Pathological findings associated with the updated European Society of Cardiology 2022 guidelines for preoperative cardiac testing: an observational cohort modelling study

BACKGROUND

In 2022, the European Society of Cardiology updated guidelines for preoperative evaluation. The aims of this study were to quantify: (1) the impact of the updated recommendations on the yield of pathological findings compared with the previous guidelines published in 2014; (2) the impact of preoperative B-type natriuretic peptide (NT-proBNP) use for risk estimation on the yield of pathological findings; and (3) the association between 2022 guideline adherence and outcomes.

METHODS

This was a secondary analysis of MET-REPAIR, an international, prospective observational cohort study (NCT03016936). Primary endpoints were reduced ejection fraction (EF<40%), stress-induced ischaemia, and major adverse cardiovascular events (MACE). The explanatory variables were class of recommendations for transthoracic echocardiography (TTE), stress imaging, and guideline adherence. We conducted second-order Monte Carlo simulations and multivariable regression.

RESULTS

In total, 15,529 patients (39% female, median age 72 [inter-quartile range: 67-78] yr) were included. The 2022 update changed the recommendation for preoperative TTE in 39.7% patients, and for preoperative stress imaging in 12.9% patients. The update resulted in missing 1 EF <40% every 3 fewer conducted TTE, and in 4 additional stress imaging per 1 additionally detected ischaemia events. For cardiac stress testing, four more investigations were performed for every 1 additionally detected ischaemia episodes. Use of NT-proBNP did not improve the yield of pathological findings. Multivariable regression analysis failed to find an association between adherence to the updated guidelines and MACE.

CONCLUSIONS

The 2022 update for preoperative cardiac testing resulted in a relevant increase in tests receiving a stronger recommendation. The updated recommendations for TTE did not improve the yield of pathological cardiac testing.

One-Lung Ventilation and Postoperative Pulmonary Complications After Major Lung Resection Surgery. A Multicenter Randomized Controlled Trial

OBJECTIVES

The effect of one-lung ventilation (OLV) strategy based on low tidal volume (TV), application of positive end-expiratory pressure (PEEP), and alveolar recruitment maneuvers (ARM) to reduce postoperative acute respiratory distress syndrome (ARDS) and pulmonary complications (PPCs) compared with higher TV without PEEP and ARM strategy in adult patients undergoing lobectomy or pneumonectomy has not been well established.

DESIGN

Multicenter, randomized, single-blind, controlled trial.

SETTING

Sixteen Italian hospitals.

PARTICIPANTS

A total of 880 patients undergoing elective major lung resection.

INTERVENTIONS

Patients were randomized to receive lower tidal volume (LTV group: 4 mL/kg predicted body weight, PEEP of 5 cmH2O, and ARMs) or higher tidal volume (HTL group: 6 mL/kg predicted body weight, no PEEP, and no ARMs). After OLV, until extubation, both groups were ventilated using a tidal volume of 8 mL/kg and a PEEP value of 5 cmH2O. The primary outcome was the incidence of in-hospital ARDS. Secondary outcomes were the in-hospital rate of PPCs, major cardiovascular events, unplanned intensive care unit (ICU) admission, in-hospital mortality, ICU length of stay, and in-hospital length of stay.

MEASUREMENTS AND MAIN RESULTS

ARDS occurred in 3 of 438 patients (0.7%, 95% CI 0.1-2.0) and in 1 of 442 patients (0.2%, 95% CI 0-1.4) in the LTV and HTV group, respectively (Risk ratio: 3.03 95% CI 0.32-29, p = 0.372). Pulmonary complications occurred in 125 of 438 patients (28.5%, 95% CI 24.5-32.9) and in 136 of 442 patients (30.8%, 95% CI 26.6-35.2) in the LTV and HTV group, respectively (risk ratio: 0.93, 95% CI 0.76-1.14, p = 0.507). The incidence of major complications, in-hospital mortality, and unplanned ICU admission, ICU and in-hospital length of stay were comparable in both groups.

