefits. Several studies and professional guidelines suggest avoiding screening tests prior to minor operations. We aimed to assess the prevalence and patient characteristics associated with low-value preoperative tests (LVTs) prior to carpal tunnel release (CTR) at an academic medical center. Methods: From electronic medical records, we identified patients aged ≥18 who underwent CTR from 2015 to 2017. We determined the occurrence of 9 common LVTs, such as complete blood count (CBC), basic metabolic profile (BMP), and electrocardiogram (ECG), in the 30 days prior to CTR. Multivariable logistic and Poisson regression were used to identify factors associated with receiving any LVT and the number of LVTs, respectively. Results: Among 572 patients, 248 (43.4%) had at least 1 LVT. The most common tests were ECG (31.3% of CTRs), CBC (27.3% of CTRs), and BMP (23.6% of CTRs). Patient factors associated with higher odds of receiving LVT included older age, higher Elixhauser comorbidity score, and general or regional anesthesia (vs monitored anesthesia care). Conclusions: Low-value preoperative tests were frequently received by patients undergoing CTR and were associated with anesthesia type, age, and number of comorbidities. Although our study focused on CTR, these results likely have implications for other commonly performed low-risk procedures. These findings can help guide efforts to improve the quality and value of surgery for carpal tunnel syndrome and facilitate the development of strategies to reduce LVT, such as audit feedback and provider education.
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Affiliation(s)
- Qian Ding
- Stanford University School of Medicine, CA, USA
| | | | - Seshadri Mudumbai
- Stanford University School of Medicine, CA, USA,VA Palo Alto Health Care System, Menlo Park, CA, USA
| | | | | | - Alex H. S. Harris
- Stanford University School of Medicine, CA, USA,VA Palo Alto Health Care System, Menlo Park, CA, USA,Alex H. S. Harris, Department of Surgery, Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford University School of Medicine, MC5552, Stanford, CA 94305, USA.
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28
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Niedermeier A, Vitali-Serdoz L, Fischlein T, Kirste W, Buia V, Walaschek J, Rittger H, Bastian D. Perioperative Sensor and Algorithm Programming in Patients with Implanted ICDs and Pacemakers for Cardiac Resynchronization Therapy. SENSORS 2021; 21:s21248346. [PMID: 34960440 PMCID: PMC8705781 DOI: 10.3390/s21248346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/06/2021] [Accepted: 12/09/2021] [Indexed: 11/17/2022]
Abstract
Background: ICDs and pacemakers for cardiac resynchronization therapy (CRT) are complex devices with different sensors and automatic algorithms implanted in patients with advanced cardiac diseases. Data on the perioperative management and outcome of CRT carriers undergoing surgery unrelated to the device are scarce. Methods: Data from 198 CRT device carriers (100 with active rate responsive sensor) were evaluated regarding perioperative adverse (device-related) events (A(D)E) and lead parameter changes. Results: Thirty-nine adverse observations were documented in 180 patients during preoperative interrogation, which were most often related to the left-ventricular lead and requiring intervention/reprogramming in 22 cases (12%). Anesthesia-related events occurred in 69 patients. There was no ADE for non-cardiac surgery and in pacemaker-dependent patients not programmed to an asynchronous pacing mode. Post-operative device interrogation showed significant lead parameter changes in 64/179 patients (36%) requiring reprogramming in 29 cases (16%). Conclusion: The left-ventricular pacing lead represents the most vulnerable system component. Comprehensive pre and post-interventional device interrogation is mandatory to ensure proper system function. The type of ICD function suspension has no impact on each patient’s outcome. Precautionary activity sensor deactivation is not required for non-cardiac interventions. Routine prophylactic device reprogramming to asynchronous pacing appears inessential. Most of the CRT pacemakers do not require surgery-related reprogramming.
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Affiliation(s)
- Alexander Niedermeier
- Faculty of Medicine, Friedrich-Alexander-University Erlangen-Nuernberg (FAU), 91054 Erlangen, Germany;
| | - Laura Vitali-Serdoz
- Department of Cardiology, Klinikum Fuerth, Teaching Hospital of Erlangen-Nuernberg University, 90766 Fuerth, Germany; (V.B.); (J.W.); (H.R.); (D.B.)
- Correspondence: ; Tel.: +49-911-7580-992981
| | - Theodor Fischlein
- Department of Cardiac Surgery, Cardiovascular Center, Klinikum Nuernberg—Paracelsus Medical University, Breslauer Str. 201, 90419 Nuremberg, Germany;
| | - Wolfgang Kirste
- Outpatient Clinic for Cardiology and Diabetes, 91126 Schwabach, Germany;
| | - Veronica Buia
- Department of Cardiology, Klinikum Fuerth, Teaching Hospital of Erlangen-Nuernberg University, 90766 Fuerth, Germany; (V.B.); (J.W.); (H.R.); (D.B.)
| | - Janusch Walaschek
- Department of Cardiology, Klinikum Fuerth, Teaching Hospital of Erlangen-Nuernberg University, 90766 Fuerth, Germany; (V.B.); (J.W.); (H.R.); (D.B.)
| | - Harald Rittger
- Department of Cardiology, Klinikum Fuerth, Teaching Hospital of Erlangen-Nuernberg University, 90766 Fuerth, Germany; (V.B.); (J.W.); (H.R.); (D.B.)
| | - Dirk Bastian
- Department of Cardiology, Klinikum Fuerth, Teaching Hospital of Erlangen-Nuernberg University, 90766 Fuerth, Germany; (V.B.); (J.W.); (H.R.); (D.B.)
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Oyedeji CI. Optimizing management of sickle cell disease in patients undergoing surgery. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:405-410. [PMID: 34889383 PMCID: PMC8791118 DOI: 10.1182/hematology.2021000274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Individuals with sickle cell disease (SCD) are likely to be referred for surgery at some point in their lifetime due to a high incidence of musculoskeletal and intrabdominal complications such as avascular necrosis and gallbladder disease. Preoperative optimization is a multidisciplinary process that involves a hematologist with SCD expertise, an anesthesiologist, and the surgical team. The type and risk classification of the surgery, disease severity, medications, baseline hemoglobin, transfusion history, and history of prior surgical complications are often documented. Clinicians should consider perioperative risk assessment that includes determining the patient's functional status and cardiovascular risk and screening for obstructive sleep apnea. Many patients will require preoperative transfusion to reduce the risk of postoperative complications such as acute chest syndrome and vaso-occlusive pain crises. The hematologist should consider the patient's preoperative transfusion requirements and ensure that the surgical team has an appropriate plan for postoperative observation and management. This often includes follow-up laboratory studies, a postoperative pain management plan, and venous thromboembolism prophylaxis. The transfusion plan should be patient-specific and take into account the SCD genotype, baseline hemoglobin, disease severity, risk classification of the surgery, and history of prior surgical complications. In the intraoperative and postoperative period, dehydration, hypothermia, hypotension, hypoxia, and acidosis should be avoided, and incentive spirometry should be utilized to minimize complications such as acute chest syndrome. In this review we discuss preoperative, intraoperative, and postoperative strategies to optimize patients with SCD undergoing surgery.
