Association Between Heart Failure and Postoperative Mortality Among Patients Undergoing Ambulatory Noncardiac Surgery

General Anesthesia Surgery for Early Breast Cancer in a Patient with Severe Heart Failure due to Dilated Cardiomyopathy: A Case Report

INTRODUCTION

Perioperative mortality is significantly higher in cases of heart failure with severe left ventricular ejection fraction (LVEF) reduction, making it challenging to decide whether to proceed with surgery for early-stage breast cancer, which is not immediately fatal. However, the prognosis of heart failure has improved and breast cancer is increasingly becoming a prognostic factor. Herein, we report the case of a breast cancer patient with severe heart failure due to dilated cardiomyopathy (DC), who was deemed fit to undergo surgery under general anesthesia after obtaining sufficient informed consent and achieving improvement in heart failure symptoms during endocrine therapy.

CASE PRESENTATION

A 64-year-old female with a history of DC and sustained ventricular tachycardia, who had received cardiac resynchronization therapy with defibrillator implantation, underwent breast cancer surgery. She had been repeatedly hospitalized for heart failure with an LVEF of 19% and New York Heart Association (NYHA) Class III status, and heart transplant surgery was considered. However, a screening computed tomography scan revealed right breast cancer, and neither heart transplantation nor breast cancer surgery was performed. Endocrine therapy was initiated and failed 48 months after administration. Although the LVEF remained low at 21%, the NYHA classification improved to Class II, and she had not been hospitalized for heart failure for an extended period since her breast cancer diagnosis. Therefore, breast cancer surgery was performed under general anesthesia and no postoperative complications were observed throughout the course of the surgery.

CONCLUSION

Given that the prognosis for heart failure may statistically be better than that for breast cancer, early breast cancer surgery should be performed in patients with stable heart failure symptoms.

Postoperative Adverse Outcomes in Patients With Frailty Undergoing Urologic Surgery Among American Patients: A Propensity-Score Matched Retrospective Cohort Study

Objective

Although the 5-item modified frailty index (mFI-5) has been found to be associated postoperative outcomes, there are limited studies examining its utility in urologic surgery. Our purpose is to evaluate the association between the mFI-5 and postoperative mortality and complications among patients undergoing urologic surgery.

Methods

This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2020. All adult patients who underwent urologic procedures were included. The mFI-5 includes five items: hypertension, diabetes, congestive heart failure, chronic obstructive pulmonary disease, and physical function status. Each item is assigned one point, and an mFI-5 score of 2 or greater indicates frailty. The primary outcome was postoperative mortality, while secondary outcomes were postoperative complications. Propensity score analysis was employed to control for confounders.

Results

After propensity score matching, each group contained 55,322 surgical patients. The patients in the frailty group were at risks of in-hospital mortality (absolute risk increase [ARI] 0.29%) and higher postoperative complications, including acute myocardial infarction (ARI 0.25%), pneumonia (ARI 0.42%), sepsis (ARI 0.41%), and septic shock (0.2%). Compared to the non-frailty group, the length of hospital stay was higher in the frailty group.

Conclusion

Patients with an mFI-5 score of 2 or greater were associated with an increased risk of postoperative mortality and complications, including myocardial infarction, pneumonia, sepsis, and septic shock. The mFI-5 is a simple index that quickly identifies frail patients. This allows for the implementation of prehabilitation and nutritional strategies targeted at enhancing their physiological reserve and optimizing their surgical outcomes.

Navigating Cardiovascular Events in Non-Cardiac Surgery: A Comprehensive Review of Complications and Risk Assessment Strategies

Cardiovascular complications following non-cardiac surgery pose a significant global concern, affecting millions of patients annually. These complications, ranging from asymptomatic troponin elevations to major adverse cardiac events, contribute to heightened morbidity, mortality, and health care expenditures. The underlying mechanisms involve oxygen supply-demand imbalances and acute coronary syndromes precipitated by perioperative stressors. High-risk surgeries, including vascular and major abdominal procedures, are particularly susceptible to these complications. Risk assessment tools and biomarkers, especially high-sensitivity cardiac troponins, play pivotal roles in prognostication. However, despite advances in perioperative care, optimal management strategies remain elusive, as underscored by conflicting guidelines regarding interventions such as β-blockers and statins. This review aims to consolidate current evidence on cardiovascular complications following non-cardiac surgery, evaluate the utility of biomarkers, and discuss international guidelines for risk mitigation. An enhanced understanding regarding the standardized approaches is imperative in mitigating these complications effectively. Further research is essential to refine risk prediction models, validate biomarker thresholds, and elucidate the efficacy of preventive measures. Addressing these challenges can eventually lead to improved patient outcomes and more efficient healthcare resource utilization worldwide.

Successful Perianal Wound Treatment Using the Fecal Management System: A Report of 2 Cases

BACKGROUND

Fecal diversion is important for healing of perianal wounds. However, traditional fecal diversion with colostomy is associated with risks of general anesthesia and requires healthy abdominal skin for stoma creation. Alternative methods of fecal diversion are needed.

AIM AND OBJECTIVES

We aimed to illustrate an effective alternate method of fecal diversion in patients with perianal wounds by reporting 2 patients with perianal wounds who were successfully treated using the fecal management system.

MATERIALS AND METHODS

The first patient was a 79-year-old female with a grade IV sacral pressure injury who underwent operative debridements and vacuum-assisted wound closure. The second patient was a 21-year-old female with extensive perianal burn wounds who underwent a series of debridements, wound dressing changes, and split-thickness skin grafts. The fecal management system was utilized for fecal diversion in both patients.

RESULTS

Satisfactory wound healing was achieved in each patient using the fecal management system for fecal diversion.

CONCLUSIONS

Based on our 2 patients and previous studies that have reported successful treatment of perianal wounds using the fecal management system, this system is feasible to use and effective. We suggest its use in patients with perianal wounds, particularly those in whom colostomy is not preferable or contraindicated.

The activated caveolin-3/μ-opioid receptor complex drives morphine-induced rescue therapy in failing hearts

BACKGROUND AND PURPOSE

Opioid analgesics can alleviate ischaemia/reperfusion (I/R) injury in chronic heart failure. However, the underlying mechanisms and targets remain unknown. Here, we investigate if caveolin-3 (Cav3) interacts with μ opioid receptors and if Cav3-μ receptor interactions play a role in morphine-induced cardioprotection in failing hearts.

EXPERIMENTAL APPROACH

Cav3 and μ receptor proteins in human and rat heart tissue were determined by western blot, immunofluorescence and co-immunoprecipitation. Methyl-β-cyclodextrin (MβCD), a destroyer of caveolae, and AAV-Cav3 shRNA were used to reduce Cav3 expression in failing rat hearts. CTOP, a specific μ antagonist, was administrated before morphine preconditioning in perfused failing heart models of myocardial I/R injury.

KEY RESULTS

Levels of Cav3 and μ receptor proteins were significantly higher in human and rat myocardial tissues with heart failure than in control tissues. Cav3 and μ receptor expression levels were positively correlated with disease severity. The signal of the cardiac Cav3 protein was colocalized with μ receptor in both the human and rat heart sections. Disruption of caveolae in the failing heart by either MβCD or AAV-Cav3 shRNA significantly inhibits morphine-induced phosphorylation of ERK1/2 and cardioprotection. Administration of CTOP substantially reduced Cav3 expression and morphine-induced cardioprotective effect in heart failure.

CONCLUSION AND IMPLICATIONS

Our data suggest that up-regulation of the Cav3/μ receptor complex is critical for morphine protection of the failing heart against I/R injury by regulating the ERK1/2 pathway. The activated Cav3/μ receptor complex is an understudied therapeutic target for opioid treatment of heart failure and ischaemic insult.

