scholarly journals Myocardial Injury after Noncardiac Surgery and Perioperative Atrial Fibrillation

2021 ◽  
Vol 16 (SP1) ◽  
pp. 18-26
Author(s):  
Flavia Borges ◽  
Sandra Ofori ◽  
Maura Marcucci
Keyword(s):  
Atrial Fibrillation ◽  
Myocardial Injury ◽  
Prediction Models ◽  
Controlled Trial ◽  
Noncardiac Surgery ◽  
Prise En Charge ◽  
Individual Risk ◽  
Cardiac Complications ◽  
Risk Of Death ◽  
Fibrillation Auriculaire

One in 60 patients who undergo major noncardiac surgery dies within 30 days following surgery. The most common cause is cardiac complications, of which myocardial injury after noncardiac surgery (MINS) and perioperative atrial fibrillation (POAF) are common, affecting about 18 and 11% of adults, respectively, after noncardiac surgery. Patients who suffer MINS are at a higher risk of death compared to patients without MINS. Similarly, patients who develop POAF are at a higher risk of stroke and death compared to patients who do not. Most patients who suffer MINS are asymptomatic, and its diagnosis is not possible without routine troponin monitoring. Observational studies support the use of statins and aspirin in the management of patients with MINS. The only randomized controlled trial to date that has specifically addressed the management of MINS was the MANAGE trial that demonstrated the efficacy and safety of intermediate dose dabigatran in this population. There are no specific prediction models for POAF and no randomised controlled trial evidence to guide the specific management of POAF. Management guidelines in the acute period follow the management of nonoperative atrial fibrillation. The role of long-term anticoagulation in this population is still uncertain and should be guided by a shared care decision model with the patient, and with consideration of the individual risk for stroke balanced against the risk of bleeding. In this review, we present a case-based approach to the detection, prognosis, and management of MINS and POAF based on the existing evidence. RÉSUMÉUn patient sur 60 qui subit une intervention chirurgicale majeure non cardiaque meurt dans les 30 jours suivant l’opération. La cause la plus fréquente est celle des complications cardiaques, dont les lésions myocardiques après une chirurgie non cardiaque (LMCNC) et la fibrillation auriculaire périopératoire (FAPO) sont courantes et touchent respectivement environ 18 et 11 % des adultes après une chirurgie non cardiaque. Les patients présentant des LMCNC sont exposés à un risque plus élevé de décès que les patients qui ne présentent pas de LMCNC. De même, les patients chez qui on voit apparaître une FAPO ont un risque plus élevé d’accident vasculaire cérébral et de décès que ceux qui ne connaîtront pas cette complication. La plupart des patients atteints de LMCNC sont asymptomatiques, et il est impossible d’établir un diagnostic sans surveiller régulièrement la troponine. Des études d’observation appuient l’utilisation des statines et de l’aspirine dans la prise en charge des patients atteints de LMCNC. À ce jour, le seul essai contrôlé randomisé qui s’est penché précisément sur le traitement des LMCNC est l’essai MANAGE qui a démontré l’efficacité et l’innocuité du dabigatran à dose intermédiaire chez cette population. Il n’existe aucun modèle de prédiction précis pour la FAPO ni aucune donnée probante provenant d’essais contrôlés randomisés pour orienter précisément son traitement. Les lignes directrices concernant la prise en charge au cours de la période aiguë suivent celles de la prise en charge de la fibrillation auriculaire non liée à une opération. Le rôle de l’anticoagulation à long terme chez cette population est encore incertain et devrait être guidé par un modèle de prise de décision partagée avec le patient et tenir compte du risque individuel d’accident vasculaire cérébral par rapport à celui d’hémorragie. Dans cette revue, nous présentons une approche fondée sur des cas pour la détection, le pronostic et le traitement des LMCNC et de la FAPO sur la base des données probantes existantes.

scholarly journals Myocardial injury after major noncardiac surgery: A secondary analysis of a randomized controlled trial

Surgery ◽  
2021 ◽  
Author(s):  
Christoph Ellenberger ◽  
Raoul Schorer ◽  
John Diaper ◽  
Alexandre Jeleff ◽  
Stéphane Luise ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
Myocardial Injury ◽  
Controlled Trial ◽  
Secondary Analysis ◽  
Noncardiac Surgery ◽  
Randomized Controlled

scholarly journals Biochemical response to cryothermal and radiofrequency exposure of the human myocardium at surgical ablation of atrial fibrillation: a randomized controlled trial.

