Repair of an Infrarenal Abdominal Aortic Aneurysm is Associated with Persistent Left Ventricular Diastolic Dysfunction

Perioperative Diastolic Dysfunction in Patients Undergoing Noncardiac Surgery Is an Independent Risk Factor for Cardiovascular Events

Background

The prognostic value of perioperative diastolic dysfunction (PDD) in patients undergoing noncardiac surgery remains uncertain, and the current guidelines do not recognize PDD as a perioperative risk factor. This systematic review aimed to investigate whether existing evidence supports PDD as an independent predictor of adverse events after noncardiac surgery.

Methods

Ovid MEDLINE, PubMed, EMBASE, the Cochrane Library, and Google search engine were searched for English-language citations in April 2015 investigating PDD as a risk factor for perioperative adverse events in adult patients undergoing noncardiac surgery. Two reviewers independently assessed the study risk of bias. Extracted data were verified. Random-effects model was used for meta-analysis, and reviewers’ certainty was graded.

Results

Seventeen studies met eligibility criteria; however, 13 contributed to evidence synthesis. The entire body of evidence addressing the research question was based on a total of 3,876 patients. PDD was significantly associated with pulmonary edema/congestive heart failure (odds ratio [OR], 3.90; 95% CI, 2.23 to 6.83; 3 studies; 996 patients), myocardial infarction (OR, 1.74; 95% CI, 1.14 to 2.67; 3 studies; 717 patients), and the composite outcome of major adverse cardiovascular events (OR, 2.03; 95% CI, 1.24 to 3.32; 4 studies; 1,814 patients). Evidence addressing other outcomes had low statistical power, but higher long-term cardiovascular mortality was observed in patients undergoing open vascular repair (OR, 3.00; 95% CI, 1.50 to 6.00). Reviewers’ overall certainty of the evidence was moderate.

Conclusion

Evidence of moderate certainty indicates that PDD is an independent risk factor for adverse cardiovascular outcomes after noncardiac surgery.

Analysis of transthoracic echocardiographic data in major vascular surgery from a prospective randomised trial comparing sevoflurane and fentanyl with propofol and remifentanil anaesthesia

The aim of this study was to define pre-operative echocardiographic data and explore if postoperative indices of cardiac function after open abdominal aortic surgery were affected by the anaesthetic regimen. We hypothesised that volatile anaesthesia would improve indices of cardiac function compared with total intravenous anaesthesia. Transthoracic echocardiography was performed pre-operatively in 78 patients randomly assigned to volatile anaesthesia and 76 to total intravenous anaesthesia, and compared with postoperative data. Pre-operatively, 16 patients (10%) had left ventricular ejection fraction < 46%. In 138 patients with normal left ventricular ejection fraction, 5/8 (62%) with left ventricular dilatation and 41/130 (33%) without left ventricular dilatation had evidence of left ventricular diastolic dysfunction (p < 0.001). Compared with pre-operative findings, significant increases in left ventricular end-diastolic volume, left atrial maximal volume, cardiac output, velocity of early mitral flow and early myocardial relaxation occurred postoperatively (all p < 0.001). The ratio of the velocity of early mitral flow to early myocardial relaxation remained unchanged. There were no significant differences in postoperative echocardiographic findings between patients anaesthetised with volatile anaesthesia or total intravenous anaesthesia. Patients had an iatrogenic surplus of approximately 4.1 l of fluid volume by the first postoperative day. N-terminal prohormone of brain natriuretic peptide increased on the first postoperative day (p < 0.001) and remained elevated after 30 days (p < 0.001) in both groups. Although postoperative echocardiographic alterations were most likely to be related to increased preload due to a substantial iatrogenic surplus of fluid, a component of peri-operative myocardial ischaemia cannot be excluded. Our hypothesis that volatile anaesthesia improved indices of cardiac function compared with total intravenous anaesthesia could not be verified.

Anesthesia for Open Abdominal Aortic Aneurysm Repair

Abdominal aortic aneurysms (AAAs) are the 13th leading cause of death in the United States 1 and approximately 40,000 patients undergo elective AAA repair each year.2 With the population aging, this number is expected to increase. Although the use of endovascular AAA repair is becoming more common, open repair, first reported by Dubost et al. in 1951 remains the gold standard.2 This chapter will review the etiology, risk factors, diagnosis, pathophysiology, operative technique, perioperative management, and postoperative complications of patients undergoing open AAA repair.