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Affiliation(s)
- Charity I. Oyedeji
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, NC
- Correspondence Charity I. Oyedeji, Division of Hematology, Department of Medicine, Duke University School of Medicine, 315 Trent Dr, Hanes House, Ste 261, DUMC Box 3939, Durham, NC 27710; e-mail: char
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Ferro CJ, Berry M, Moody WE, George S, Sharif A, Townend JN. Screening for occult coronary artery disease in potential kidney transplant recipients: time for reappraisal? Clin Kidney J 2021; 14:2472-2482. [PMID: 34950460 PMCID: PMC8690093 DOI: 10.1093/ckj/sfab103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/03/2021] [Indexed: 11/14/2022] Open
Abstract
Screening for occult coronary artery disease in potential kidney transplant recipients has become entrenched in current medical practice as the standard of care and is supported by national and international clinical guidelines. However, there is increasing and robust evidence that such an approach is out-dated, scientifically and conceptually flawed, ineffective, potentially directly harmful, discriminates against ethnic minorities and patients from more deprived socioeconomic backgrounds, and unfairly denies many patients access to potentially lifesaving and life-enhancing transplantation. Herein we review the available evidence in the light of recently published randomized controlled trials and major observational studies. We propose ways of moving the field forward to the overall benefit of patients with advanced kidney disease.
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Affiliation(s)
- Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Miriam Berry
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
| | - William E Moody
- Department of Cardiology, University Hospitals Birmingham, Birmingham, UK
| | - Sudhakar George
- Department of Cardiology, University Hospitals Birmingham, Birmingham, UK
| | - Adnan Sharif
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jonathan N Townend
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, University Hospitals Birmingham, Birmingham, UK
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31
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Ferguson M, Shulman M. Cardiopulmonary Exercise Testing and Other Tests of Functional Capacity. CURRENT ANESTHESIOLOGY REPORTS 2021; 12:26-33. [PMID: 34840532 PMCID: PMC8605465 DOI: 10.1007/s40140-021-00499-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 11/29/2022]
Abstract
Purpose of Review Assessment of functional capacity is a cornerstone of preoperative risk assessment. While subjective clinician assessment of functional capacity is poorly predictive of postoperative outcomes, other objective functional assessment measures may provide more useful information. Recent Findings Cardiopulmonary exercise testing (CPET) is generally accepted as the gold standard for functional capacity assessment. However, CPET is resource-intensive and not universally available. Simpler objective tests of functional capacity such as the Duke Activity Status Index (DASI) and the 6-min walk test (6MWT) are cheap and efficient. In addition, they predict important postoperative outcomes including death, disability, and myocardial infarction. Summary Simple preoperative tests such as the DASI may be useful for routine preoperative assessment. CPET may be helpful to investigate further patients with functional status limitation, and to guide prehabilitation and perioperative shared decision-making in high-risk patients.
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Affiliation(s)
| | - Mark Shulman
- Austin Hospital, 145 Studley Rd, Heidelberg, VIC Australia
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Effects of short-term bisoprolol on perioperative myocardial injury in patients undergoing non-cardiac surgery: a randomized control study. Sci Rep 2021; 11:22006. [PMID: 34759287 PMCID: PMC8581026 DOI: 10.1038/s41598-021-01365-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/27/2021] [Indexed: 11/09/2022] Open
Abstract
The protective role of preoperative beta-blocker in patients undergoing non-cardiac surgery is unknown. We aimed to evaluate the effects of beta-blocker on perioperative myocardial injury in patients undergoing non-cardiac surgery. We consecutively enrolled 112 patients undergoing non-cardiac surgery. They were randomly allocated to receive bisoprolol or placebo given at least 2 days preoperatively and continued until 30 days after surgery. The primary outcome was incidence of perioperative myocardial injury defined by a rise of high-sensitive troponin-T (hs-TnT) more than 99th percentile of upper reference limit or a rise of hs-TnT more than 20% if baseline level is abnormal. Baseline characteristics were comparable between bisoprolol and placebo in randomized cohort Mean age was 62.5 ± 11.8 years and 76 (67.8%) of 112 patients were male. Among 112 patients, 49 (43.8%) underwent vascular surgery and 63 (56.2%) underwent thoracic surgery. The median duration of assigned treatment prior to surgery was 4 days (2-6 days). We did not demonstrate the significant difference in the incidence of perioperative myocardial injury [52.6% (30 of 57 patients) vs. 49.1% (27 of 55 patients), P = 0.706]. In addition, the incidence of intraoperative hypotension was higher in bisoprolol group than placebo group in patients undergoing non-cardiac surgery [70.2% (40 of 57 patients) vs. 47.3% (26 of 55 patients), P = 0.017]. We demonstrated that there was no statistically significant difference in perioperative myocardial injury observed between patients receiving bisoprolol and placebo who had undergone non-cardiac surgery.