2020 ◽  
Author(s):  
Gabriella Boano ◽  
Meriam Åström Aneq ◽  
Giannis Spyrou ◽  
Helena Enocsson ◽  
Charitakis Emmanouil ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Mitral Valve ◽  
Myocardial Injury ◽  
Troponin T ◽  
Controlled Trial ◽  
Mitral Valve Surgery ◽  
Valve Surgery ◽  
Cell Stress ◽  
Surgical Ablation ◽  
Apoptotic Activity

Abstract Background: Surgical cryothermia and radiofrequency (RF) ablations for atrial fibrillation (AF) seem to result in similar sinus rhythm restoration, but the biochemical consequences of the two methods are unclear. We aimed to compare the biochemical responses to the two ablative methods in concomitant mitral valve surgery (MVS). Methods: Sixty mitral valve surgery patients with AF were prospectively included. Forty-one patients planned for ablation were randomized to cryothermia (n=20) or radiofrequency (n=21) ablation and 19 served as controls. Markers for myocardial injury, inflammation, cell stress, apoptosis, and heart failure were analyzed pre- and postoperatively at different time points. Results: Troponin T and creatine kinase isoenzyme MB (CK-MB) peak levels were significantly higher in the cryothermia group compared with the RF group (12805 [6140–15700] vs. 2790 [1880–4180] ng/L; P=0.002 and 271 [217–357] vs. 79 [66–93] µg/L; P<0.001, respectively). Both groups had significantly higher levels than the no-ablation group. There were no group differences in C-reactive protein (CRP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), but there were correlations between pre- and postoperative levels of both CRP (rs=0.41, P=0.001) and NT-proBNP (rs=0.48, P<0.001). Protease-activated receptor 1 (PAR-1) and heat shock protein 27 (HSP27) were significantly increased in the cryoablation group. Conclusions: Cryoablation results in a larger myocardial injury and possibly more elevated apoptotic activity and cell stress compared with the RF technique. The type of ablation device did not have any significant influence on the postoperative inflammatory response nor on the early postoperative levels of NT-proBNP.Trial registration: DOI:10.1186/ISRCTN14454361. Registered 16 November 2014 – Retrospectively registered, http://www.isrctn.com/ISRCTN14454361

P662Association of baseline disability and major adverse outcomes in patients with atrial fibrillation: an analysis from the SPORTIF trials

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Proietti ◽  
G Y H Lip
Keyword(s):  
Atrial Fibrillation ◽  
Regression Analysis ◽  
Controlled Trial ◽  
Linear Regression Analysis ◽  
Cumulative Risk ◽  
Adverse Outcomes ◽  
Rank Test ◽  
Composite Outcome ◽  
Risk Of Death ◽  
Increased Risk

Abstract Introduction The modified Rankin Scale (mRS) is usually used to evaluate the degree of disability in patients who have suffered a stroke. Some data suggest that pre-stroke mRS may be associated with clinical outcomes. No data exist about atrial fibrillation (AF) patients. Purpose To evaluate if baseline level of disability, evaluated as mRS, is associated with major adverse outcomes in patients with AF Methods Data from the SPORTIF III and V trials were used to evaluate study aims. mRS was categorized as follows: i) mRS 0 = No Disability; ii) mRS 1 = Operational Limitation; iii) mRS ≥2 = Disability. Stroke/systemic embolism (SE), death and composite of stroke/SE/acute myocardial infarction (AMI)/death were considered as major adverse outcomes. Results Among 7329 patients enrolled in SPORTIF trials, 7325 (99.9%) had data about baseline mRS, with 5587 (76.3%) with mRS 0, 1156 (15.8%) with mRS 1 and 582 (7.9%) with mRS ≥2. Mean (SD) and median [IQR] CHA2DS2-VASc was progressively higher across the three mRS categories (both p<0.001). An adjusted linear regression analysis confirmed that mRS was associated with an increasing CHA2DS2-VASc (unstandardized B: 0.354, 95% confidence interval [CI]: 0.317–0.390, p<0.001]. After a mean (SD) 1.55 (0.40) years of follow-up 184 (2.5%) stroke/SE, 392 (5.4%) death and 597 (8.2%) composite events were recorded. Log-rank test showed that cumulative risk of stroke/SE (p=0.005), death (p<0.001) and composite outcome (p<0.001) was progressively higher across the mRS categories [Figure]. Cox adjusted regression analysis found no independent association between mRS categories and stroke/SE occurrence, but baseline disability (mRS ≥2) was independently associated with death (hazard ratio [HR]: 2.17, 95% CI: 1.65–2.86 compared with no disability). Both operational limitation (mRS 1) and disability (mRS ≥2) were associated with the composite outcome (HR: 1.28, 95% CI: 1.04–1.59 and HR: 1.91, 95% CI: 1.51–2.42, respectively) compared to no disability. Kaplan-Meier curves Conclusions In a large cohort of AF patients derived from a randomized controlled trial, baseline disability was associated with an increased risk of death and composite outcome of stroke/SEAMI/death. Acknowledgement/Funding None