Accurate diagnosis of heart failure and improved perioperative outcomes

With an ageing world population and increasing prevalence, heart failure is increasingly frequent as a comorbidity in operative patients, and its accurate preoperative diagnosis is essential to improve postoperative prognosis in patients undergoing noncardiac surgery. Use of electronic health records to assist in the accuracy of diagnosis and definition of an adjudicated heart failure reference standard could help guide intraoperative practice and improve outcomes in patients with heart failure.

Perioperative Medicine for Ambulatory Surgery

Ambulatory anesthesia for same-day surgery is a fast-growing and ever-improving branch of modern anesthesia. This is primarily driven by the involvement of anesthesiologists as perioperative physicians working in multidisciplinary groups. These groups work together to improve patient safety, patient outcomes, and overall efficiency of both in-patient and out-patient surgery. Appropriate patient selection and optimization are critical to maintain and improve the foundational entities of best ambulatory anesthesia practice. In this review article, a selection of considerations in the field of ambulatory anesthesia are featured, such as the aging population, sleep apnea, obesity, diabetes, cardiac disease, substance abuse, preoperative medication management, multimodal analgesia, social determinants of health, and surgical facility resources.

Heart failure diagnostic accuracy, intraoperative fluid management, and postoperative acute kidney injury: a single-centre prospective observational study

BACKGROUND

The accurate diagnosis of heart failure (HF) before major noncardiac surgery is frequently challenging. The impact of diagnostic accuracy for HF on intraoperative practice patterns and clinical outcomes remains unknown.

METHODS

We performed an observational study of adult patients undergoing major noncardiac surgery at an academic hospital from 2015 to 2019. A preoperative clinical diagnosis of HF was defined by keywords in the preoperative assessment or a diagnosis code. Medical records of patients with and without HF clinical diagnoses were reviewed by a multispecialty panel of physician experts to develop an adjudicated HF reference standard. The exposure of interest was an adjudicated diagnosis of heart failure. The primary outcome was volume of intraoperative fluid administered. The secondary outcome was postoperative acute kidney injury (AKI).

RESULTS

From 40 659 surgeries, a stratified subsample of 1018 patients were reviewed by a physician panel. Among patients with adjudicated diagnoses of HF, those without a clinical diagnosis (false negatives) more commonly had preserved left ventricular ejection fractions and fewer comorbidities. Compared with false negatives, an accurate diagnosis of HF (true positives) was associated with 470 ml (95% confidence interval: 120-830; P=0.009) lower intraoperative fluid administration and lower risk of AKI (adjusted odds ratio:0.39, 95% confidence interval 0.18-0.89). For patients without adjudicated diagnoses of HF, non-HF was not associated with differences in either fluids administered or AKI.

CONCLUSIONS

An accurate preoperative diagnosis of heart failure before noncardiac surgery is associated with reduced intraoperative fluid administration and less acute kidney injury. Targeted efforts to improve preoperative diagnostic accuracy for heart failure may improve perioperative outcomes.

The impact of comorbidities and functional status on outcomes in the older adult emergency general surgery patient

BACKGROUND

The aim of this study is to quantify the relative contribution of comorbidities and pre-operative functional status on outcomes in geriatric emergency general surgery (EGS) patients.

METHODS

This is a retrospective study of older-adult EGS patients at an academic medical center between 2017 and 2018. Patients ≥65 years were included. The primary outcomes examined were 30-day mortality, 30-day morbidity, and length of stay (LOS).

RESULTS

734 patients were included. The mean age was 76, and 48.9 ​% received non-operative management. The median LOS was 6.8 days; 11.8 ​% of patients died within 30 days, and 40.6 ​% developed morbidities. Lacking capacity to consent on admission was independently associated with 30-day mortality (OR: 2.63, [1.32-5.25], p ​= ​0.006). Comorbidities associated with developing morbidity were CVA with neurologic deficit (OR: 2.29, [1.20-4.36], p ​= ​0.012), CHF (OR: 2.60, [1.64-4.11], p ​< ​0.001), in addition to pre-operative delirium (OR: 3.42, [1.43-8.14], p ​= ​0.006).

CONCLUSIONS

A significant contribution to outcomes is determined by pre-admission comorbidities and cognitive and functional status. Opportunities exist for collaboration between Acute Care Surgery and geriatric medicine teams for the optimization of comorbidities.

Impact of rapid response system in mortality and complications post-orthopedic surgery: a retrospective cohort study

BACKGROUND

Rapid response systems (RRSs) are used in hospitals to identify and treat deteriorating patients. However, RRS implementation and outcomes in orthopedic and surgical patients remain controversial. We aimed to investigate whether the RRS affects mortality and complications after orthopedic surgery.

METHODS

The National Health Insurance Service of South Korea provided the data for this population-based cohort study. Individuals who were admitted to the hospital that implemented RRS were categorized into the RRS group and those admitted to a hospital that did not implement the RRS were categorized into the non-RRS group. In-hospital mortality and postoperative complications were the endpoints.

RESULTS

A total of 931,774 adult patients were included. Among them, 93,293 patients underwent orthopedic surgery in a hospital that implemented RRS and were assigned to the RRS group, whereas 838,481 patients were assigned to the non-RRS group. In multivariable logistic regression analysis, the RRS group was not associated with in-hospital mortality after orthopedic surgery compared with the non-RRS group (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.80, 1.08; P = 0.350). However, the RRS group was associated with a 14% lower postoperative complication rate after orthopedic surgery than the non-RRS group (OR 0.86, 95% CI 0.84, 0.86; P < 0.001).

CONCLUSIONS

The RRS was not associated with in-hospital mortality following orthopedic surgery in South Korea. However, RRS deployment was related to a decreased risk of postoperative complications in patients undergoing orthopedic surgery.

A Cadaveric Case Study on the Abdomen: A Temple of Surprises

Femoro-femoral bypass grafts (FFBG) are performed to connect the major vessels of the lower extremities, such as the femoral arteries, to treat patients who have injured or occluded iliac arteries. Typically, patients with multiple comorbidities, such as heart failure, aneurysms, or diabetes, have a significantly higher risk of complications for open, invasive procedures to correct lower limb ischemia. This graft poses as an effective, less invasive option to treat lower-limb ischemia for higher-risk patients. This case study presents a finding of FFBG in an 82-year-old male cadaver during cadaveric dissection in the gross anatomy lab at Geisinger Commonwealth School of Medicine in Scranton, Pennsylvania. Based on the initial findings of cardiomegaly with a triple coronary artery bypass graft (CABG) and pulmonary hypertension in the thoracic cavity and evidence of massive umbilical hernioplasty involving extensive mesh repair, our initial assumption of an FFBG placement in this cadaver was to increase perfusion to lower limbs, circumventing the need for surgical intervention due to the above-mentioned comorbidities, which act as risk factors. However, the discovery of a massive abdominal aortic aneurysm (AAA) measuring 26 cm in circumference with evidence of dissection of its wall and the presence of a stent within the aorta and common iliac arteries placed there as an endovascular aneurysm repair (EVAR) procedure came as a surprise. Publication of such findings provides awareness to curious individuals about the existence of multiple health concerns an individual suffers and how the medical as well as surgical teams work together to provide optimal treatment care to improve their standard of living and prolong their lifespan.