CONCLUSIONS

In conclusion, among adult patients undergoing elective lung resection, an OLV with lower tidal volume, PEEP 5 cmH2O, and ARMs and a higher tidal volume strategy resulted in low ARDS incidence and comparable postoperative complications, in-hospital length of stay, and mortality.

NT-proBNP or Self-Reported Functional Capacity in Estimating Risk of Cardiovascular Events After Noncardiac Surgery

Importance

Nearly 16 million surgical procedures are conducted in North America yearly, and postoperative cardiovascular events are frequent. Guidelines suggest functional capacity or B-type natriuretic peptides (BNP) to guide perioperative management. Data comparing the performance of these approaches are scarce.

Objective

To compare the addition of either N-terminal pro-BNP (NT-proBNP) or self-reported functional capacity to clinical scores to estimate the risk of major adverse cardiac events (MACE).

Design, Setting, and Participants

This cohort study included patients undergoing inpatient, elective, noncardiac surgery at 25 tertiary care hospitals in Europe between June 2017 and April 2020. Analysis was conducted in January 2023. Eligible patients were either aged 45 years or older with a Revised Cardiac Risk Index (RCRI) of 2 or higher or a National Surgical Quality Improvement Program, Risk Calculator for Myocardial Infarction and Cardiac (NSQIP MICA) above 1%, or they were aged 65 years or older and underwent intermediate or high-risk procedures.

Exposures

Preoperative NT-proBNP and the following self-reported measures of functional capacity were the exposures: (1) questionnaire-estimated metabolic equivalents (METs), (2) ability to climb 1 floor, and (3) level of regular physical activity.

Main Outcome and Measures

MACE was defined as a composite end point of in-hospital cardiovascular mortality, cardiac arrest, myocardial infarction, stroke, and congestive heart failure requiring transfer to a higher unit of care.

Results

A total of 3731 eligible patients undergoing noncardiac surgery were analyzed; 3597 patients had complete data (1258 women [35.0%]; 1463 (40.7%) aged 75 years or older; 86 [2.4%] experienced a MACE). Discrimination of NT-proBNP or functional capacity measures added to clinical scores did not significantly differ (Area under the receiver operating curve: RCRI, age, and 4MET, 0.704; 95% CI, 0.646-0.763; RCRI, age, and 4MET plus floor climbing, 0.702; 95% CI, 0.645-0.760; RCRI, age, and 4MET plus physical activity, 0.724; 95% CI, 0.672-0.775; RCRI, age, and 4MET plus NT-proBNP, 0.736; 95% CI, 0.682-0.790). Benefit analysis favored NT-proBNP at a threshold of 5% or below, ie, if true positives were valued 20 times or more compared with false positives. The findings were similar for NSQIP MICA as baseline clinical scores.

Conclusions and relevance

In this cohort study of nearly 3600 patients with elevated cardiovascular risk undergoing noncardiac surgery, there was no conclusive evidence of a difference between a NT-proBNP-based and a self-reported functional capacity-based estimate of MACE risk.

Trial Registration

ClinicalTrials.gov Identifier: NCT03016936.

Vigna unguiculata L. Walp. Leaves as a Source of Phytochemicals of Dietary Interest: Optimization of Ultrasound-Assisted Extraction and Assessment of Traditional Consumer Habits