Cardiac complications in patients with severe COVID-19 pneumonia

2021 ◽  
pp. 14-17
Author(s):  
N. А. Yaroshchuk ◽  
V. V. Kochmasheva ◽  
A. V. Vakhrameev
Keyword(s):  
Atrial Fibrillation ◽  
Differential Diagnosis ◽  
Myocardial Injury ◽  
Troponin T ◽  
Community Acquired Pneumonia ◽  
Cardiac Complications ◽  
Common Complication ◽  
Hemodynamic Changes ◽  
Severe Community Acquired Pneumonia ◽  
Atrial Fibrillation And Flutter

This article is devoted to the analysis of the most frequent cardiac complications in patients with severe community-acquired pneumonia caused by COVID-19 viral infection. The study found that cardiac complications developed in 25% of patients with COVID-19 pneumonia. The most common complication was supraventricular rhythm disturbances. Atrial fibrillation and flutter proceeded with pronounced hemodynamic changes. Myocardial injury, given the increase in cardiospecific troponin T, could be suspected in 38% of patients. Differential diagnosis between ACS and myocarditis caused the greatest difficulties.

scholarly journals Myocardial injury in noncardiac surgery – diagnostic difficulties

2020 ◽  
Vol 9 (3) ◽  
pp. 59-68
Author(s):  
S. S. Murashko ◽  
I. N. Pasechnik ◽  
S. A. Berns
Keyword(s):  
Myocardial Infarction ◽  
Myocardial Injury ◽  
Surgical Care ◽  
Myocardial Damage ◽  
Noncardiac Surgery ◽  
Cardiac Complications ◽  
Consensus Document ◽  
Long Term Prognosis ◽  
Universal Definition

A new concept was adopted by the Fourth Universal Definition of MI Expert Consensus Document in 2018 – periprocedural myocardial injury after cardiac- and noncardiac interventions, which is distinct from myocardial infarction.It is difficult to diagnose a heart attack and myocardial damage after noncardiac surgery.Postoperative myocardial injury increases mortality and worsens the long-term prognosis and quality of treatment.The quality of surgical care is determined by surgical techniques and the course of the postoperative period. Although complications often negate the results of brilliantly performed surgery, many of them would happen irrespective of surgeon`s actions. The development of complications determining the outcome of treatment can be associated with cardiac pathology. Cardiac complications may develop due to existing comorbidities, hemodynamic instability during surgery, cardiotoxic effect of drugs, etc. In 40% of cases, the risk of cardiac death after noncardiac surgery is associated with the development of perioperative myocardial infarction or myocardial injury. Myocardial infarction is the most demonstrative complication, although it is difficult to diagnose in the perioperative period in case of asymptomatic course. The link between postoperative myocardial infarction and lethality is beyond doubt. Adopted in 2018, the Fourth Universal Definition of MI Expert Consensus Document introduced a new concept of periprocedural myocardial injury after cardiac- and noncardiac interventions, which are distinct from myocardial infarction. Myocardial injury requires laboratory tests to be diagnosed. However, myocardial injury itself affects postoperative mortality and significantly worsens the long-term prognosis and quality of treatment. This article reports the features of the etiopathogenetic mechanisms of cardiac complications during surgical care, as well as the multifactorial genesis of myocardial injury. The analysis of modern scientific literature on the diagnosis of myocardial damage is given. The need for early diagnosis of myocardial damage to create optimal management tactics for patients undergoing noncardiac interventions is demonstrated.

scholarly journals Imaging Cardiovascular Inflammation in the COVID-19 Era

Diagnostics ◽  
2021 ◽  
Vol 11 (6) ◽  
pp. 1114
Author(s):  
Andras Mester ◽  
Imre Benedek ◽  
Nora Rat ◽  
Cosmin Tolescu ◽  
Stefania Alexandra Polexa ◽  
...  
Keyword(s):  
Myocardial Injury ◽  
Current Knowledge ◽  
Imaging Techniques ◽  
Underlying Mechanism ◽  
Coronary Plaque ◽  
Biological Evaluation ◽  
Cardiac Complications ◽  
Myocardial Inflammation ◽  
Risk Of Death ◽  
Clinical Scenarios