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Chu SY, Li PW, Fan FF, Han XN, Liu L, Wang J, Zhao J, Ye XJ, Ding WH. Combining CHA 2DS 2-VASc score into RCRI for prediction perioperative cardiovascular outcomes in patients undergoing non-cardiac surgery: a retrospective pilot study. BMC Anesthesiol 2021; 21:276. [PMID: 34753422 PMCID: PMC8576929 DOI: 10.1186/s12871-021-01496-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 10/29/2021] [Indexed: 12/31/2022] Open
Abstract
Background Treatment decisions in patients undergoing non-cardiac surgery are based on clinical assessment. The Revised Cardiac Risk Index (RCRI) is pragmatic and widely used but has only moderate discrimination. We aimed to test the efficacy of the CHA2DS2-VASc score and the combination of CHA2DS2-VASc and RCRI to predict perioperative risks for non-cardiac surgery. Methods This pre-specified analysis was performed in a retrospective cohort undergoing intra-abdominal surgery in our center from July 1st, 2007 to June 30th, 2008. The possible association between the baseline characteristics (as defined by CHA2DS2-VASc and RCRI) and the primary outcome of composite perioperative cardiac complications (myocardial infarction, cardiac ischemia, heart failure, arrhythmia, stroke, and/or death) and secondary outcomes of individual endpoints were explored using multivariate Logistic regression. The area under the receiver operating characteristic curve (C-statistic) was used for RCRI, CHA2DS2-VASc, and the combined models, and the net reclassification improvement (NRI) was calculated to assess the additional discriminative ability. Results Of the 1079 patients (age 57.5 ± 17.0 years), 460 (42.6%) were women. A total of 83 patients (7.7%) reached the primary endpoint. Secondary outcomes included 52 cardiac ischemic events, 40 myocardial infarction, 20 atrial fibrillation, 18 heart failure, four strokes, and 30 deaths. The endpoint events increased with the RCRI and CHA2DS2-VASc grade elevated (P < 0.05 for trend). The RCRI showed a moderate predictive ability with a C-statistics of 0.668 (95%CI 0.610–0.725) for the composite cardiac outcome. The C-statistics for the CHA2DS2-VASc was 0.765 (95% CI 0.709–0.820), indicating better performance than the RCRI (p = 0.011). Adding the CHA2DS2-VASc to the RCRI further increased the C-statistic to 0.774(95%CI 0.719–0.829), improved sensitivity, negative predictive value, and enhanced reclassification in reference to RCRI. Similar performance of the combined scores was demonstrated in the analysis of individual secondary endpoints. The best cut-off of a total of 4 scores was suggested for the combined CHA2DS2-VASc and RCRI in the prediction of the perioperative cardiac outcomes. Conclusions The CHA2DS2-VASc score significantly enhanced risk assessment for the composite perioperative cardiovascular outcome in comparison to traditional RCRI risk stratification. Incorporation of CHA2DS2-VASc scores into clinical-decision making to improve perioperative management in patients undergoing non-cardiac surgery warrants consideration. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01496-2.
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Affiliation(s)
- Song-Yun Chu
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Pei-Wen Li
- Department of Cardiology, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Fang-Fang Fan
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Xiao-Ning Han
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Lin Liu
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Jie Wang
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Jing Zhao
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Xiao-Jin Ye
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Wen-Hui Ding
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China.
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Ruetzler K, Smilowitz NR, Berger JS, Devereaux PJ, Maron BA, Newby LK, de Jesus Perez V, Sessler DI, Wijeysundera DN. Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e287-e305. [PMID: 34601955 DOI: 10.1161/cir.0000000000001024] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Myocardial injury after noncardiac surgery is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay and are attributable to a presumed ischemic mechanism, with or without concomitant symptoms or signs. Myocardial injury after noncardiac surgery occurs in ≈20% of patients who have major inpatient surgery, and most are asymptomatic. Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction. Consequently, surveillance of myocardial injury after noncardiac surgery is warranted in patients at high risk for perioperative cardiovascular complications. This scientific statement provides diagnostic criteria and reviews the epidemiology, pathophysiology, and prognosis of myocardial injury after noncardiac surgery. This scientific statement also presents surveillance strategies and treatment approaches.
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Preoperative Assessment and Management of Cardiovascular Risk in Patients Undergoing Non-Cardiac Surgery: Implementing a Systematic Stepwise Approach during the COVID-19 Pandemic Era. J Cardiovasc Dev Dis 2021; 8:jcdd8100126. [PMID: 34677195 PMCID: PMC8541645 DOI: 10.3390/jcdd8100126] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/22/2021] [Accepted: 09/29/2021] [Indexed: 02/05/2023] Open
Abstract
Major adverse cardiac events, defined as death or myocardial infarction, are common causes of perioperative mortality and major morbidity in patients undergoing non-cardiac surgery. Reduction of perioperative cardiovascular risk in relation to non-cardiac surgery requires a stepwise patient evaluation that integrates clinical risk factors, functional status and the estimated stress of the planned surgical procedure. Major guidelines on preoperative cardiovascular risk assessment recommend to establish, firstly, the risk of surgery per se (low, moderate, high) and the related timing (elective vs. urgent/emergent), evaluate the presence of unstable cardiac conditions or a recent coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting), assess the functional capacity of the patient (usually expressed in metabolic equivalents), determine the value of non-invasive and/or invasive cardiovascular testing and then combine these data in estimating perioperative risk for major cardiac adverse events using validated scores (Revised Cardiac Risk Index (RCRI) or National Surgical Quality Improvement Program (NSQIP)). This stepwise approach has the potential to guide clinicians in determining which patients could benefit from cardiovascular therapy and/or coronary artery revascularization before non-cardiac surgery towards decreasing the incidence of perioperative morbidity and mortality. Finally, it should be highlighted that there is a need to implement specific strategies in the 2019 Coronavirus disease (COVID-19) pandemic to minimize the risk of transmission of COVID-19 infection during the preoperative risk assessment process.
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Debry N, Altes A, Vincent F, Delhaye C, Schurtz G, Nedjari F, Legros G, Porouchani S, Coisne A, Richardson M, Cosenza A, Verdier B, Denimal T, Pamart T, Spillemaeker H, Sylla H, Sudre A, Janah D, Aouate D, Marsou W, Appert L, Lemesle G, Labreuche J, Maréchaux S, Van Belle E. Balloon aortic valvuloplasty for severe aortic stenosis before urgent non-cardiac surgery. EUROINTERVENTION 2021; 17:e680-e687. [PMID: 34105511 PMCID: PMC9724970 DOI: 10.4244/eij-d-20-01423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Balloon aortic valvuloplasty (BAV) has been proposed as a therapeutic option in patients suffering from severe aortic stenosis (SAS) who need urgent non-cardiac surgery (NCS). Whether this strategy is better than medical therapy in this very specific population is unknown. AIMS We aimed to evaluate the clinical benefit of an invasive strategy (IS) with preoperative BAV in patients with SAS requiring urgent NCS. METHODS From 2011 to 2019, a registry conducted in two centres included 133 patients with SAS undergoing urgent NCS, of whom 93 underwent preoperative BAV (IS) and 40 a conservative strategy (CS) without BAV. All analyses were adjusted for confounding using inverse probability of treatment weighting (IPTW) (10 clinical and anatomical variables). RESULTS The primary outcome was MACE at one-month follow-up after NCS including mortality, heart failure, and other cardiovascular outcomes. In patients managed conservatively, occurrence of MACE was 20.0% (n=8) and death was 10.0% (n=4) at 1 month. In patients undergoing BAV, the occurrence of MACE was 20.4% (n=19) and death was 5.4% (n=5) at 1 month. Among patients undergoing conservative management, all events were observed after NCS while, in patients undergoing BAV, 12.9% (n=12) had events between BAV and NCS including 3 deaths, and 7.5% (n=7) had events after NCS including 2 deaths. In IPTW propensity analyses, the incidence of the primary outcome (20.4% vs 20.0%; OR 0.93, 95% CI: 0.38-2.29) and three-month survival (89.2% vs 90.0%; IPTW-adjusted HR 0.90, 95% CI: 0.31-2.60) were similar in both groups. CONCLUSIONS Patients with SAS managed conservatively before urgent NCS are at high risk of events. A systematic invasive strategy using BAV does not provide a significant improvement in clinical outcome.
