Follow-up at one year of percutaneous dilational tracheostomy in cardiac surgery patients

Abstract Background In order to differentiate perioperative myocardial infarction/injury (PMI) after non-cardiac surgery from preexisting cardiomyocyte injury from chronic disorders, recent studies have shown the importance of using an acute absolute increase as a criterion for PMI. For high-sensitivity troponin T (hs-cTnT), PMI defined as an absolute increase of 14ng/L (the 99th percentile) has been shown to be strongly associated with 30-day mortality. Until now, no data on hs-cTnI are available. This is a major unmet clinical need, as relevant differences between hs-cTnT and hs-cTnI have recently been identified and, as worldwide hs-cTnI is more commonly used as compared to hs-cTnT. We hypothesized that applying the same criterion to hs-cTnI, would reveal a similar association with outcomes. Purpose To evaluate the incidence and outcome of PMI diagnosed by hs-cTnI after non-cardiac surgery. Methods We included prospectively consecutive high cardiovascular risk patients undergoing non-cardiac surgery. Hs-cTnI concentrations were measured before surgery and, daily after surgery, for three days. PMI was defined as an absolute rise of ≥26ng/L (the 99th percentile of the assay studied) from baseline values. The primary outcome was major adverse cardiovascular events (MACE), a composite of cardiovascular death, myocardial infarction, acute heart failure and arrhythmias, and the secondary outcome was all-cause mortality, within 30 days and one year. Results We included 2,018 patients submitted to 2,551 surgeries. Patients had median age of 73 years (IQR 68–79) and 56% were male. After surgery, 231 patients (9%, 95% CI 8–10%) fulfilled PMI diagnostic criterion. Patients with PMI had higher rates of MACE than patients without PMI, at 30 days (13% vs. 2%; P<0.001) and, at one-year follow-up (25% vs. 8%; P<0.001). All-cause mortality was also higher in PMI patients within 30 days and one year (9% vs. 1.5% and, 22% vs. 8%, respectively; P<0.001). In multivariate cox regression analysis, PMI showed a hazard ratio (HR) of 4.7 (95% CI, 2.9–7.6; P<0.001) within 30 days, and a HR of 2.7 (95% CI, 2.0–3.7; P<0.001) within one year for the occurrence of MACE. For total mortality, PMI showed a HR of 3.8 (95% CI, 2.1–6.8; P<0.001) within 30 days and a HR of 2.0 (95% CI, 1.4–2.7; P<0.001) after one year. Conclusion PMI is frequent and associated with high rates of MACE and mortality in short- and long-term follow-up after non-cardiac surgery, regardless of the high-sensitivity troponin assay used for diagnosis. Acknowledgement/Funding Swiss Heart Foundation, University basel, Abbott, Astra zeneca, Forschungsfond Kantonsspital Aarau, Cardiovascular Research Foundation Basel, FAPESP

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How to develop a simply frailty score for predicting postoperative morbidity in cardiac surgery

Cardiology Open Access ◽

10.33140/coa/02/01/00001 ◽

2017 ◽

Vol 2 (1) ◽

Keyword(s):

Cardiac Surgery ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Gait Speed ◽

Albumin Level ◽

Old Patients ◽

One Year ◽

Frailty Score

Introduction: Ageing and elderly people have greater risk. Physical state and frailty status represent an important risk and must be considered before cardiac surgery. More than one third of current surgeries are performed in patients older than 70 years. This is a factor to keep on mind in our routine evaluation. Currently an accepted definition for frailty is not well established. It has been considered as a physiological decline in multiple organ systems, decreasing the patient’s capacity to withstand the stresses of surgery and disease. The aim of our study was to determinate a correlation between preoperative features and the morbidity after cardiac surgery in aortic valve replacement population. Methods: We selected the 70 years old patients or older who underwent an elective aortic valve replacement. We collected prospectively all preoperative features and frailty traits (Barthel Test; Gait Speed test, Handgrip) also taking into account blood parameters like albumin level and hematocrit previous to the surgery, hospital admissions within 6 months, and we analyze the demographics and medical history of the patients. We compare patients who undergo to stented prosthesis, sutureless or Transcatheter prostheses (TAVI) procedure and follow up. Results: Two hundred patients were enrolled. The mean age was 78 years all. The predicted mortality with Logistic euroScore I was 12,8% with a real mortality lower than expected (3,5%). Pre-surgery frailty in our population was associated with a Gait Speed higher of 7 seconds, Barthel less of 90%, anemia with Hematocrit <32%, albumin level< 3,4g/dl, chronic renal failure, preoperative re-admission and artery disease. The TAVI group had higher morbidity, no differences statistically significant between Stented and sutureless prosthesis group. Frail individuals had longer hospital stays, readmissions and respiratory/ infectious complications. The mortality at 6 months /one year follow up was 4,1 % /0 % respectively; and morbidity (pacemaker implant, respiratory events, readmission); at 6 months /one year of follow up was 13,47 % to 3%. Conclusions: Elderly and frailty population present more complications after a cardiac surgery. A simple frailty score must be considered in cardiac population to avoid increased morbidity.

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