Preoperative Congestive Heart Failure Is Associated with Higher 30-Day Myocardial Infarction and Pneumonia after Endovascular Repair of Abdominal Aortic Aneurysm

INTRODUCTION

Preoperative congestive heart failure (CHF) is associated with higher postoperative mortality and complications in noncardiac surgery. However, postoperative outcomes for patients with preoperative CHF undergoing endovascular aneurysm repair (EVAR) have not been thoroughly established. This study evaluated the effect of preoperative CHF on 30-day outcomes following nonemergent intact EVAR using a large-scale national registry.

METHODS

Patients who had infrarenal EVAR were identified in the ACS-NSQIP database from 2012 to 2022. A 1:5 propensity-score matching was used to match demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, anesthesia, and concomitant procedures between patients with and without preoperative CHF. Thirty-day postoperative outcomes were examined.

RESULTS

467 (2.84%) CHF patients underwent intact EVAR. Meanwhile, 15,996 non-CHF patients underwent EVAR, where 2,248 of them were matched to all CHF patients. Patients with and without preoperative CHF had comparable 30-day mortality (3.02% vs. 2.62%, p = 0.64). However, CHF patients had higher myocardial infarction (3.02% vs. 1.47%, p = 0.03), pneumonia (3.23% vs. 1.73%, p = 0.04), 30-day readmission (p = 0.01), and longer length of stay (p < 0.01).

CONCLUSION

While patients with and without preoperative CHF had comparable 30-day mortality rates, those with CHF faced higher risks of cardiopulmonary complications. Effective management of preoperative CHF may help prevent postoperative complications in these patients.

Preoperative Variables of 30-Day Mortality in Adults Undergoing Percutaneous Coronary Intervention: A Systematic Review

BACKGROUND AND AIM

Risk adjustment following percutaneous coronary intervention (PCI) is vital for clinical quality registries, performance monitoring, and clinical decision-making. There remains significant variation in the accuracy and nature of risk adjustment models utilised in international PCI registries/databases. Therefore, the current systematic review aims to summarise preoperative variables associated with 30-day mortality among patients undergoing PCI, and the other methodologies used in risk adjustments.

METHOD

The MEDLINE, EMBASE, CINAHL, and Web of Science databases until October 2022 without any language restriction were systematically searched to identify preoperative independent variables related to 30-day mortality following PCI. Information was systematically summarised in a descriptive manner following the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies checklist. The quality and risk of bias of all included articles were assessed using the Prediction Model Risk Of Bias Assessment Tool. Two independent investigators took part in screening and quality assessment.

RESULTS

The search yielded 2,941 studies, of which 42 articles were included in the final assessment. Logistic regression, Cox-proportional hazard model, and machine learning were utilised by 27 (64.3%), 14 (33.3%), and one (2.4%) article, respectively. A total of 74 independent preoperative variables were identified that were significantly associated with 30-day mortality following PCI. Variables that repeatedly used in various models were, but not limited to, age (n=36, 85.7%), renal disease (n=29, 69.0%), diabetes mellitus (n=17, 40.5%), cardiogenic shock (n=14, 33.3%), gender (n=14, 33.3%), ejection fraction (n=13, 30.9%), acute coronary syndrome (n=12, 28.6%), and heart failure (n=10, 23.8%). Nine (9; 21.4%) studies used missing values imputation, and 15 (35.7%) articles reported the model's performance (discrimination) with values ranging from 0.501 (95% confidence interval [CI] 0.472-0.530) to 0.928 (95% CI 0.900-0.956), and four studies (9.5%) validated the model on external/out-of-sample data.

CONCLUSIONS

Risk adjustment models need further improvement in their quality through the inclusion of a parsimonious set of clinically relevant variables, appropriately handling missing values and model validation, and utilising machine learning methods.

Management of Uncomplicated Appendicitis in Adults: A Nationwide Analysis From 2018 to 2019

INTRODUCTION

Nonoperative management (NOM) of uncomplicated appendicitis (UA) has been increasingly utilized in recent years. The aim of this study was to describe nationwide trends of sociodemographic characteristics, outcomes, and costs of patients undergoing medical versus surgical management for UA.

METHODS

The 2018-2019 National (Nationwide) Inpatient Sample was queried for adults (age ≥18 y) with UA; diagnosis, as well as laparoscopic and open appendectomy, were defined by the International Classification of Diseases, 10th Revision, Clinical Modification codes. We examined several characteristics, including cost of care and length of hospital stay.

RESULTS

Among the 167,125 patients with UA, 137,644 (82.4%) underwent operative management and 29,481 (17.6%) underwent NOM. In bivariate analysis, we found that patients who had NOM were older (53 versus 43 y, P < 0.001) and more likely to have Medicare (33.6% versus 16.1%, P < 0.001), with higher prevalence of comorbidities such as diabetes (7.8% versus 5.5%, P < 0.001). The majority of NOM patients were treated at urban teaching hospitals (74.5% versus 66.3%, P < 0.001). They had longer LOS's (5.4 versus 2.3 d, P < 0.001) with higher inpatient costs ($15,584 versus $11,559, P < 0.001) than those who had an appendectomy. Through logistic regression we found that older patients had up to 4.03-times greater odds of undergoing NOM (95% CI: 3.22-5.05, P < 0.001).

CONCLUSIONS

NOM of UA is more commonly utilized in patients with comorbidities, older age, and those treated in teaching hospitals. This may, however, come at the price of longer length of stay and higher costs. Further guidelines need to be developed to clearly delineate which patients could benefit from NOM.

Outcomes of Women Undergoing Noncardiac Surgery in Veterans Affairs Compared With Non-Veterans Affairs Care Settings

Importance

Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. Although veterans are predominantly male, the number of women receiving care within the VA has nearly doubled to 10% over the past decade and recent data comparing the surgical care of women in VA and non-VA care settings are lacking.

Objective

To compare postoperative outcomes among women treated in VA hospitals vs private-sector hospitals.

Design, Setting, and Participants

This coarsened exact-matched cohort study across 9 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) took place from January 1, 2016, to December 31, 2019. Multivariable Poisson models with robust standard errors were used to evaluate the association between VA vs private-sector care settings and 30-day mortality. Hospitals participating in American College of Surgeons NSQIP and VASQIP were included. Data analysis was performed in January 2023. Participants included female patients 18 years old or older.

Exposures

Surgical care in VA or private-sector hospitals.

Main Outcomes and Measures

Postoperative 30-day mortality and failure to rescue (FTR).

Results

Among 1 913 033 procedures analyzed, patients in VASQIP were younger (VASQIP: mean age, 49.8 [SD, 13.0] years; NSQIP: mean age, 55.9 [SD, 16.9] years; P < .001) and although most patients in both groups identified as White, there were significantly more Black women in VASQIP compared with NSQIP (29.6% vs 12.7%; P < .001). The mean risk analysis index score was lower in VASQIP (13.9 [SD, 6.4]) compared with NSQIP (16.3 [SD, 7.8]) (P < .001 for both). Patients in the VA were more likely to have a preoperative acute serious condition (2.4% vs 1.8%: P < .001), but cases in NSQIP were more frequently emergent (6.9% vs 2.6%; P < .001). The 30-day mortality, complications, and FTR were 0.2%, 3.2%, and 0.1% in VASQIP (n = 36 762 procedures) as compared with 0.8%, 5.0%, and 0.5% in NSQIP (n = 1 876 271 procedures), respectively (all P < .001). Among 1 763 540 matched women (n = 36 478 procedures in VASQIP; n = 1 727 062 procedures in NSQIP), these rates were 0.3%, 3.7%, and 0.2% in NSQIP and 0.1%, 3.4%, and 0.1% in VASQIP (all P < .01). Relative to private-sector care, VA surgical care was associated with a lower risk of death (adjusted risk ratio [aRR], 0.41; 95% CI, 0.23-0.76). This finding was robust among women undergoing gynecologic surgery, inpatient surgery, and low-physiologic stress procedures. VA surgical care was also associated with lower risk of FTR (aRR, 0.41; 95% CI, 0.18-0.92) for frail or Black women and inpatient and low-physiologic stress procedures.