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Affiliation(s)
- Nicolas Debry
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France,Groupement des Hôpitaux de l’Institut Catholique de Lille (GHICL), Cardiology Department and Heart Valve Centre, Faculté Libre de Médecine/Université Catholique de Lille, Lille, France,INSERM, U1011, Lille, France
| | - Alexandre Altes
- Groupement des Hôpitaux de l’Institut Catholique de Lille (GHICL), Cardiology Department and Heart Valve Centre, Faculté Libre de Médecine/Université Catholique de Lille, Lille, France
| | - Flavien Vincent
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France,INSERM, U1011, Lille, France,Université de Lille, Lille, France
| | - Cédric Delhaye
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France
| | - Guillaume Schurtz
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France
| | - Farid Nedjari
- Groupement des Hôpitaux de l’Institut Catholique de Lille (GHICL), Cardiology Department and Heart Valve Centre, Faculté Libre de Médecine/Université Catholique de Lille, Lille, France
| | - Gabin Legros
- Groupement des Hôpitaux de l’Institut Catholique de Lille (GHICL), Cardiology Department and Heart Valve Centre, Faculté Libre de Médecine/Université Catholique de Lille, Lille, France
| | - Sina Porouchani
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France
| | - Augustin Coisne
- INSERM, U1011, Lille, France,Université de Lille, Lille, France,CHU Lille, Department of Clinical Physiology and Echocardiography, Lille, France
| | - Marjorie Richardson
- CHU Lille, Department of Clinical Physiology and Echocardiography, Lille, France
| | - Alessandro Cosenza
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France
| | - Basile Verdier
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France
| | - Tom Denimal
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France
| | - Thibault Pamart
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France
| | - Hugues Spillemaeker
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France
| | - Habib Sylla
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France
| | - Arnaud Sudre
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France
| | - Dany Janah
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France
| | - David Aouate
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France
| | - Wassima Marsou
- Groupement des Hôpitaux de l’Institut Catholique de Lille (GHICL), Cardiology Department and Heart Valve Centre, Faculté Libre de Médecine/Université Catholique de Lille, Lille, France
| | - Ludovic Appert
- Groupement des Hôpitaux de l’Institut Catholique de Lille (GHICL), Cardiology Department and Heart Valve Centre, Faculté Libre de Médecine/Université Catholique de Lille, Lille, France
| | - Gilles Lemesle
- CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Lille, France,INSERM, U1011, Lille, France,Université de Lille, Lille, France
| | | | - Sylvestre Maréchaux
- Groupement des Hôpitaux de l’Institut Catholique de Lille (GHICL), Cardiology Department and Heart Valve Centre, Faculté Libre de Médecine/Université Catholique de Lille, Lille, France
| | - Eric Van Belle
- Cardiology Department, Institut Coeur-Poumons, CHU Lille, Boulevard du Professeur Jules Leclercq, 59000 Lille, France
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Adverse outcomes after noncardiac surgery in patients with aortic stenosis. Sci Rep 2021; 11:19517. [PMID: 34593867 PMCID: PMC8484466 DOI: 10.1038/s41598-021-98507-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 09/08/2021] [Indexed: 11/10/2022] Open
Abstract
Whether aortic stenosis (AS) increases perioperative risk in noncardiac surgery remains controversial. Limited information is available regarding adequate anesthetic techniques for patients with AS. Using the reimbursement claims data of Taiwan’s National Health Insurance, we performed propensity score matching analyses to evaluate the risk of adverse outcomes in patients with or without AS undergoing noncardiac surgery between 2008 and 2013. We also compared the perioperative risk of AS patients undergoing general anesthesia or neuraxial anesthesia. Multivariable logistic regressions were applied to calculate the adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for postoperative mortality and major complications. The matching procedure generated 9741 matched pairs for analyses. AS was significantly associated with 30-day in-hospital mortality (aOR 1.31, 95% CI 1.03–1.67), acute renal failure (aOR 1.42, 95% CI 1.12–1.79), pneumonia (aOR 1.16, 95% CI 1.02–1.33), stroke (aOR 1.14, 95% CI 1.01–1.29), and intensive care unit stay (aOR 1.38, 95% CI 1.27–1.49). Compared with neuraxial anesthesia, general anesthesia was associated with increased risks of acute myocardial infarction (aOR 3.06, 95% CI 1.22–7.67), pneumonia (aOR 1.80, 95% CI 1.32–2.46), acute renal failure (aOR 1.82, 95% CI 1.11–2.98), and intensive care (aOR 4.05, 95% CI 3.23–5.09). The findings were generally consistent across subgroups. AS was an independent risk factor for adverse events after noncardiac surgery. In addition, general anesthesia was associated with greater postoperative complications in AS patients compared to neuraxial anesthesia. This real-world evidence suggests that neuraxial anesthesia should not be contraindicated in patients with AS.
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Fataliev GB, Arakelian VS, Shubin AA. [Hybrid operations in treatment of patients with multi-level lesions of lower limb arteries]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:173-179. [PMID: 34528603 DOI: 10.33529/angiq2021321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The article is a review of literature dedicated to simultaneous open and endovascular (hybrid) operations in treatment of patients with chronic ischaemia of lower limbs. Despite good results of endovascular interventions, in many situations involvement of arteries below the inguinal fold and multilevel lesions are arguments in favour of performing an open operation. On the other hand, open multilevel interventions are accompanied by an increased risk of complications and mortality. Hybrid interventions appear to be a safe and efficient alternative combining advantages of two methods of treatment and making it possible to achieve an optimal outcome with a minimal surgical wound. Also discussed herein are the problems of terminology, indications for, techniques and results of treatment, providing a historical background, followed by analysing problem spots of using this technique and trends of development.
