Sarcopenia in open heart surgery patients: A cohort study

Sarcopenia and adverse surgical outcomes following cholecystectomy

PURPOSE

Postoperative complications and mortality following cholecystectomy persist despite the procedural simplicity. We utilized a nationwide administrative database from Taiwan and conducted propensity score matching (PSM) to investigate the association between sarcopenia and major postoperative complications.

PATIENTS AND METHODS

This retrospective cohort study analyzed data from the Taiwan National Health Insurance Research Database from 2016 to 2020. Patients who underwent elective cholecystectomy under general anesthesia for gallstone disease were included. They were categorized into two groups: those with sarcopenia and those without. The cohorts were matched at a 1:4 ratio using PSM.

RESULTS

PSM yielded a final cohort of 13,330 surgical patients (10,664 without sarcopenia and 2666 with sarcopenia). Multivariate logistic regression demonstrated that sarcopenia was significantly associated with higher 30 day mortality (adjusted odds ratio [aOR] = 2.26, 95% confidence interval [CI] 1.61-3.18) and major complications, including acute renal failure (aOR = 1.71, 95% CI 1.02-2.84), pneumonia (aOR = 1.68, 95% CI 1.22-2.31), stroke (aOR = 1.13, 95% CI 1.06-1.57), and overall complications (aOR = 1.23, 95% CI 1.07-1.41). Sarcopenia also increased the risk of 90-day mortality (aOR = 2.09, 95% CI 1.58-2.76) and 90-day major complications, including acute renal failure (aOR = 1.61, 95% CI 1.01-2.56), pneumonia (aOR = 1.70, 95% CI 1.30-2.21), stroke (aOR = 1.28, 95% CI 1.04-1.58), and overall complications (aOR = 1.24, 95% CI 1.09-1.41).

CONCLUSIONS

We found that sarcopenia is an independent risk factor for increased postoperative complications and mortality following cholecystectomy. These findings highlight the importance of preoperative sarcopenia assessment to improve surgical outcomes.

Sarcopenia is linked to malnutrition among Palestinian patients aged >50 years admitted for elective surgeries, along with associated factors

ObjectiveThis study aimed to evaluate the prevalence of sarcopenia and malnutrition among patients undergoing elective operations and the associated factors.MethodsA cross-sectional study design was used to analyze data collected from 111 participants (60 males and 51 females) aged ≥50 years. The European Working Group on Sarcopenia in Older People criteria were used to define sarcopenia; anthropometric measurements, body composition data, and Mini Nutritional Assessment-Short Form questionnaire responses were used to assess the nutritional status of the participants.ResultsThe prevalence rates of malnutrition and sarcopenia were 34% and 39%, respectively, in the study population. In addition, we found that malnourished patients were more likely to be female, unemployed, diabetic, and dyslipidemic. The study also showed that patients with sarcopenia were more likely to be older and have diabetes.ConclusionsMalnutrition, diagnosed using the Mini Nutritional Assessment-Short Form questionnaire, is associated with sarcopenia, female sex, working condition, diabetes, and dyslipidemia. A significant association was reported between sarcopenia, age, and diabetes.

Association Between SARC-F and Clinical Outcomes in Older Adults With Cardiovascular Diseases Admitted to the Emergency Room: A Longitudinal Study

INTRODUCTION

Sarcopenia can be more significant and severe in the presence of cardiovascular diseases. In hospitalized older adults with acute cardiac disease, assessing strength parameters, muscle mass, and physical performance is difficult largely because of bed rest restrictions. In this context, simple questionnaire to rapidly diagnose sarcopenia (SARC-F) emerges as a feasible screening tool to identify sarcopenia in an emergency room setting.

OBJECTIVES

Assess the association between SARC-F, length of stay, mechanical ventilation, and in-hospital mortality in older adults with cardiovascular diseases admitted to the ER.

METHODOLOGY

An observational longitudinal study with 160 Brazilian older adults with cardiovascular diseases admitted to the hospital following an ER visit. The risk of sarcopenia was assessed by the SARC-F tool (independent variable). Length of stay, use of mechanical ventilation, and in-hospital mortality were the dependent variables, collected via an electronic medical chart. Data were analyzed by simple and multiple linear and logistic regression.

RESULTS

SARC-F explained 62% of length of stay, adjusted for the confounding variables age, male sex, and use of continuous medication, mechanical ventilation, and corticosteroids. Risk of sarcopenia was also associated with mechanical ventilation during hospitalization (odds ratio = 1.398; 95% CI, 1.018-1.919). SARC-F was not related to mortality.

CONCLUSION

Older adults with cardiovascular diseases hospitalized at greater risk of sarcopenia were more likely to need invasive mechanical ventilation and more prone to prolonged hospital stays.

Association of frailty and sarcopenia with short-term mortality in older critically ill patients

BACKGROUND

There is still no study on the use of the SARC-CalF questionnaire for older critically ill patients. Moreover, there is limited evidence on whether a combination of sarcopenia and frailty can provide incremental improvements in risk stratification for older critically ill patients.

METHODS

A total of 653 patients older than 60 years were recruited. We used the clinical frailty scale (CFS) and SARC-CalF questionnaire to assess the frailty status and sarcopenia risk, respectively, of older patients shortly after admission to the ICU. The effect of frailty and sarcopenia risk on ICU mortality and 30-day mortality was evaluated.