Conclusions and Relevance

Although women comprise the minority of veterans receiving care within the VA, in this study, VA surgical care for women was associated with half the risk of postoperative death and FTR. The VA appears better equipped to meet the unique surgical needs and risk profiles of veterans, regardless of sex and health policy decisions, including funding, should reflect these important outcome differences.

Association Between Modified Frailty Index and Postoperative Outcomes of Tracheostomies

OBJECTIVE

The 5-item modified frailty index (mFI-5) has been used to stratify patients based on the risk of postoperative complications in several surgical procedures but has not yet been done in tracheostomies. This study investigates the association between the mFI-5 score and tracheostomy complications.

STUDY DESIGN

Retrospective database review.

SETTING

United States hospitals.

METHODS

The National Surgical Quality Improvement Program database was queried for tracheostomy patients between 2005 and 2018. The mFI-5 was calculated for each patient by assigning 1 point for each of the following comorbidities: diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functionally dependent health status. Univariate and multivariable analyses were conducted to determine associations between the mFI-5 score and postoperative complications.

RESULTS

A total of 4438 patients undergoing tracheostomies were queried and stratified into the following groups: mFI = 0 (N = 1741 [39.2%], mFI = 1 (N = 1720 [38.8%]), mFI = 2 (N = 726 [16.4%]), and mFI of 3 or higher (N = 251 [5.7%]). Univariate analysis showed that patients with higher mFI-5 scores had a greater proportion of smoking, dyspnea, obesity, steroid use, emergency cases, complications, reoperations, and mortality (P < .001). Multivariable analyses found associations between mFI-5 score and any complication (odds ratio [OR]: 1.49, 95% confidence interval [CI]: 1.03-2.16, P = .035), mortality (OR: 2.32, 95% CI: 1.15-4.68, P = .019), and any medical complication (OR: 2.75, 95% CI: 1.88-4.02, P < .001).

CONCLUSION

This study suggests an association between the mFI-5 score and postoperative complications in tracheostomies. mFI-5 score can be used to stratify tracheostomy patients by operative risk.

Prognostic value of left ventricular systolic function before vascular surgery: a systematic review

BACKGROUND

Vascular surgery carries a high risk of post-operative cardiac complications. Recent studies have shown an association between asymptomatic left ventricular systolic dysfunction and increased risk of major adverse cardiovascular events (MACE). This systematic review aims to evaluate the prognostic value of left ventricular function as determined by left ventricular ejection fraction (LVEF) measured by resting echocardiography before vascular surgery.

METHODS

This review conformed to PRISMA and MOOSE guidelines. PubMed, OVID Medline and Cochrane databases were searched from inception to 27 October 2022. Eligible studies assessed vascular surgery patients, with multivariable-adjusted or propensity-matched observational studies measuring LVEF via resting echocardiography and providing risk estimates for outcomes. The primary outcomes measures were all-cause mortality and congestive heart failure at 30 days. Secondary outcome included the composite outcome MACE.

RESULTS

Ten observational studies were included (4872 vascular surgery patients). Studies varied widely in degree of left ventricular systolic dysfunction, symptom status, and outcome reporting, precluding reliable meta-analysis. Available data demonstrated a trend towards increased incidence of all-cause mortality, congestive heart failure and MACE in patients with pre-operative LVEF <50%. Methodological quality of the included studies was found to be of moderate quality according to the Newcastle Ottawa Checklist.

CONCLUSION

The evidence surrounding the prognostic value of LVEF measurement before vascular surgery is currently weak and inconclusive. Larger scale, prospective studies are required to further refine cardiac risk prediction before vascular surgery.

Perioperative Management of Novel Pharmacotherapies for Heart Failure and Pulmonary Hypertension

Heart failure (HF) and pulmonary hypertension (PH) are increasingly prevalent comorbidities in patients presenting for noncardiac surgery. The unique pathophysiology and pharmacotherapies associated with these syndromes have important perioperative implications. As new medications for HF and PH emerge, it is imperative that anesthesiologists and other perioperative providers understand their mechanisms of action, pharmacokinetics, and potential adverse effects. We present an overview of the novel HF and PH pharmacotherapies and strategies for their perioperative management.

Chronic heart failure in patients undergoing major head and neck surgery: A hospital-based study

OBJECTIVE

To investigate the effects of chronic heart failure on various post-operative outcomes in head and neck cancer patients undergoing major cancer surgery.

STUDY DESIGN

For this retrospective cohort study of patients undergoing major head and neck cancer surgery, a sample of 10,002 patients between 2017 and 2019 were identified through the Nationwide Inpatient Sample.

SETTING

Patients were selected as undergoing major head and neck cancer surgery, defined as laryngectomy, pharyngectomy, glossectomy, neck dissection, mandibulectomy, and maxillectomy, then separated based on pre-surgical diagnosis of chronic heart failure.

METHODS

The effects of pre-operative chronic heart failure on post-surgical outcomes in these patients were investigated by univariable and multivariable logistic regression using ICD-10 codes and SPSS.

RESULTS

A diagnosis of chronic heart failure was observed in 265 patients (2.6 %). Patients with chronic heart failure had more preexisting comorbidities when compared to patients without chronic heart failure (mean ± SD; 4 ± 1 vs. 2 ± 1). Multivariable logistic regression showed that chronic heart failure patients had significantly greater odds of dying during hospitalization (OR 2.86, 95 % CI 1.38-5.91) and experiencing non-routine discharge from admission (OR 1.89, 95 % CI 1.41-2.54) after undergoing major head and neck cancer surgery.

CONCLUSION

Chronic heart failure is associated with greater length of stay and hospital charges among head and neck cancer patients undergoing major head and neck cancer surgeries. Chronic heart failure patients have significantly greater rates of unfavorable post-operative outcomes, including death during hospitalization and non-routine discharge from admission.

Differences between patients in whom physicians agree versus disagree about the preoperative diagnosis of heart failure

STUDY OBJECTIVE

To quantify preoperative heart failure (HF) diagnostic agreement and identify characteristics of patients in whom physicians agreed versus disagreed about the diagnosis.

DESIGN

Observational cohort study.

SETTING

Patients undergoing major non-cardiac surgery at an academic center between 2015 and 2019.

PATIENTS

40,659 patients undergoing major non-cardiac surgery, among which a stratified subsample of 1018 patients with and without documented HF was reviewed.

INTERVENTIONS

Via a panel of physicians frequently managing patients with HF (cardiologists, cardiac anesthesiologists, intensivists), detailed chart reviews were performed (two per patient; median review time 32 min per reviewer per patient) to render adjudicated HF diagnoses.

MEASUREMENTS

Adjudicated diagnostic agreement measures (percent agreement, Krippendorf's alpha) and univariate comparisons (standardized differences) between patients in whom physicians agreed versus disagreed about the preoperative HF diagnosis.

MAIN RESULTS

Among patients with documented HF, physicians agreed about the diagnosis in 80.0% of cases (consensus positive), disagreed in 13.8% (disagreement), and refuted the diagnosis in 6.3% (consensus negative). Conversely, among patients without documented HF, physicians agreed about the diagnosis in 88.0% (consensus negative), disagreed in 8.4% (disagreement), and refuted the diagnosis in 3.6% (consensus positive). The estimated agreement for the 40,659 cases was 91.1% (95% CI 88.3%-93.9%); Krippendorff's alpha was 0.77 (0.75-0.80). Compared to patients in whom physicians agreed about a HF diagnosis, patients in whom physicians disagreed exhibited fewer guideline-defined HF diagnostic criteria.