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Affiliation(s)
- G B Fataliev
- Municipal Clinical Hospital named after S.P. Botkin of the Moscow Healthcare Department, Moscow, Russia
| | - V S Arakelian
- A.N.Bakulev National Medical Research Center of Cardiovascular Surgery of the RF Ministry of Public Health, Moscow, Russia
| | - A A Shubin
- Municipal Clinical Hospital named after S.P. Botkin of the Moscow Healthcare Department, Moscow, Russia
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Garcia GA, Bair H, Kossler AL. Perioperative Management of Antithrombotic Medications: An Investigation into Current U. S. Ophthalmologic Recommendations. J Curr Ophthalmol 2021; 33:182-188. [PMID: 34409230 PMCID: PMC8365588 DOI: 10.4103/2452-2325.303201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/16/2021] [Accepted: 03/03/2021] [Indexed: 12/01/2022] Open
Abstract
Purpose: To investigate the availability and content of educational statements or recommendations disseminated by U. S. ophthalmologic organizations regarding perioperative management of antithrombotic agents for ophthalmic and orbital surgery, given the highly variable management of these agents by U. S. ophthalmologists and limited consensus recommendations in the literature. Methods: National U. S. ophthalmic surgical organization websites were systematically examined for educational statements, which were reviewed for discussion of perioperative management of antithrombotic agents including antiplatelet and anticoagulant medications. A “statement” was defined as either: (a) a guideline directed toward ophthalmologists or (b) a surgical/clinical educational posting directed toward ophthalmologists or patients. Results: Fourteen surgical organizations were identified, with eight of these publishing clinical/surgical educational statements. A total of 3408 organizational statements were identified, with 252 (7.4%) and 3156 (92.6%) statements directed toward physicians and patients, respectively. In total, 0.3% (9/3408) of statements discussed perioperative management of antithrombotics. These accounted for 0.8% (2/252) of ophthalmologist-directed statements and 0.2% (7/3156) of patient-directed statements. The majority of patient-directed statements (57.1%, 4/7) recommended that patients discuss antithrombotic cessation with their ophthalmologists, though ophthalmologist-directed information regarding these medications was scant or absent. Conclusions: Educational material from U. S. ophthalmologic organizations regarding perioperative management of antithrombotics is notably lacking despite the fact that ophthalmic and orbital surgeries carry unique vision-threatening hemorrhagic risks. Given these risks, as well as the medicolegal consequences of hemorrhagic complications in ophthalmic surgery, increased dissemination of educational material, and consensus statements by ophthalmic surgical organizations on the perioperative management of antithrombotics may be justified.
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Affiliation(s)
- Giancarlo A Garcia
- Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Henry Bair
- Stanford University School of Medicine, Stanford, CA, USA
| | - Andrea L Kossler
- Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
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Hennrikus MT, Hennrikus WP, Lehman E, Hennrikus EF. Obesity, Angiotensin-Blocking Drugs, and Acute Kidney Injury in Orthopedic Surgery. Orthopedics 2021; 44:e253-e258. [PMID: 33373462 DOI: 10.3928/01477447-20201216-08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Postoperative acute kidney injury occurs in 7% to 11% of orthopedic surgeries. The effect of preoperative angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) on the development of postoperative acute kidney injury remains controversial. Adipose tissue has its own independently regulated angiotensin system. The primary aim of this study was to examine the effects of obesity and preoperative ACEIs and ARBs on postoperative acute kidney injury. Charts were reviewed of adult elective orthopedic surgery patients during a 2-year period when patients were instructed to take their ACEI or ARB on the morning of surgery. The patients were divided into an obese cohort (body mass index [BMI] ≥30 kg/m2) and a nonobese cohort (BMI <30 kg/m2). A multivariable model was created for the outcome of acute kidney injury, using obesity as a primary predictor and adjusting for demographics, medications, comorbidities, and intraoperative parameters in a logistic regression analysis. Obesity increased the likelihood of developing acute kidney injury after orthopedic surgery (odds ratio [OR], 1.86; 95% CI, 1.07-3.22; P=.028). For every 5-unit increase in BMI, the odds of acute kidney injury were 1.43 (95% CI, 1.26-1.62; P<.001). When receiving ACEIs or ARBs, only the nonobese patients had a statistically increased likelihood of postoperative acute kidney injury (OR, 3.30; 95% CI, 1.12-9.70; P=.030). Obesity is an independent risk factor for postoperative acute kidney injury. Obesity appears to influence the effect that preoperative ACEIs and ARBs have on postoperative acute kidney injury. [Orthopedics. 2021;44(2):e253-e258.].
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Kawamoto S. Clinical Impacts of Myocardial Injury After Noncardiac Surgery on Younger Generation. Circ J 2021; 85:2089-2091. [PMID: 34121055 DOI: 10.1253/circj.cj-21-0407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shunsuke Kawamoto
- Division of Cardiovascular Surgery, Faculty of Medicine, Tohoku Medical and Pharmaceutical University
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Rose GA, Adamson MJ, Davies RG, Appadurai IR, Bailey DM. High-intensity exercise training improves perioperative risk stratification in the high-risk patient. Physiol Rep 2021; 8:e14409. [PMID: 32378338 PMCID: PMC7202981 DOI: 10.14814/phy2.14409] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 01/22/2023] Open
Abstract
Exercise prehabilitation prior to major surgery can improve cardiorespiratory fitness (CRF) and clinical outcome. However, in patients deemed “high‐‐risk” for surgery, the feasibility, optimum training modality and its intensity, duration, and frequency are yet to be defined. We assessed the cardiorespiratory fitness of a 70‐year‐old female patient requiring major thoraco‐abdominal surgery for reconstruction of her esophagus. Cardiopulmonary exercise testing (CPET) on a cycle ergometer was used to determine CRF. A baseline CPET confirmed poor CRF and placed her in a high surgical risk group. This was followed by 16 weeks of unsupervised, home‐based, moderate‐intensity steady‐state (MISS) training followed by 10 weeks of high‐intensity interval training (HIIT) under the combined supervision of an exercise physiologist and clinician in hospital. Following MISS training, CPET metrics failed to improve: peak oxygen uptake decreased (14.7–13.7 ml O2·kg−1·min−1; −7%) together with peak power (73–70 W; −4%) and anaerobic threshold (AT) increased (7.8–8.3 ml O2·kg−1·min−1; +6%). However, HIIT resulted in impressive improvement in CRF. Peak oxygen uptake (13.7–18.6 ml O2·kg−1·min−1; +36%), AT (8.3–10.5 ml O2·kg−1·min−1; +27%), peak power (70–102 W; +46%), minute ventilation (35.8–57.7 L·min−1; +61%), and peak heart rate (100–133 b·min−1; +33%) all increased. Ventilatory equivalents for carbon dioxide at AT (V˙E/V˙CO2‐AT) improved (30–28; −7%). The improvement in CRF resulted in surgical reclassification from high to low risk. In conclusion, preoperative HIIT training can confer a marked improvement in CRF in an elderly surgical patient and is associated with a corresponding reduction in perioperative risk.