Vigna unguiculata L. Walp. is an African crop spread worldwide mainly for pulses production. Despite being a neglected and under-utilized food, cowpea leaves are a rich source of phytochemicals and micronutrients. The aim of the work is to characterize the phytochemical composition of cowpea leaves by an optimized ultrasound-assisted extraction (USAE) and to compare raw and boiled leaves. A three-level factorial design (Box-Behnken) was employed for the optimization of the USAE considering three different parameters (% ethanol, drug-to-solvent ratio, and number of cycles). The optimized extracts were characterized by LC/MS/MS. Finally, leaves were boiled at 100 °C for 30 min to simulate traditional cooking procedures and compared to raw leaves. The best extraction condition was EtOH/H2 O 1 : 2 v/v, drug to solvent ratio 1 : 47 w/v, and 3 extraction cycles. The phytochemicals identified mainly belong to the family of phenolic acids, flavonoids, terpenoids, and alkaloids. Boiled leaves revealed a significant loss of most phytochemicals and a net decrease of their antioxidant activity compared to the raw ones. The results highlight the potential nutraceutical value of cowpea leaves whilst the impoverishment triggered by traditional consumer habits pushes the need to evaluate alternative cooking procedures helpful in the maintenance of their phytochemical properties.

Organ ischemia after Thoracic Endovascular Aortic Repair

OBJECTIVES

To evaluate incidence and outcomes of ischaemic organ complications after thoracic endovascular aortic repair (TEVAR).

METHODS

This is a multicentre, retrospective, observational cohort study. We analyzed data from patients treated with TEVAR between June 22nd 2001 and December 10th 2022. Primary outcomes were postoperative overall organ ischaemic complications and early (≤ 30 days) survival. Secondary outcomes were long-term survival, and freedom from aorta-related mortality (ARM).

RESULTS

A total of 255 patients were included in this study. We performed 233 (91.4%) isolated TEVARs, 14 (5.5%) fenestrated or branched TEVARs, and 8 (3.1%) TEVARs in combination with normal infrarenal stent graft. Overall, 31 organ ischaemic complications were detected in 29 (11.4%) cases, out of which 8 (3.1%) complications were cerebrovascular, 8 (3.1%) spinal cord, 6 (2.3%) visceral, 4 (1.6%) renal, 2 (0.8%) peripheral, and 3 (1.2%) myocardial. Binary logistic regression analysis identified grade III-IV aortic arch atheroma (OR: 6.6, P = 0.001; 95% CI: 2.9-14-9) and shaggy aorta (OR: 12.1, P = 0.003; 95% CI: 2.3-64.1) to be associated with the development of organ ischaemic complications. In patients with organ ischaemia, we observed higher early (≤ 30 days) mortality (20.7% vs 6.2%; OR: 3.6, P = 0.016), prolonged hospitalization (P = 0.001), and inferior estimated survival (Log-rank, P = 0.001).

CONCLUSIONS

Aortic arch atherosclerotic overload as well as the presence of shaggy aorta are predictors of organ ischaemic complications following TEVAR. They are neither uncommon nor negligible, and are associated with perioperative mortality, prolonged hospitalization, and a negative impact on long-term survival.

Acute problems of hemodialysis access: Thrombosis, aneurysms, symptomatic high-flow fistulas, and complications related to central lines

Hemodynamic complications frequently affect vascular access and are important causes of morbidity and mortality. We present a review of acute complications affecting vascular accesses, focusing on classical and new treatments. Acute complications in hemodialysis vascular access are often underestimated and undertreated, and can present a challenge for both vascular surgeons and anesthesiologists. Accordingly, we considered different anesthesiologic approaches to both hemorrhagic and nonhemorrhagic patients. A strict collaboration among nephrologists, surgeons, and anesthesiologists can potentially improve prevention and management of acute complications and quality of life.

Risk assessment for major adverse cardiovascular events after noncardiac surgery using self-reported functional capacity: international prospective cohort study

BACKGROUND

Guidelines endorse self-reported functional capacity for preoperative cardiovascular assessment, although evidence for its predictive value is inconsistent. We hypothesised that self-reported effort tolerance improves prediction of major adverse cardiovascular events (MACEs) after noncardiac surgery.