CONCLUSIONS

Physicians usually agree about HF diagnoses adjudicated via chart review, although disagreement is not uncommon and may be partly explained by heterogeneous clinical presentations. Our findings inform preoperative screening processes by identifying patients whose characteristics contribute to physician disagreement via chart review. Clinical Trial Number / Registry URL: Not applicable.

Older age impacts outcomes after adrenalectomy

BACKGROUND

Adrenalectomy is well tolerated with low complication rates. It is unclear if these excellent outcomes are consistent across all age groups.

METHODS

The 2015-2020 American College of Surgeons National Surgical Quality Improvement Program datasets were used. Patients who underwent adrenalectomy were identified and grouped based on age: ≤60, 61 to 70, 71 to 80, and >80 years. Patient characteristics, surgical indications, operative characteristics, and postoperative outcomes were compared between age groups. Primary outcome measures were mortality, morbidity, postoperative length of stay, non-home discharge, and unplanned readmission. Multivariable logistic regression analysis was performed.

RESULTS

Adrenalectomy was performed on 6,114 patients. Younger patients more frequently had surgery for non-functional benign neoplasms compared with older (55.7% vs 52.8% vs 45.9% vs 45.3%, for patients ≤60, 61 to 70, 71 to 80, and >80 years, respectively, P < .001), and less frequently had surgery for malignancy (8.8% vs 14.4% vs 22.5% vs 24.5%, P < .001). The median length of stay for patients ≤60 was 1 day compared with 2 days for patients 61-70, 71-80, and >80 (P < .001). The overall mortality rate was <1% and did not differ based on age (P = .18). Morbidity occurred less frequently in the younger age groups (7.3% vs 8.9% vs 11.2% vs 16.0%, P < .001) compared with older. Similar trends were seen for non-home discharge (1.4% vs 2.5% vs 4.8% vs 17.0%, P < .001). On multivariable analysis, patients aged >80 had a 2-fold increased likelihood of morbidity and a 9-fold increased likelihood of non-home discharge compared to patients aged ≤60.

CONCLUSION

Older age is associated with morbidity and non-home discharge after adrenalectomy. Knowledge of these risks is critical when counseling an aging surgical population.

Patient selection in ambulatory surgery

Patient selection is important for ambulatory surgical practices. Proper patient selection for ambulatory practices will optimize resources and lead to increased patient and provider satisfaction. As the number and complexity of procedures in ambulatory surgical centers increase, it is important to ensure that patients are best cared for in facilities that can provide appropriate levels of care. This review addresses the multiple variables and resources that should be considered when selecting patients for anesthesia in ambulatory centers and offices.

Treatment of adult deformity surgery by orthopedic and neurological surgeons: trends in treatment, techniques, and costs by specialty

BACKGROUND CONTEXT

Surgery to correct adult spinal deformity (ASD) is performed by both neurological surgeons and orthopedic surgeons. Despite well-documented high costs and complication rates following ASD surgery, there is a dearth of research investigating trends in treatment according to surgeon subspeciality.

PURPOSE

The purpose of this investigation was to perform an analysis of surgical trends, costs and complications of ASD operations by physician specialty using a large, nationwide sample.

STUDY DESIGN/SETTING

Retrospective cohort study using an administrative claims database.

PATIENT SAMPLE

A total of 12,929 patients were identified with ASD that underwent deformity surgery performed by neurological or orthopedic surgeons.

OUTCOME MEASURES

The primary outcome was surgical case volume by surgeon specialty. Secondary outcomes included costs, medical complications, surgical complications, and reoperation rates (30-day, 1-year, 5-year, and total).

METHODS

The PearlDiver Mariner database was queried to identify patients who underwent ASD correction from 2010 to 2019. The cohort was stratified to identify patients who were treated by either orthopedic or neurological surgeons. Surgical volume, baseline characteristics, and surgical techniques were examined between cohorts. Multivariable logistic regression was employed to assess the cost, rate of reoperation and complication according to each subspecialty while controlling for number of levels fused, rate of pelvic fixation, age, gender, region and Charlson Comorbidity Index (CCI). Alpha was set to 0.05 and a Bonferroni correction for multiple comparisons was utilized to set the significance threshold at p ≤.000521.

RESULTS

A total of 12,929 ASD patients underwent deformity surgery performed by neurological or orthopedic surgeons. Orthopedic surgeons performed most deformity procedures accounting for 64.57% (8,866/12,929) of all ASD operations, while the proportion treated by neurological surgeons increased 44.2% over the decade (2010: 24.39% vs 2019: 35.16%; p<.0005). Neurological surgeons more frequently operated on older patients (60.52 vs 55.18 years, p<.0005) with more medical comorbidities (CCI scores: 2.01 vs 1.47, p<.0005). Neurological surgeons also performed higher rates of arthrodesis between one and six levels (OR: 1.86, p<.0005), three column osteotomies (OR: 1.35, p<.0005) and navigated or robotic procedures (OR: 3.30, p<.0005). Procedures performed by orthopedic surgeons had significantly lower average costs as compared to neurological surgeons (orthopedic surgeons: $17,971.66 vs neurological surgeons: $22,322.64, p=.253). Adjusted logistic regression controlling for number of levels fused, pelvic fixation, age, sex, region, and comorbidities revealed that patients within neurosurgical care had similar odds of complications to orthopaedic surgery.

CONCLUSIONS

This investigation of over 12,000 ASD patients demonstrates orthopedic surgeons continue to perform the majority of ASD correction surgery, although neurological surgeons are performing an increasingly larger percentage over time with a 44% increase in the proportion of surgeries performed in the decade. In this cohort, neurological surgeons more frequently operated on older and more comorbid patients, utilizing shorter-segment fixation with greater use of navigation and robotic assistance.

Preoperative risk factors and postoperative complications associated with mortality after outpatient surgery in a broad surgical population: an analysis of 2.8 million ACS-NSQIP patients

BACKGROUND

Thirty-day mortality after outpatient surgery is unexpected and undesired. We investigated preoperative risk factors, operative variables, and postoperative complications associated with 30-day death after outpatient surgery.

METHODS

Using the 2005 to 2018 American College of Surgeons National Surgical Quality Improvement Program database, we evaluated 30-day mortality rate trends over time after outpatient operations. We analyzed associations between 37 preoperative variables, operation time, hospital length of stay, and 9 postoperative complications with mortality rate using χ2 analyses for categorical data and tests for continuous data. We used forward selection logistic regression models to determine the best predictors of mortality preoperatively and postoperatively. We also separately analyzed mortality by age group.

RESULTS

A total of 2,822,789 patients were included. The 30-day mortality rate did not change significantly over time (P = .34, Cochran-Armitage trend test), remaining steady at around 0.06%. The most significant preoperative predictors of mortality included the patient having disseminated cancer, decreased functional health status, increased American Society of Anesthesiology Physical Status classification, increased age, and ascites, accounting for 95.8% (0.837/0.874) of the full model c-index. The most significant postoperative complications associated with increased risk of mortality included having cardiac (26.95% yes vs 0.04% no), pulmonary (10.25% vs 0.04%), stroke (9.22% vs 0.06%), and renal (9.33% vs 0.06%) complications. Postoperative complications conferred a greater risk for mortality than preoperative variables. Mortality risk increased incrementally with age, particularly past age 80.

CONCLUSION

The operative mortality rate after outpatient surgery has not changed over time. Patients over 80 years with disseminated cancer, decreased functional health status, or increased ASA class should generally be considered for inpatient surgery. However, there might be some circumstances where outpatient surgery could be considered.