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Affiliation(s)
- George A Rose
- Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Michael J Adamson
- Department of Anaesthetics, University Hospital of Wales, Cardiff, UK
| | - Richard G Davies
- Department of Anaesthetics, University Hospital of Wales, Cardiff, UK
| | - Ian R Appadurai
- Department of Anaesthetics, University Hospital of Wales, Cardiff, UK
| | - Damian M Bailey
- Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
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Barman PM, VanWagner LB. Cardiac Risk Assessment in Liver Transplant Candidates: Current Controversies and Future Directions. Hepatology 2021; 73:2564-2576. [PMID: 33219576 PMCID: PMC8220582 DOI: 10.1002/hep.31647] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/25/2020] [Accepted: 10/13/2020] [Indexed: 12/12/2022]
Abstract
In the changing landscape of liver transplantation (LT), we are now evaluating older and sicker patients with more cardiovascular comorbidities, and the spectrum of cardiovascular disease is uniquely physiologically impacted by end-stage liver disease. Cardiac complications are now the leading cause of morbidity and mortality in LT recipients, and the pretransplant risk is exacerbated immediately during the transplant operation and continues long term under the umbrella of immunosuppression. Accurate risk estimation of cardiac complications before LT is paramount to guide allocation of limited health care resources and to improve both short-term and long-term clinical outcomes for patients. Current screening and diagnostic testing are limited in their capacity to accurately identify early coronary disease and myocardial dysfunction in persons with end-stage liver disease physiology. Furthermore, a number of testing modalities have not been evaluated in patients with end-stage liver disease. As a result, there is wide variation in cardiac risk assessment practices across transplant centers. In this review, we propose a definition for defining cardiac events in LT, evaluate the current evidence for surgery-related, short-term and long-term cardiac risk assessment in LT candidates, propose an evidence-based testing algorithm, and highlight specific gaps in knowledge and current controversies, identifying areas for future research.
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Affiliation(s)
- Pranab M. Barman
- Department of Medicine-Division of Gastroenterology & Hepatology, University of California San Diego, San Diego, CA
| | - Lisa B. VanWagner
- Department of Medicine-Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL,Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
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Implementation of the Canadian Cardiovascular Society guidelines for perioperative risk assessment and management: an interrupted time series study. Can J Anaesth 2021; 68:1135-1145. [PMID: 34031808 DOI: 10.1007/s12630-021-02026-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE The Canadian Cardiovascular Society (CCS) guidelines for patients undergoing non-cardiac surgery address the lack of standardized management for patients at risk of perioperative cardiovascular complications. Our interdisciplinary group evaluated the implementation of these guidelines. METHODS We used an interrupted time series design to evaluate the effect of implementation of the CCS guidelines, using routinely collected hospital data. The study population consisted of elective, non-cardiac surgery patients who were: i) inpatients following surgery and ii) age ≥ 65 or age 45-64 yr with a Revised Cardiac Risk Index ≥ 1. Outcomes included adherence to troponin I (TnI) monitoring (primary) and adherence to appropriate consultant care for patients with elevated TnI (secondary). Exploratory outcomes included cost measures and clinical outcomes such as length of stay. RESULTS We included 1,421 patients (706 pre- and 715 post-implementation). We observed a 67% absolute increase (95% confidence interval, 55 to 80; P < 0.001) in adherence to TnI testing following the implementation of the guidelines. In patients who had elevated TnI following guideline implementation (n = 64), the majority (85%) received appropriate follow-up care in the form of a general medicine or cardiology consult, all received at least one electrocardiogram, and half received at least one advanced cardiac test (e.g., cardiac perfusion scan, or percutaneous intervention). CONCLUSIONS Our study showed the ability to implement and adhere to the CCS guidelines. Large-scale multicentre evaluations of CCS guideline implementation are needed to gain a better understanding of potential effects on clinically relevant outcomes.
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Park J, Kwon JH, Lee SH, Lee JH, Min JJ, Kim J, Oh AR, Yang K, Choi JH, Lee SC, Kim K, Ahn J, Gwon HC. Prognosis of Myocardial Injury After Non-Cardiac Surgery in Adults Aged Younger Than 45 Years. Circ J 2021; 85:2081-2088. [PMID: 33980764 DOI: 10.1253/circj.cj-21-0106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This study compared myocardial injury after non-cardiac surgery (MINS) and mortalities between patients under and over the age of 45 years.Methods and Results:From January 2010 and June 2019, patients with cardiac troponin measurement within 30 days after non-cardiac surgery were enrolled and divided into groups according to age: >45 (≥45 years) and <45 (<45 years). Further analyses were conducted only in patients who were diagnosed with MINS. The outcomes were MINS and 30-day mortality. Of the 35,223 patients, 31,161 (88.5%) patients were in the >45-year group and 4,062 (11.5%) were in the <45-year group. After adjustment with inverse probability of weighting, the <45-years group showed a lower incidence of MINS and cardiovascular mortality (16.6% vs. 11.7%; odds ratio, 0.77; 95% confidence interval [CI], 0.69-0.84; P<0.001 and 0.4% vs. 0.2%; hazard ratio [HR], 0.41; 95% CI, 0.19-0.88; P=0.02, respectively). In a comparison of only the <45-years group, MINS was associated with increased 30-day mortality (0.7% vs. 10.3%; HR, 10.48; 95% CI, 6.18-17.78; P<0.001), but the mortalities of patients with MINS did not differ according to age. CONCLUSIONS MINS has a comparable prognostic impact in patients aged under and over 45 years; therefore, future studies need to also consider patients aged <45 years regarding risk factors of MINS and screening of perioperative troponin elevation.