Cardiac complications are among the most frequent extrapulmonary manifestations of COVID-19 and are associated with high mortality rates. Moreover, positive SARS-CoV-2 patients with underlying cardiovascular disease are more likely to require intensive care and are at higher risk of death. The underlying mechanism for myocardial injury is multifaceted, in which the severe inflammatory response causes myocardial inflammation, coronary plaque destabilization, acute thrombotic events, and ischemia. Cardiac magnetic resonance (CMR) imaging is the non-invasive method of choice for identifying myocardial injury, and it is able to differentiate between underlying causes in various and often challenging clinical scenarios. Multimodal imaging protocols that incorporate CMR and computed tomography provide a complex evaluation for both respiratory and cardiovascular complications of SARS-CoV2 infection. This, in relation to biological evaluation of systemic inflammation, can guide appropriate therapeutic management in every stage of the disease. The use of artificial intelligence can further improve the diagnostic accuracy of these imaging techniques, thus enabling risk stratification and evaluation of prognosis. The present manuscript aims to review the current knowledge on the possible modalities for imaging COVID-related myocardial inflammation or post-COVID coronary inflammation and atherosclerosis.

scholarly journals RE: Myocardial Injury After Noncardiac Surgery and Perioperative Atrial Fibrillation: From Evidence to Clinical Practice

2021 ◽  
Vol 16 (3) ◽  
pp. 1
Author(s):  
Daniel Esau
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Practice ◽  
Myocardial Injury ◽  
Noncardiac Surgery ◽  
Perioperative Medicine ◽  
High Dose ◽  
Insufficient Evidence ◽  
Special Issue

In the perioperative medicine special issue, Borges et al. discussed aspects of myocardial injury after noncardiac surgery (MINS) care and recommend initiating aspirin and moderate-to-high dose statin in all patients diagnosed with MINS. One aspect of MINS management that was not discussed in the article was patients in whom MINS management might be different, such as with patients on dialysis. Borges et al. are not alone in this regard: the CCS perioperative guidelines do not mention any specific exclusions for the initiation of ASA and statin in patients diagnosed with MINS. However, there is insufficient evidence to recommend aspirin and statins in all patients with MINS, as exemplified by patients requiring dialysis.

scholarly journals Biochemical response to cryothermal and radiofrequency exposure of the human myocardium at surgical ablation of atrial fibrillation: a randomized controlled trial.

2020 ◽  
Author(s):  
Gabriella Boano ◽  
Meriam Åström Aneq ◽  
Giannis Spyrou ◽  
Helena Enocsson ◽  
Charitakis Emmanouil ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Mitral Valve ◽  
Myocardial Injury ◽  
Troponin T ◽  
Controlled Trial ◽  
Mitral Valve Surgery ◽  
Valve Surgery ◽  
Cell Stress ◽  
Surgical Ablation ◽  
Apoptotic Activity

Abstract Background Surgical cryothermia and radiofrequency (RF) ablations for atrial fibrillation (AF) seem to result in similar sinus rhythm restoration, but the biochemical consequences of the two methods are unclear. We aimed to compare the biochemical responses to the two ablative methods in concomitant mitral valve surgery (MVS).Methods Sixty mitral valve surgery patients with AF were prospectively included. Forty-one patients planned for ablation were randomized to cryothermia (n = 20) or radiofrequency (n = 21) ablation and 19 served as controls. Markers for myocardial injury, inflammation, cell stress, apoptosis, and heart failure were analyzed pre- and postoperatively at different time points.Results Troponin T and creatine kinase isoenzyme MB (CK-MB) peak levels were significantly higher in the cryothermia group compared with the RF group (12805 [6140–15700] vs. 2790 [1880–4180] ng/L; P = 0.002 and 271 [217–357] vs. 79 [66–93] µg/L; P < 0.001, respectively). Both groups had significantly higher levels than the no-ablation group. There were no group differences in C-reactive protein (CRP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), but there were correlations between pre- and postoperative levels of both CRP (rs=0.41, P = 0.001) and NT-proBNP (rs=0.48, P < 0.001). Protease-activated receptor 1 (PAR-1) and heat shock protein 27 (HSP27) were significantly increased in the cryoablation group.Conclusions Cryoablation results in a larger myocardial injury and possibly more elevated apoptotic activity and cell stress compared with the RF technique. The type of ablation device did not have any significant influence on the postoperative inflammatory response nor on the early postoperative levels of NT-proBNP.

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