Postoperative 30-Day Comparative Complications of Multilevel Anterior Cervical Discectomy and Fusion and Laminoplasty for Cervical Spondylotic Myelopathy: An Evidence in Reaching Consensus

Although a few large-scale studies have investigated multilevel anterior cervical discectomy and fusion (ACDF) and laminoplasty (LAMP) and their related complications for cervical spondylotic myelopathy (CSM), the optimal surgical intervention remains controversial. Therefore, we compared their 30 days of postoperative complications. Through the 2010-2019 ACS NSQIP Participant Use Data Files, we estimated the risk of serious morbidity, reoperation, readmission, mortality, and other postoperative complications. Initially, propensity score matching (PSM) of the preoperative characteristics of both groups was performed for further analysis. Multivariable logistic regression analysis provided OR and 95% CI for comparative complications. After PSM, 621 pairs of cohorts were generated for both groups. Increased frequency of postoperative complications was observed in the LAMP group, especially for surgical wound infection, no matter whether superficial (ACDF/LAMP = 0%/1.13%, p = 0.0154) or deep wound infection (ACDF/LAMP = 0%/0.97%, p = 0.0309). The mean length of total hospital stays (ACDF/LAMP = 2.25/3.11, p < 0.0001) and days from operation to discharge (ACDF/LAMP = 2.12/3.08, p < 0.0001) were longer, while the hospitalization rate for over 30 days (ACDF/LAMP = 4.67%/7.41%, p = 0.0429) and unplanned reoperation (ACDF/LAMP = 6.12%/9.34%, p = 0.0336) were higher in LAMP. Results also indicated congestive heart failure as a risk factor (adjusted OR = 123.402, p = 0.0002). Conclusively, multilevel ACDF may be a safer surgical approach than LAMP for CSM in terms of perioperative morbidities, including surgical wound infection, prolonged hospitalization, and unplanned reoperation. However, these approaches showed no significant differences in systemic complications and perioperative mortality.

Association of Preoperative Medical Consultation With Reduction in Adverse Postoperative Outcomes and Use of Processes of Care Among Residents of Ontario, Canada

Importance

It is uncertain whether preoperative medical consultation reduces adverse postoperative clinical outcomes.

Objective

To investigate the association of preoperative medical consultation with reduction in adverse postoperative outcomes and use of processes of care.

Design, Setting, and Participants

This was a retrospective cohort study using linked administrative databases from an independent research institute housing routinely collected health data for Ontario's 14 million residents, including sociodemographic features, physician characteristics and services, and receipt of inpatient and outpatient care. The study sample included Ontario residents aged 40 years or older who underwent their first qualifying intermediate- to high-risk noncardiac operation. Propensity score matching was used to adjust for differences between patients who did and did not undergo preoperative medical consultation with discharge dates between April 1, 2005, and March 31, 2018. The data were analyzed from December 20, 2021, to May 15, 2022.

Exposures

Receipt of preoperative medical consultation in the 4 months preceding the index surgery.

Main Outcomes and Measures

The primary outcome was 30-day all-cause postoperative mortality. Secondary outcomes included 1-year mortality, inpatient myocardial infarction and stroke, in-hospital mechanical ventilation, length of stay, and 30-day health system costs.

Results

Of the total 530 473 individuals (mean [SD] age, 67.1 [10.6] years; 278 903 [52.6%] female) included in the study, 186 299 (35.1%) received preoperative medical consultation. Propensity score matching resulted in 179 809 well-matched pairs (67.8% of the full cohort). The 30-day mortality rate was 0.9% (n = 1534) in the consultation group and 0.7% (n = 1299) in the control group (odds ratio [OR], 1.19; 95% CI, 1.11-1.29). The ORs for 1 year mortality (OR, 1.15; 95% CI, 1.11-1.19), inpatient stroke (OR, 1.21; 95% CI, 1.06-1.37), in-hospital mechanical ventilation (OR, 1.38; 95% CI, 1.31-1.45), and 30-day emergency department visits (OR, 1.07; 95% CI, 1.05-1.09) were higher in the consultation group; however, the rates of inpatient myocardial infarction did not differ. The lengths of stay in acute care were a mean (SD) 6.0 (9.3) days in the consultation group and 5.6 (10.0) days in the control group (difference, 0.4 [95% CI, 0.3-0.5] days), and the median (IQR) total 30-day health system cost was CAD $317 ($229-$959) (US $235 [$170-$711]) higher in the consultation group. Preoperative medical consultation was associated with increased use of preoperative echocardiography (OR, 2.64; 95% CI, 2.59-2.69) and cardiac stress tests (OR, 2.50; 95% CI, 2.43-2.56) and higher odds of receiving a new prescription for β-blockers (OR, 2.96; 95% CI, 2.82-3.12).

Conclusions and Relevance

In this cohort study, preoperative medical consultation was not associated with a reduction but rather with an increase in adverse postoperative outcomes, suggesting a need for further refinement of target populations, processes, and interventions related to preoperative medical consultation. These findings highlight the need for further research and suggest that referral for preoperative medical consultation and subsequent testing should be carefully guided by individual-level consideration of risks and benefits.

Impact of kidney transplant on post-operative morbidity and mortality in patients with pre-operative cardiac dysfunction

BACKGROUND

Several studies show an increase in complications, both cardiac and non-cardiac, and a higher mortality in patients with preexisting cardiac disease when they undergo elective surgery. Due to the high incidence of cardiac dysfunction in patients with concomitant chronic kidney disease, we wanted to determine if the same negative impact is demonstrated in patients undergoing kidney transplantation.

METHODS

A retrospective analysis was done on 582 patients who underwent kidney transplant from a single transplant center between 2014 and 2019. Participants for this study were divided into two groups based on cardiac ejection fraction: normal EF (≥40%) (n = 540) and low EF (<40%) (n = 33); exclusion criteria included patients undergoing multi-organ transplants (n = 9). Characteristics and outcomes of patients were compared before and after transplant using chi-square tests for categorical measures, and either Kruskal-Wallis or paired Student's t tests for continuous measures. Overall survival (OS) between groups was assessed using the Kaplan-Meier test. We compared outcomes between the normal EF and low EF groups using logistic regression in raw data, and propensity score matched sample and inverse-probability-weighting to mitigate selection bias.

RESULTS

There was no significant difference in survival between patients in the low EF and normal EF groups (p = .33). Among patients with low EF, mean EF after transplant significantly improved (mean: 55.83% ± 5.75%) compared to mean EF before transplant (38.28% ± 7.35%), (p = < .0001). Of the patients with a low EF before transplant, 1 in 5 had a history of CAD, compared to only 1 in 10 among those patients with a normal EF, p = .0657. Post-transplant complications were comparable between the groups.

CONCLUSION

Patients undergoing kidney transplantation with a low ejection fraction do not demonstrate an increased incidence of morbidity or mortality in the peri- and post-transplant follow-up compared with patients with a normal ejection fraction. Cardiac events post-transplantation is also comparable between the two groups. Of note, patients with a low EF have a significantly improved EF after kidney transplant which is likely a function of improvement in their physiologic state after the kidney transplant.

Quantification of left ventricular ejection fraction and cardiac output using a novel semi-automated echocardiographic method: a prospective observational study in coronary artery bypass patients

BACKGROUND

Echocardiographic quantification of ejection fraction (EF) by manual endocardial tracing requires training, is time-consuming and potentially user-dependent, whereas determination of cardiac output by pulmonary artery catheterization (PAC) is invasive and carries a risk of complications. Recently, a novel software for semi-automated EF and CO assessment (AutoEF) using transthoracic echocardiography (TTE) has been introduced. We hypothesized that AutoEF would provide EF values different from those obtained by the modified Simpson's method in transoesophageal echocardiography (TOE) and that AutoEF CO measurements would not agree with those obtained via VTI_LVOT in TOE and by thermodilution using PAC.