METHODS

This is an international prospective cohort study (June 2017 to April 2020) in patients undergoing elective noncardiac surgery at elevated cardiovascular risk. Exposures were (i) questionnaire-estimated effort tolerance in metabolic equivalents (METs), (ii) number of floors climbed without resting, (iii) self-perceived cardiopulmonary fitness compared with peers, and (iv) level of regularly performed physical activity. The primary endpoint was in-hospital MACE consisting of cardiovascular mortality, non-fatal cardiac arrest, acute myocardial infarction, stroke, and congestive heart failure requiring transfer to a higher unit of care or resulting in a prolongation of stay on ICU/intermediate care (≥24 h). Mixed-effects logistic regression models were calculated.

RESULTS

In this study, 274 (1.8%) of 15 406 patients experienced MACE. Loss of follow-up was 2%. All self-reported functional capacity measures were independently associated with MACE but did not improve discrimination (area under the curve of receiver operating characteristic [ROC AUC]) over an internal clinical risk model (ROC AUC_baseline 0.74 [0.71-0.77], ROC AUC_{baseline+4METs} 0.74 [0.71-0.77], ROC AUC_{baseline+floors climbed} 0.75 [0.71-0.78], AUC_{baseline+fitnessvspeers} 0.74 [0.71-0.77], and AUC_{baseline+physical activity} 0.75 [0.72-0.78]).

CONCLUSIONS

Assessment of self-reported functional capacity expressed in METs or using the other measures assessed here did not improve prognostic accuracy compared with clinical risk factors. Caution is needed in the use of self-reported functional capacity to guide clinical decisions resulting from risk assessment in patients undergoing noncardiac surgery.

CLINICAL TRIAL REGISTRATION

NCT03016936.

OC-027 IS THERE A CORRELATION BETWEEN TYPE OF PROSTHESIS FIXATION IN T.A.P.P. AND AFTER SURGERY RECOVERY? OUR CENTER EXPERIENCE

Aim

A retrospective study was carried out on patients treated for bilateral inguinal hernia with TAPP technique by the department of Urgency Surgery and Transplantation of Varese's hospital in order to investigate the VAS one month after surgery and functional recovery in two groups of patients.

Material and Methods

38 patients treated in the last year were enrolled, dividing them in two groups: those who received a single fixing material (reabsorbable clips) and those with a double fixing material (reabsorbable clips and glue). Primary end point was the post-operative pain using the VAS scale at one month. Secondary end-point was the return to daily activities and work in days. The Mann-Whitney test with p-value set&lt; 0.05 was used.

Results

The single fixing material group shown a 1-month VAS of 0.57 ±1, versus 1.43±4 of the second group (p-value&lt;0.05); with a return of daily activities in 4.92± 8 days, versus 8.06 ± 11 days (p-value&lt;0.05). In addition, analyzing the subpopulation of still active workers (28 of the 38 patient), it was assessed the working back timing. The positioning of only reabsorbable clips, compared with a double fixing material, ensured a faster return to work in 8.2 ±10 days versus 20 ± 30 days (p-value&lt;0.05).

Conclusions

Fixing the prosthetic mesh with resorbable clips alone, could lead to a more rapid resumption of daily and work activities, with less pain one month after surgery.

P-099 PERSISTENT POST-SURGICAL PAIN AFTER SURGICAL CORRECTION OF VENTRAL HERNIA REPAIR. PRELIMINARY DATA OF AN OBSERVATIONAL STUDY AT VARESE UNIVERSITY HOSPITAL

Aim

Persistent post-surgical pain (PPSP) is one of the most frequent complication after surgery and has important socio-economic consequences.

Materials and methods

We performed an observational analysis of the patients submitted to surgical correction of ventral hernia repair at our University Hospital between 1st February 2021 and 1st January 2022.We registered data about perioperative surgical period. After at least 3 months we proceeded with a phone interview in order to record the incidence of PPSP according to its definition.