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Ji-Hye Kwon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Seung-Hwa Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jeong Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jihoon Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Kwangmo Yang
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jin-Ho Choi
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Sang-Chol Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Kyunga Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center.,Department of Digital Health, SAIHST, Sungkyunkwan University
| | - Joonghyun Ahn
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
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Cao Y, Forssten MP, Mohammad Ismail A, Borg T, Ioannidis I, Montgomery S, Mohseni S. Predictive Values of Preoperative Characteristics for 30-Day Mortality in Traumatic Hip Fracture Patients. J Pers Med 2021; 11:353. [PMID: 33924993 PMCID: PMC8146802 DOI: 10.3390/jpm11050353] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/21/2021] [Accepted: 04/23/2021] [Indexed: 12/23/2022] Open
Abstract
Hip fracture patients have a high risk of mortality after surgery, with 30-day postoperative rates as high as 10%. This study aimed to explore the predictive ability of preoperative characteristics in traumatic hip fracture patients as they relate to 30-day postoperative mortality using readily available variables in clinical practice. All adult patients who underwent primary emergency hip fracture surgery in Sweden between 2008 and 2017 were included in the analysis. Associations between the possible predictors and 30-day mortality was performed using a multivariate logistic regression (LR) model; the bidirectional stepwise method was used for variable selection. An LR model and convolutional neural network (CNN) were then fitted for prediction. The relative importance of individual predictors was evaluated using the permutation importance and Gini importance. A total of 134,915 traumatic hip fracture patients were included in the study. The CNN and LR models displayed an acceptable predictive ability for predicting 30-day postoperative mortality using a test dataset, displaying an area under the ROC curve (AUC) of as high as 0.76. The variables with the highest importance in prediction were age, sex, hypertension, dementia, American Society of Anesthesiologists (ASA) classification, and the Revised Cardiac Risk Index (RCRI). Both the CNN and LR models achieved an acceptable performance in identifying patients at risk of mortality 30 days after hip fracture surgery. The most important variables for prediction, based on the variables used in the current study are age, hypertension, dementia, sex, ASA classification, and RCRI.
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Affiliation(s)
- Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, 70182 Örebro, Sweden;
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska Institute, 17177 Stockholm, Sweden
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Orebro University Hospital, 70185 Orebro, Sweden; (M.P.F.); (A.M.I.); (T.B.); (I.I.)
- School of Medical Sciences, Orebro University, 70182 Orebro, Sweden;
| | - Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Orebro University Hospital, 70185 Orebro, Sweden; (M.P.F.); (A.M.I.); (T.B.); (I.I.)
- School of Medical Sciences, Orebro University, 70182 Orebro, Sweden;
| | - Tomas Borg
- Department of Orthopedic Surgery, Orebro University Hospital, 70185 Orebro, Sweden; (M.P.F.); (A.M.I.); (T.B.); (I.I.)
- School of Medical Sciences, Orebro University, 70182 Orebro, Sweden;
| | - Ioannis Ioannidis
- Department of Orthopedic Surgery, Orebro University Hospital, 70185 Orebro, Sweden; (M.P.F.); (A.M.I.); (T.B.); (I.I.)
- School of Medical Sciences, Orebro University, 70182 Orebro, Sweden;
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, 70182 Örebro, Sweden;
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, 17177 Stockholm, Sweden
- Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, 70182 Orebro, Sweden;
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 70185 Orebro, Sweden
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Kim C, Kim JS, Kim H, Ahn SG, Cho S, Lee OH, Park JK, Shin S, Moon JY, Won H, Suh Y, Cho JR, Cho YH, Oh SJ, Lee BK, Hong SJ, Shin DH, Ahn CM, Kim BK, Ko YG, Choi D, Hong MK, Jang Y. Consensus Decision-Making for the Management of Antiplatelet Therapy before Non-Cardiac Surgery in Patients Who Underwent Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents: A Cohort Study. J Am Heart Assoc 2021; 10:e020079. [PMID: 33843258 PMCID: PMC8174156 DOI: 10.1161/jaha.120.020079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Although antiplatelet therapy (APT) has been recommended to balance ischemic‐bleeding risks, it has been left to an individualized decision‐making based on physicians' perspectives before non‐cardiac surgery. The study aimed to assess the advantages of a consensus among physicians, surgeons, and anesthesiologists on continuation and regimen of preoperative APT in patients with coronary drug‐eluting stents. Methods and Results A total of 3582 adult patients undergoing non‐cardiac surgery after percutaneous coronary intervention with second‐generation stents was retrospectively included from a multicenter cohort. Physicians determined whether APT should be continued or discontinued for a recommended period before non‐cardiac surgery. There were 3103 patients who complied with a consensus decision. Arbitrary APT, not based on a consensus decision, was associated with urgent surgery, high bleeding risk of surgery, female sex, and dual APT at the time of preoperative evaluation. Arbitrary APT independently increased the net clinical adverse event (adjusted odds ratio [ORadj], 1.98; 95% CI, 1.98–3.11), major adverse cardiac event (ORadj, 3.11; 95% CI, 1.31–7.34), and major bleeding (ORadj, 2.34; 95% CI, 1.45–3.76) risks. The association was consistently noted, irrespective of the surgical risks, recommendations, and practice on discontinuation of APT. Conclusions Most patients were treated in agreement with a consensus decision about preoperative APT based on a referral system among physicians, surgeons, and anesthesiologists. The risk of perioperative adverse events increased if complying with a consensus decision was failed. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03908463.
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Affiliation(s)
- Choongki Kim
- Department of Cardiology Ewha Womans University College of Medicine Seoul Hospital Seoul Korea
| | - Jung-Sun Kim
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Hyeongsoo Kim
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Sung Gyun Ahn
- Division of Cardiology Department of Internal Medicine Wonju Severance Christian Hospital Yonsei University Wonju College of Medicine Wonju Korea
| | - Sungsoo Cho
- Division of Cardiovascular Medicine Department of Internal Medicine Dankook University HospitalDankook University College of Medicine Cheonan Korea
| | - Oh-Hyun Lee
- Division of Cardiology Yongin Severance HospitalYonsei University College of Medicine Gyeonggi-do Korea
| | - Jong-Kwan Park
- Division of Cardiology National Health Insurance Service Ilsan Hospital Goyang Korea
| | - Sanghoon Shin
- Department of Cardiology Ewha Womans University College of Medicine Seoul Hospital Seoul Korea
| | - Jae Youn Moon
- Department of Cardiology CHA Bundang Medical Center CHA University Seongnam Korea
| | - Hoyoun Won
- Cardiovascular & Arrhythmia Center Chung-Ang University HospitalChung-Ang University College of Medicine Seoul Korea
| | - Yongsung Suh
- Department of Cardiology Myongji HospitalHanyang University College of Medicine Goyang Korea
| | - Jung Rae Cho
- Division of Cardiology Kangnam Sacred Heart Hospital Hallym University Medical Center Seoul South Korea
| | - Yun-Hyeong Cho
- Department of Cardiology Myongji HospitalHanyang University College of Medicine Goyang Korea
| | - Seung-Jin Oh
- Division of Cardiology National Health Insurance Service Ilsan Hospital Goyang Korea
| | - Byoung-Kwon Lee
- Division of Cardiology Gangnam Severance HospitalYonsei University College of Medicine Seoul South Korea
| | - Sung-Jin Hong
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Dong-Ho Shin
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Chul-Min Ahn
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Byeong-Keuk Kim
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Young-Guk Ko
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Donghoon Choi
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Myeong-Ki Hong
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
| | - Yangsoo Jang
- Division of Cardiology Department of Internal Medicine Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul Korea
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48
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Benesch C, Glance LG, Derdeyn CP, Fleisher LA, Holloway RG, Messé SR, Mijalski C, Nelson MT, Power M, Welch BG. Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association. Circulation 2021; 143:e923-e946. [PMID: 33827230 DOI: 10.1161/cir.0000000000000968] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.