METHODS

In 167 patients undergoing coronary artery bypass graft surgery (CABG), TTE cine loops of apical 4- and 2-chamber views were recorded after anaesthesia induction under steady-state conditions. Subsequently, TOE was performed following a standardized protocol, and CO was determined by thermodilution. EF and CO were assessed by TTE AutoEF as well as TOE, using the modified Simpson's method, and Doppler measurements via velocity time integral in the LV outflow tract (VTI_LVOT). We determined Pearson's correlation coefficients r and carried out Bland-Altman analyses. The primary endpoints were differences in EF and CO. The secondary endpoints were differences in left ventricular volumes at end diastole (LVEDV) and end systole (LVESV).

RESULTS

AutoEF and the modified Simpson's method in TOE showed moderate EF correlation (r = 0.38, p < 0.01) with a bias of -12.6% (95% limits of agreement (95%LOA): -36.6 - 11.3%). AutoEF CO correlated poorly both with VTI_LVOT in TOE (r = 0.19, p < 0.01) and thermodilution (r = 0.28, p < 0.01). The CO bias between AutoEF and VTI_LVOT was 1.33 l min^-1 (95%LOA: -1.72 - 4.38 l min^-1) and 1.39 l min^-1 (95%LOA -1.34 - 4.12 l min^-1) between AutoEF and thermodilution, respectively. AutoEF yielded both significantly lower EF (EF_AutoEF: 42.0% (IQR 29.0 - 55.0%) vs. EF_{TOE Simpson}: 55.2% (IQR 40.1 - 70.3%), p < 0.01) and CO values than the reference methods (CO_{AutoEF biplane}: 2.30 l min^-1 (IQR 1.30 - 3.30 l min^-1) vs. CO_{VTI LVOT}: 3.64 l min^-1 (IQR 2.05 - 5.23 l min^-1) and CO_PAC: 3.90 l min^-1 (IQR 2.30 - 5.50 l min^-1), p < 0.01)).

CONCLUSIONS

AutoEF correlated moderately with TOE EF determined by the modified Simpson's method but poorly both with VTI_LVOT and thermodilution CO. A systematic bias was detected overestimating LV volumes and underestimating both EF and CO compared to the reference methods.

TRIAL REGISTRATION

German Register for Clinical Trials (DRKS-ID DRKS00010666, date of registration: 08/07/2016).

Utility of Blood Culture in Patients with Community-Acquired Pneumonia: A Propensity Score-Matched Analysis Based on a Japanese National Health Insurance Database

Community-acquired pneumonia (CAP) is an acute pulmonary parenchymal infection acquired outside the hospital. The utility of blood cultures in inpatients with CAP to reduce mortality and length of hospital stay is controversial. This study aimed to determine the utility of blood cultures on the first day of hospitalization for CAP inpatients and its influence on mortality, length of hospital stay, and antibiotics use. We conducted a fact-finding survey on the implementation of blood culture in inpatients with CAP in Japan. A propensity score (PS)-matched analysis based on the National Database of Health Insurance Claims and Specific Health Check-ups of Japan database was conducted. Overall, 163173 patients were included in the analysis, and PS matching extracted 68104 pairs. The results of the comparison between the PS-matched blood culture group and PS-matched control group were as follows: mortality and length of hospital stay were significantly lower in the PS-matched blood culture group than in the control group. The adjusted odds ratio (OR) (95% confidence interval (CI)) for in-hospital mortality with blood culture test was 0.73 (0.68-0.79). Moreover, for days of antibiotic usage, number of antibiotics used were significantly higher in the PS-matched blood culture group than that in the control group. Our findings indicated that performing a blood culture on the first day of hospitalization for inpatients with CAP was associated with reduced mortality. To our knowledge, this is the largest epidemiological study to assess the utility of blood culture in Japanese inpatients with CAP. This testing method shows potential for application in clinical practice.

Preoperative Heart Failure Treatment Prevents Postoperative Cardiac Complications in Patients With Lower Risk: A Retrospective Cohort Study

OBJECTIVE

The objective of this study was to identify undertreated subgroups of patients with heart failure who would benefit from better perioperative optimization.

SUMMARY OF BACKGROUND DATA

Patients with heart failure have increased risks of postoperative cardiac complications after noncardiac surgery.

METHODS

In this analysis of hospital registry data of 130,677 patients undergoing noncardiac surgery, the exposure was preoperative history of heart failure. The outcome, cardiac complications, was defined as a composite of myocardial infarction, cardiac arrest, acute heart failure, and mortality within 30 postoperative days.

RESULTS

History of heart failure (n = 10,256; 7.9%) was associated with increased risk of cardiac complications [8.1% vs 1.1%; adjusted odds ratio, 2.28 (95% CI, 2.02-2.56); P < 0.001). Patients with heart failure and who carried a lower risk profile had increased risks of postoperative cardiac complications secondary to heart failure [adjusted absolute risk difference, 1.7% (95% CI, 1.4%-2.0%, lower risk); P < 0.001 vs 0.5% (95% CI, -0.6% to 1.6%, higher risk); P = 0.38]. Patients with heart failure and lower risk received a lower level of health care utilization preoperatively, and less frequently received anti-heart failure medications (59% vs 72% and 61% vs 82%; both P < 0.001). These preventive therapies significantly decreased the risk of cardiac complications in patients with heart failure.

CONCLUSIONS

In patients with heart failure who have a lower preoperative risk profile, clinicians often make insufficient attempts to optimize their clinical condition preoperatively. Preoperative preventive treatment reduces the risk of postoperative cardiac complications in these lower-risk patients with heart failure.

Preoperative clinical diagnostic accuracy of heart failure among patients undergoing major noncardiac surgery: a single-centre prospective observational analysis

Background

Reliable diagnosis of heart failure during preoperative evaluation is important for perioperative management and long-term care. We aimed to quantify preoperative heart failure diagnostic accuracy and explore characteristics of patients with heart failure misdiagnoses.

Methods

We performed an observational cohort study of adults undergoing major noncardiac surgery at an academic hospital between 2015 and 2019. A preoperative clinical diagnosis of heart failure was defined using keywords from the history and clinical examination or administrative documentation. Across stratified subsamples of cases with and without clinically diagnosed heart failure, health records were intensively reviewed by an expert panel to develop an adjudicated heart failure reference standard using diagnostic criteria congruent with consensus guidelines. We calculated agreement among experts, and analysed performance of clinically diagnosed heart failure compared with the adjudicated reference standard.

Results

Across 40 555 major noncardiac procedures, a stratified subsample of 511 patients was reviewed by the expert panel. The prevalence of heart failure was 9.1% based on clinically diagnosed compared with 13.3% (95% confidence interval [CI], 10.3-16.2%) estimated by the expert panel. Overall agreement and inter-rater reliability (kappa) among heart failure experts were 95% and 0.79, respectively. Based upon expert adjudication, heart failure was clinically diagnosed with an accuracy of 92.8% (90.6-95.1%), sensitivity 57.4% (53.1-61.7%), specificity 98.3% (97.1-99.4%), positive predictive value 83.5% (80.3-86.8%), and negative predictive value 93.8% (91.7-95.9%).

Conclusions

Limitations exist to the preoperative clinical diagnosis of heart failure, with nearly half of cases undiagnosed preoperatively. Considering the risks of undiagnosed heart failure, efforts to improve preoperative heart failure diagnoses are warranted.

