Cardiac

Cardiovascular complications with atrial fibrillation and non‐cardiac surgery

This study compared the revised cardiac risk index and three atrial fibrillation thrombo‐embolic risk models for predicting 30‐day cardiovascular events after non‐cardiac surgery in patients with a pre‐operative history of atrial fibrillation.

Such patients had a higher rate of 30 day myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death (29% vs. 13%).

The study found that the revised cardiac risk index was outperformed by other thromboembolic scores – CHADS2 , CHA2DS2‐VASc and R2CHADS2.

However “none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri‐operative risk prediction model.”

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New Index for Preoperative Cardiovascular Evaluation

Another attempt to update or simplify prediction of cardiovascular morbidity and mortality in non-cardiac surgery.

Outcomes were: incidence of 30-day postoperative all-cause mortality, myocardial infarction (MI), or stroke.

This study identified six predictors of primary outcome: age ≥75 years, any history of heart disease, symptoms of angina or dyspnea with regular activities, hemoglobin <12 mg/dl, planned vascular surgery, and emergency surgery.

It is dubbed the Cardiovascular Risk Index (CVRI)

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Complications related to peri‐operative transesophageal echocardiography

Trans-esophageal echocardiography (TEE, TOE) has become a standard monitor for real time cardiac assessment in cardiac and other major surgery and critical care hemodynamic management. However it does have a complication rate.

The Association of Cardiothoracic Anaesthesia and Critical Care carried out a one year prospective audit in cardiac surgery cases in the UK and Ireland. Complications included nine upper gastro‐intestinal perforations and eight upper gastro‐intestinal bleeds. Esophageal stenting, video‐assisted thoracoscopic surgery, gastrostomy, and open surgical repair were listed in the management.

Upper GI injuries are more likely during insertion and lower GI injuries during probe manipulation.

The incidence of peri‐operative TOE‐related complications in the included population was 0.08% and the incidence of death due to a TOE‐related complication was 0.03%.

The implication is that major complications have a 40% risk of death. The authors suggest greater training, use of checklists for safe insertion, and laryngoscope use during insertion, as well as incorporating the risks into consent discussions.

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Prolonged Perioperative Use of Pregabalin and Ketamine & Chronic Pain

This was a randomized study in cardiac surgery. Patients were randomly assigned to receive either usual care, pregabalin (150 mg preoperatively and twice daily for 14 postoperative days) alone, or pregabalin in combination with a 48-h postoperative infusion of intravenous ketamine at 0.1 mg · kg−1 · h−1.

Conclusions: Preoperative administration of 150 mg of pregabalin and postoperative continuation twice daily for 14 days significantly lowered the prevalence of persistent pain after cardiac surgery.

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Trans-Nasal Evaporative Intra-arrest Cooling

Much of the earlier enthusiasm for therapeutic hypothermia has been tempered with disappointing trial results. This study examined cooling of the brain initiated during cardiopulmonary resuscitation and its impact on survival with good neurologic outcome in patients with out-of-hospital cardiac arrest.

Trans-nasal evaporative intra-arrest cooling did not result in a statistically significant improvement in survival with good neurologic outcome.

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Off or On Pump CABG

Much hope for improvement in outcomes and cognitive impairment was held out for off pump CABG. This study shows no difference.

“The present study’s data did not show differences in key long-term outcomes between patients who underwent revascularization with or without cardiopulmonary bypass, supporting the idea that both methods achieve similar late results regarding overall survival, need for reintervention, and postoperative myocardial infarction.”

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Incentive Spirometry after CABG

The ubiquitous incentive spirometer for breathing exercise after surgery has often been questioned as lacking evidence. Many prehabilitation programs use structured deep breathing as well as inspiratory muscle strength training, along with aerobic and resistance training. Australian choosing wisely physiotherapy guidelines recommended against incentive spirometry ( link ).

This was a single center randomized trial in coronary artery bypass surgery which aimed to improve adherence by incorporating hourly reminder bells. The results were quite impressive in improved Incentive Spirometer use adherence, atelectasis severity, early postoperative fevers, noninvasive positive pressure ventilation use, intensive care unit length of stay by a day, and 6-month mortality rates.

“Incentive spirometers can be clinically effective, but perhaps only when adherence is high”. Further studies are recommended on incentive spirometry without reminders. As a relatively small trial, further larger studies with balanced patient populations are essential.

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Second Generation Drug Eluting Stents and Surgery

Non-cardiac elective surgery after placement of coronary stents is performed after time guidelines delineated previously (eg. link ).

Second generation drug eluting stents were reviewed in medical records in this study. The rates of major adverse cardiac events were 17.1%, 10.0%, 0.0%, and 3.1% for patients undergoing non-cardiac surgery at 0–90, 91–180, 181–365, and ≥366 days, respectively. 

The rate of excessive surgical bleeding was 6.7% with the highest observed rate in those on dual antiplatelet therapy although not statistically significant compared to those not receiving dual antiplatelet therapy in the 7 days before surgery, although numbers were small.

The important takeaway is that 180 days (6 months) is still a reasonable minimum before elective non-cardiac surgery for those on dual antiplatelet therapy.

Full details are discussed, along with comparisons to various guidelines at the link.

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Volatile Anesthetics vs. Total Intravenous Anesthesia for Cardiac Surgery

The ‘cardioprotective’ effects of volatile anesthesia gases have been seen as useful during coronary artery bypass surgery (CABG). This controlled study in elective CABG compared volatile anesthesia with total intravenous anesthesia (TIVA) and found no difference in 30 day or 1 year mortality.

The findings are important as anesthetic gases have been even recommended as useful in American and European guidelines, based on known cellular protective effects and effects on cardiac biomarkers, and suggested by previous observational and meta-analysis studies.

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