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49
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Azizi PM, Wijeysundera DN, Wijeysundera HC, Austin PC, Jerath A, Han L, Koh M, Ko DT. Troponin Testing After Noncardiac Surgery in Ontario: An Observational Study. CJC Open 2021; 3:904-912. [PMID: 34401697 PMCID: PMC8348325 DOI: 10.1016/j.cjco.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 03/08/2021] [Indexed: 11/25/2022] Open
Abstract
Background In 2017, the Canadian Cardiovascular Society (CCS) published guidelines recommending postoperative troponin surveillance in higher-risk patients having major noncardiac surgery. The objective of this study was to evaluate the proportion of major noncardiac surgery patients that would meet recommendations for troponin testing and to assess the rates of troponin testing before guideline adoption. Methods We conducted a retrospective observational study of patients age 40 to 105 undergoing a subset of major noncardiac surgeries that included orthopedics, gynecology, general, urology, vascular, and thoracic surgeries in Ontario, Canada from January 1, 2010 to December 31, 2017. The primary outcomes were the proportion of patients recommended for testing based on the guidelines and rates of troponin testing within 2 days of surgery. Results We identified 257,704 patients who underwent noncardiac surgery. Mean age was 66.4 ± 11.9 years, and 12.4% underwent urgent surgery. Applying the CCS guidelines, 71.2% of elective surgery patients and 81.0% of urgent surgery patients would have met recommendations for postoperative troponin screening, whereas 10.8% and 27.1% received postoperative troponin testing, respectively. Most elective surgery patients met recommendations for testing based on the age criterion (54.9%), followed by diabetes (24.6%) and high-risk surgery (22.7%) criteria. Troponin testing varied substantially by types of surgery: highest for open abdominal aortic aneurisms and lowest for hysterectomies. Conclusions Based on the CCS guidelines, most patients undergoing the subset of surgeries assessed would have met recommendations for routine troponin testing. In contrast, routine troponin testing before guideline adoption was done infrequently in Ontario, with substantial variations based on the surgery type.
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Affiliation(s)
- Paymon M Azizi
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | | | - Lu Han
- ICES, Toronto, Ontario, Canada
| | | | - Dennis T Ko
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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50
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Zientara A, Schwegler I, Dzemali O, Bruijnen H, Bernheim A, Dick F, Attigah N. Evaluation of metabolic equivalents of task (METs) in the preoperative assessment in aortic repair. BMC Surg 2021; 21:130. [PMID: 33714271 PMCID: PMC7955627 DOI: 10.1186/s12893-021-01143-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 03/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Reliable prediction of the preoperative risk is of crucial importance for patients undergoing aortic repair. In this retrospective cohort study, we evaluated the metabolic equivalent of task (MET) in the preoperative risk assessment with clinical outcome in a cohort of consecutive patients. METHODS Retrospective analysis of prospectively collected data in a single center unit of 296 patients undergoing open or endovascular aortic repair from 2009 to 2016. The patients were divided into four anatomic main groups (infrarenal (endo: n = 94; open: n = 88), juxta- and para-renal (open n = 84), thoraco-abdominal (open n = 13) and thoracic (endo: n = 11; open: n = 6). Out of these, 276 patients had a preoperative statement of their functional capacity in metabolic units and were evaluated concerning their postoperative outcome including survival, in-hospital mortality, postoperative complications, myocardial infarction and stroke, and the need of later cardiovascular interventions. RESULTS The median follow-up of the cohort was 10.8 months. Patients with < 4MET had a higher incidence of diabetes mellitus (p = 0.0002), peripheral arterial disease (p < 0.0001), history of smoking (p = 0.003), obesity (p = 0.03) and chronic obstructive pulmonary disease (p = 0.05). Overall in-hospital mortality was 4.4% (13 patients). There was no significant difference in the survival between patients with a functional capacity of more than 4 MET (220 patients, mean survival: 74.5 months) and patients with less than 4 MET (56 patients, mean survival: 65.4 months) (p = 0.64). The mean survival of the infrarenal cohort (n = 169) was 74.3 months with no significant differences between both MET groups (> 4 MET: 131 patients, mean survival 75.5 months; < 4 MET: 38 patients, mean survival 63.6 months. p = 0.35). The subgroup after open surgical technique with less than 4 MET had the lowest mean survival of 38.8 months. In 46 patients with > 4MET (20.9%) perioperative complications occurred compared to the group with < 4MET with 18 patients (32.1%) (p = 0.075). There were no significant differences in both groups in the late cardiovascular interventions (p = 0.91) and major events including stroke and myocardial infarction (p = 0.4) monitored during the follow up period. The risk to miss a potential need for cardiac optimization in patients > 4MET was 7%. CONCLUSION The functional preoperative evaluation by MET in patients undergoing aortic surgery is a useful surrogate marker of perioperative performance but cannot be seen as a substitute for preoperative cardiopulmonary testing in selected individuals. Trial registration clinicaltrials.gov, registration number NCT03617601 (retrospectively registered).
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Affiliation(s)
- Alicja Zientara
- Department of Cardiac Surgery, Royal Brompton and Harefield Hospital, Sydney Street, London, SW3 6NP, UK
| | - Igor Schwegler
- Department of Vascular Surgery, Triemli Hospital, Birmensdorferstrasse 496, 8063, Zürich, Switzerland
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli Hospital, Birmensdorferstrasse 496, 8063, Zürich, Switzerland
| | - Hans Bruijnen
- Department of Vascular and Thoracic Surgery, Augsburg Hospital, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Alain Bernheim
- Department of Cardiology, Triemli Hospital, Birmensdorferstrasse 496, 8063, Zürich, Switzerland
| | - Florian Dick
- Department of Vascular Surgery, Cantonal Hospital, Rohrschacher Strasse 95, 9007, St. Gallen, Switzerland
| | - Nicolas Attigah
- Department of Vascular Surgery, Triemli Hospital, Birmensdorferstrasse 496, 8063, Zürich, Switzerland.
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