Results

We enrolled 61 patients and 26 patients were lost to follow-up. 9 patients (25%) denveloped chronic pain after surgery and 3 cases reported pain that had deteriorated the quality of life (PPSP group).In the PPSP group median age was 53; obesity, COPD, diabetes mellitus, smoking status, were not significant (p &gt; 0,05). Male sex, previous abdominal surgery and open approach showed correlation with PPSP onset. In our cohort demographical and clinical characteristics were not statistically related to PPSP, while the use of locoregional anesthesia could be protective in front of PPSP onset.

Conclusion

At the moment, although there is no shared protocol in the prevention of PPSP, it is possible to implement some interventions to reduce its risk. Our results show that more effective analgesic/anesthetic perioperative measures may help to prevent the adverse consequences of poorly controlled pain, including its transition to PPSP. The main limits of our data is the small cohort analysed and the study protocol without an analysis about immediate postoperative pain and PPSP outbreak.

Predictive Models for the Functional Recovery of Transplanted Kidney

BACKGROUND

Renal transplantation is the gold standard treatment for end-stage renal disease, however, in 20% of cases, the graft develops a delayed graft function (DGF) that is associated with both early and late worsening of the outcome. The aim of this study was to examine and validate in a population of transplanted patients the appropriateness of the predictive score systems of DGF available to identify patients who might take advantage of a tailored immunosuppressive therapy.

MATERIALS AND METHODS

We conducted a systematic review of the literature to identify articles concerning scoring systems predicting DGF to identify those applicable to the study population and subsequently comparing their appropriateness for defining the most accurate one.

RESULTS

From an analysis of the scientific literature, we found 7 scoring systems predicting DGF. Of these, 3 can be calculated for the study population. We enrolled 247 renal transplants in the study. DGF was recorded in 41 cases (15.95%). The Irish score recognized 25 of 41 cases (60.98%), the Jeldres score 41 of 41 cases (100%), and the Chapal score only 7 of 41 (17.07%). Although the Irish score did not identify all cases of DGF, the analysis of data revealed that it is the most accurate, with area under the receiver operating characteristic almost overlapping.

CONCLUSIONS

The study resulted in some interesting and promising conclusions about the predictability of DGF, defining the Irish score as the most reliable. This result can be considered the fundamental requirement to develop a custom therapeutic algorithm to be applied to all recipients with higher probability of developing DGF.

Indocyanine Green Angiography for Quality Assessment of the Kidney During Transplantation: An Outcome Predictor Prospective Study

BACKGROUND

Microvascular damage is the main cause of delayed graft function (DGF) after kidney transplant. Assessing its extent may be helpful in predicting DGF to achieve better postoperative management, especially in terms of an immunosuppressive regimen. Our aim was to explore the capability of intraoperative indocyanine green (ICG) angiography to examine the microvasculature of the kidney.

METHODS

We conducted a prospective cohort study on 37 kidney transplant recipients in a high-volume kidney transplant center. During surgery, after graft implant, an ICG angiography was performed through a high-definition Storz camera system (Karl Storz GmbH, Tuttlingen, Germany) with successive quantitative assessment of fluorescence using Icy bioimage analysis.

RESULTS

All transplanted kidneys that showed immediate recovery of their function had a fluorescent intensity ≥49.953 with a mean of 96.930 ± 21. The fluorescence intensity for kidneys that showed a delayed recovery of their function never exceeded 55.648, and the mean was 37.718 ± 13. The difference between the 2 groups was statistically significant with a P value < .001. The only kidney that never recovered showed a fluorescence intensity consistently <25.220, the lowest detected.

CONCLUSIONS

This study demonstrates that intraoperative ICG angiography may be used to assess the microvasculature of the graft. A statistically significant difference in terms of fluorescent intensity can be highlighted between kidneys that immediately recover their function and those with delayed recovery. Further larger studies are needed to confirm the capability of the technique to predict DGF to optimize the transplanted patients' management.

Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial

BACKGROUND

Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications.

METHODS

HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896).

FINDINGS

Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4-9) in the accelerated-surgery group and 24 h (10-42) in the standard-care group (p<0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (-1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (-2 to 4; p=0·71).