The Association Between Congestive Heart Failure and One-Year Mortality After Surgery in Singaporean Adults: A Secondary Retrospective Cohort Study Using Propensity-Score Matching, Propensity Adjustment, and Propensity-Based Weighting

Background

Although congestive heart failure (CHF) is considered a risk factor for postoperative mortality, reliable quantification of the relationship between CHF and postoperative mortality risk is limited. We aimed to investigate the association between CHF and 1-year mortality after surgery in a large cohort of the Singaporean population.

Methods

In this retrospective cohort study, the study population included 69,032 adult patients who underwent surgery at Singapore General Hospital between 1 January 2012 and 31 October 2016. The target independent and dependent variables were CHF and 1-year mortality after surgery, respectively. Propensity score was estimated using a non-parsimonious multivariable logistic regression model. Multivariable adjustment, propensity score matching, propensity score adjustment, and propensity score-based weighting Cox proportional-hazards regression were performed to investigate the association between CHF and 1-year mortality after surgery.

Results

The multivariate-adjusted hazard ratio (HR) in the original cohort was 1.39 (95% confidence interval (CI): 1.20–1.61, P < 0.001). In additional propensity score adjustment, the HR between CHF and 1-year mortality after surgery was 1.34 (95% CI: 1.15–1.56, P < 0.001). In the propensity score-matched cohort, the multivariate-adjusted Cox proportional hazard regression model analysis showed participants with CHF had a 54% increased risk of 1-year mortality after surgery (HR 1.54, 95% CI: 1.19–1.98, P < 0.001). The multivariate-adjusted HR of the inverse probability of treatment-weighted and standardised mortality ratio-weighted cohorts was 1.34 (95% CI: 1.10–1.62, P = 0.004) and 1.24 (95% CI: 1.17–1.32, P < 0.001), respectively.

Conclusion

CHF is an independent risk factor for 1-year mortality after surgery in patients undergoing surgery. Depending on the statistical method, patients with CHF had a 24–54% increased risk of 1-year all-cause mortality after surgery. This provides a reference for optimising clinical decision-making, improving preoperative consultation, and promoting clinical communication.

Perioperative Venous Excess Ultrasound Score (VExUS) to Guide Decongestion in a Dilated Cardiomyopathy Patient Presenting for Urgent Surgery

Venous excess ultrasound score (VExUS) is a recently described ultrasound-based scoring system that quantifies systemic congestion using Doppler flow indices of the hepatic and portal vein in addition to inferior vena cava assessment. There are many potential and emerging applications of this modality. We discuss the case of a severely congested heart failure patient presenting for urgent non-cardiac surgery where VExUS parameters were used to monitor and guide his decongestive therapy postoperatively.

Patient Selection for Adult Ambulatory Surgery: A Narrative Review

With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.

Case Report: Successful Cerebral Revascularization and Cardiac Transplant in a 16-Year-Old Male With Syndromic BRCC3-Related Moyamoya Angiopathy

Background:BRCC3/MTCP1 deletions are associated with a rare familial moyamoya angiopathy with extracranial manifestations.

Case: We report the case of an adolescent male presenting with progressive and symptomatic moyamoya angiopathy and severe dilated cardiomyopathy caused by a hemizygous deletion of BRCC3/MTCP1. He was treated for renovascular hypertension by left kidney homograft and right nephrectomy in infancy and had other syndromic features, including cryptorchidism, growth hormone deficiency, and facial dysmorphism. Due to worsening of the neurological and cardiac condition, he was treated by a direct superficial temporal artery to middle cerebral artery bypass to enable successful cardiac transplant without cerebral damage.

Conclusions:BRCC3-related moyamoya is a devastating disease with severe heart and brain complications. This case shows that aggressive management with cerebral revascularization to allow cardiac transplant is feasible and efficient despite end-stage heart failure.

Preoperative Point-of-Care Assessment of Left Ventricular Systolic Dysfunction With Transthoracic Echocardiography

BACKGROUND

Left ventricular (LV) systolic dysfunction is an acknowledged perioperative risk factor and should be identified before surgery. Conventional echocardiographic assessment of LV ejection fraction (LVEF) obtained by biplane LV volumes is the gold standard to detect LV systolic dysfunction. However, this modality needs extensive training and is time consuming. Hence, a feasible point-of-care screening method for this purpose is warranted. The aim of this study was to evaluate 3 point-of-care echocardiographic methods for identification of LV systolic dysfunction in comparison with biplane LVEF.

METHODS

One hundred elective surgical patients, with a mean age of 63 ± 12 years and body mass index of 27 ± 4 kg/m2, were consecutively enrolled in this prospective observational study. Transthoracic echocardiography was conducted 1-2 hours before surgery. LVEF was obtained by automatic two-dimensional (2D) biplane ejection fraction (EF) software. We evaluated if Tissue Doppler Imaging peak systolic myocardial velocities (TDISm), anatomic M-mode E-point septal separation (EPSS), and conventional M-mode mitral annular plane systolic excursion (MAPSE) could discriminate LV systolic dysfunction (LVEF <50%) by calculating accuracy, efficiency, correlation, positive (PPV) respective negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC) for each point-of-care method.

RESULTS

LVEF<50% was identified in 22% (21 of 94) of patients. To discriminate an LVEF <50%, AUROC for TDISm (mean <8 cm/s) was 0.73 (95% confidence interval [CI], 0.62-0.84; P < .001), with a PPV of 47% and an NPV of 90%. EPSS with a cutoff value of >6 mm had an AUROC 0.89 (95% CI, 0.80-0.98; P < .001), with a PPV of 67% and an NPV of 96%. MAPSE (mean <12 mm) had an AUROC 0.80 (95% CI, 0.70-0.90; P < 0.001) with a PPV of 57% and an NPV of 98%.

CONCLUSIONS

All 3 point-of-care methods performed reasonably well to discriminate patients with LVEF <50%. The clinician may choose the most suitable method according to praxis and observer experience.

Pre-operative transthoracic echocardiography in ambulatory surgery-A cross-sectional study

BACKGROUND

Cardiac disease and aberrations in central volume status are risk factors for perioperative complications, and should be identified prior to surgery. This study investigated the benefit of transthoracic echocardiography (TTE) for pre-operative identification of cardiac disease and hypovolemia in ambulatory surgery.

METHODS

Ninety-six patients, with a mean age of 63.5 ± 12.2 years and body mass index of 27.0 ± 4.3 kg/m² , scheduled for ambulatory surgery (breast, thyroid, and minor gastrointestinal), were consecutively enrolled in this prospective observational study. Pre-operative comprehensive TTE was performed in order to assess heart failure (HF), asymptomatic left ventricular dysfunction, valvular disease, and aberrations in central volume status.

RESULTS

Pre-operative TTE identified a total of 28 cases of HF, 13 cases of HF with reduced or moderately reduced, ejection fraction (EF), and 15 cases of HF with preserved EF. Furthermore, 46 cases of asymptomatic left ventricular (LV) dysfunction were identified. 44/96 patients were hypovolemic, 16 of whom in severe hypovolemia. Seven cases of previously unknown obstructive valvular or myocardial disease and six cases of right ventricular systolic dysfunction were identified. A total of 24% (23/96) were classified as potential critical hemodynamic findings. The number needed (NNT) to treat for pre-operative TTE in order to find one critical finding was 4.2.

CONCLUSION

In this ambulatory surgical cohort, a high prevalence of pre-operative LV dysfunction and aberrations in volume status was observed. The results demonstrate that pre-operative TTE contributed valuable hemodynamic information. The standard pre-operative assessment for this cohort might need to be revised.