One-year follow-up of patients undergoing elective cardiac surgery assessed with the Comprehensive Assessment of Frailty test and its simplified form

Abstract Between November 1999 and August 2002, consenting adult elective cardiac surgery patients at Oregon Health & Science University, Portland Veteran’s Administration Medical Center, and St. Vincent’s Hospital who were undergoing cardiopulmonary bypass (CPB) were randomized at admission to receive either prestorage leukoreduced red cells (PSL-RBCs) or standard red cells (S-RBCs) in a prospective double-blind fashion. Only data from those transfused were analyzed. Outcome measures included death at 60 days, 60 day infection rate, and length of hospital stay (LOS). Patients at all 3 institutions were operated on by the same group of cardiovascular surgeons. Given higher baseline infection rates for coronary artery bypass grafts (CABG) randomization was stratified by CABG vs valve replacement (VR). All RBCs were issued with blinding hoods. All platelet transfusion were prestorage leukoreduced. RBC transfusion rates were 30% for CABG, 38 % for VR, and 63% for CABG + VR. Infections were determined by infection control nurses using standardized Centers for Disease Control criteria from hospital surveillance and records and follow-up phone calls. Deaths were determined from hospital records and follow-up calls, and verified by National Death Index data. The PSL-RBC arm included 304 patients and the S-RBC arm 258 patients. The two groups were well-matched demographically and by cardiovascular risk factors. Intent-to-treat analysis showed a 60 day mortality of 9.7% in the S-RBC arm and of 4.9% in the PSL-RBC arm (p=0.029). Heart failure as the sentinel cause of death accounted for most of the difference (45.5% of deaths in the S-RBC group vs 13.3% in the PSL-LR group). Death rates were procedure specific: CABG alone > CABG + VR > VR alone. There was no significant difference between the S-RBC and PSL-RBC groups with regard to overall infection rate at 60 days. Most infections were superficial wound infections in the CABG patients; however groups did not differ in more serious infections such as bacteremia (p=0.369) or pneumonia (p=0.360). There was no significant difference between the groups with respect to LOS exclusive of in-hospital deaths. Our results essentially replicate in a North American context those of a previous European trial (Van de Watering et al Circulation1998; 97:562) involving elective cardiac surgery patients undergoing CABG and/or VR surgery randomized to receive S-RBCs prepared by the European buffy coat method vs leukoreduced RBCs. Despite technical differences in RBC preparation, the excess deaths in both studies in the S-RBC group vs the leukoreduced group suggests that elective cardiac surgery patients undergoing CPB constitute an at-risk group both in the US and Europe which may benefit from use of PSL-RBC. The significance of transfusion-related immunomodulation (TRIM) in man has been the subject of intense controversy. Interestingly the cause of the increased mortality in the S-RBC group, both in this study and the European study, could not be explained by differences in infection rates. Given the preponderance of deaths in the CABG patients it is tempting to speculate this may reflect an interaction between residual passenger leukocytes and ischemia which is independent of the TH1/TH2 lymphocyte shift postulated to underlie TRIM.

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P2532Incidence and outcome of perioperative myocardial infarction/injury after non-cardiac surgeries diagnosed by high-sensitivity cardiac troponin I

European Heart Journal ◽

10.1093/eurheartj/ehz748.0861 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

D M Gualandro ◽

C Puelacher ◽

R Hidvegi ◽

F A Cardozo ◽

S Marbot ◽

...

Keyword(s):

Myocardial Infarction ◽

Cardiac Surgery ◽

High Sensitivity ◽

Secondary Outcome ◽

Perioperative Myocardial Infarction ◽

Absolute Increase ◽

High Sensitivity Troponin ◽

All Cause Mortality ◽

One Year

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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