INTERPRETATION

Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care.

FUNDING

Canadian Institutes of Health Research.

Predictive features associated with thyrotoxic storm and management

Thyroid storm (TS) is an endocrine emergency characterized by rapid deterioration, associated with high mortality rate therefore rapid diagnosis and emergent treatment is mandatory. In the past, thyroid surgery was the most common cause of TS, but recent preoperative medication creates a euthyroid state before performing surgery. An active approach during perioperative period could determine an effective clinical treatment of this life-threating diseases. Recently, the Japan Thyroid Association and Japan Endocrine Society developed diagnostic criteria for TS focusing on premature and prompt diagnosis avoiding inopportune e useless drugs. This review analyses predictive features associated with thyrotoxic storm highlighting recent literature to optimize the patient quality of care.

Chimeric anterolateral thigh free flap for reconstruction of complex cranio-orbito-facial defects after skull base cancers resection

Complex cranio-orbito-facial defects after skull base cancers resection entail a functional and esthetic reconstruction. The introduction of endoscopic assisted techniques for excision surgery with the advances in reconstructive surgery and anesthesiology allowed to improve the management of such critical patients. We report a series of chimeric anterolateral thigh (ALT) flaps used to reconstruct complex cranio-orbital-facial defects after skull base surgery. A retrospective review of patients that underwent cranio-orbito-facial reconstruction using a chimeric ALT flap from March 2013 to October 2015 at a single tertiary care referral Institute was performed. All patients were affected by locally-advanced malignant tumor and the resulting defects involved the skull base in all cases. The ALT flaps were perforator-based flaps with different components: fascia, skin and muscle. The different flap territories had independent vascular supply and were independent of any physical interconnection except where linked by a common source vessel. Ten patients were included in the study. Three patients underwent adjuvant radiotherapy and to chemotherapy. The mean hospitalization time was 21 days (range, 8-24 days). One failure was observed. After a mean follow-up of 12.4 months, 3 patients died of the disease, 2 are alive with disease, while 5 patients (50%) are currently alive without evidence of disease. Chimeric ALT flap is a reliable and versatile reconstructive option for complex cranio-orbito-facial defects resulting from skull base surgery. The chimeric flap composed of different territories proved to be adequate for a patient-tailored three-dimensional reconstruction of the defects as well as able to resist to the postoperative adjuvant treatments.

Preoperative methods to improve erythropoiesis

Preoperative anemia creates a challenge for surgical treatment and patient outcomes after major surgery. Prior to a surgical intervention, it is optimal to increase erythropoiesis to improve oxygen transport through the bloodstream for patients at high risk of anemia and to avoid the complications of allogeneic blood transfusion. In this way, patients could receive predeposited autologous blood or, during the surgical procedures, undergo acute normovolemic hemodilution. This approach is allowed by the use of recombinant human erythropoietin in association with erythropoiesis-inducing factors such as iron and folic acid. In this article, we discuss the recent clinical evidences.

[Comparison of diagnostic methods for Clostridium difficile-associated diarrhea]

In order to compare different methods for the diagnosis of Clostridium difficile-associated diarrhea, fecal filtrates from patients presenting symptoms compatible with this condition, were analyzed. Biological activity on Vero cells (biological assay), dot blot with antibodies anti-TcdA and anti-TcdB, and a PCR assay for the tcdB gene, were evaluated. Titles of biological assays were > or =64 for 44 out of 177 samples. Nineteen samples were positive in both biological and PCR assays. The analysis by dot blot using anti-TcdA and anti-TcdB antibodies showed that 46 samples out of 149 were positive for both toxins whereas 12 samples were only positive for TcdB, and 5 samples only positive for TcdA. Discrepancies in the different methods could be related to truncated genes, low number of microorganisms in the samples and toxin degradation. The results herein presented show the need for developing diagnostic approaches compatible with the complex epidemiological situation of this clinically relevant intestinal pathogen.