RESULTS

A total of 147 (22.5%) patients died in the ICU, and 187 (28.6%) patients died within 30 days after ICU admission. The CFS score was associated with increased ICU mortality [per 1-score increase: odds ratio (OR) = 1.222, 95% confidential interval (CI): 1.003-1.489] and 30-day mortality (per 1-score increase: OR = 1.307, 95% CI: 1.079-1.583). The SARC-CalF score was also associated with increased ICU mortality (per 1-score increase: OR = 1.204, 95% CI: 1.120-1.294) and 30-day mortality (per 1-score increase: OR = 1.247, 95% CI: 1.163-1.337). The addition of the CFS + SARC-CalF score to Acute Physiology and Chronic Health Evaluation (APACHE) II improved discrimination and reclassified ICU and 30-day mortality risk.

CONCLUSIONS

Sarcopenia risk assessed by the SARC-CalF questionnaire provided independent prognostic information for older critically ill patients. A combination of sarcopenia and frailty improved the prediction of mortality for older critically ill patients and thus might be useful in the clinical decision-making process.

Potential of Lycii Radicis Cortex as an Ameliorative Agent for Skeletal Muscle Atrophy

Lycii Radicis Cortex (LRC) is a traditional medicine in East Asia with various beneficial effects, including antioxidant, anti-inflammatory, anti-tumor, anti-diabetic, and anti-depressant properties. However, its potential effects on skeletal muscle atrophy have not been studied. In this study, the protective effects of LRC extract (LRCE) on dexamethasone (DEX)-induced muscle atrophy were investigated in C2C12 myotubes and mice. We evaluated the effect of LRCE on improving muscle atrophy using a variety of methods, including immunofluorescence staining, quantitative polymerase chain reaction (qPCR), Western blot, measurements of oxidative stress, apoptosis, ATP levels, and muscle tissue analysis. The results showed that LRCE improved myotube diameter, fusion index, superoxide dismutase (SOD) activity, mitochondrial content, ATP levels, expression of myogenin and myosin heavy chain (MHC), and reduced reactive oxygen species (ROS) production in dexamethasone-induced C2C12 myotubes. LRCE also enhanced protein synthesis and reduced protein degradation in the myotubes. In mice treated with DEX, LRCE restored calf thickness, decreased mRNA levels of muscle-specific RING finger protein 1 (MuRF1) and atrogin-1, and increased insulin-like growth factor 1 (IGF-1) mRNA level. Moreover, LRCE also repaired gastrocnemius muscle atrophy caused by DEX. Although human studies are not available, various preclinical studies have identified potential protective effects of LRCE against muscle atrophy, suggesting that it could be utilized in the prevention and treatment of muscle atrophy.

Utility of growth differentiation factor-15 as a predictor of cardiovascular surgery outcomes: Current research and future directions

In a world increasingly confronted by cardiovascular diseases (CVDs) and an aging population, accurate risk assessment prior to cardiac surgery is critical. Although effective, traditional risk calculators such as the Japan SCORE, Society of Thoracic Surgeons score, and EuroSCORE II may not completely capture contemporary risks, particularly due to emerging factors such as frailty and sarcopenia. These calculators often focus on regional and ethnic specificity and rely heavily on evaluations based on age and underlying diseases. Growth differentiation factor-15 (GDF-15) is a stress-responsive cytokine that has been identified as a potential biomarker for sarcopenia and a tool for future cardiac risk assessment. Preoperative plasma GDF-15 levels have been associated with preoperative, intraoperative, and postoperative factors and short- and long-term mortality rates in patients undergoing cardiac surgery. Increased plasma GDF-15 levels have prognostic significance, having been correlated with the use of cardiopulmonary bypass during surgery, amount of bleeding, postoperative acute kidney injury, and intensive care unit stay duration. Notably, the inclusion of preoperative levels of GDF-15 in risk stratification models enhances their predictive value, especially when compared with those of the N-terminal prohormone of brain natriuretic peptide, which does not lead to reclassification. Thus, this review examines traditional risk assessments for cardiac surgery and the role of the novel biomarker GDF-15. This study acknowledges that the relationship between patient outcomes and elevated GDF-15 levels is not limited to CVDs or cardiac surgery but can be associated with variable diseases, including diabetes and cancer. Moreover, the normal range of GDF-15 is not well defined. Given its promise for improving patient care and outcomes in cardiovascular surgery, future research should explore the potential of GDF-15 as a biomarker for postoperative outcomes and target therapeutic intervention.

The prevalence and impact of sarcopenia in older cardiac patients undergoing inpatient cardiac rehabilitation - results from a prospective, observational cohort pre-study

BACKGROUND

The prevalence of sarcopenia and its impact in older patients undergoing inpatient cardiac rehabilitation (iCR) after cardiac procedure has been insufficiently studied. The main aim of this study was to evaluate the prevalence of sarcopenia and quantify the functional capacity of older sarcopenic and non-sarcopenic patients participating in iCR.

METHODS

Prospective, observational cohort study within the framework of the ongoing multicenter prehabilitation study "PRECOVERY". A sample of 122 patients ≥75 years undergoing iCR after cardiac procedure were recruited in four German iCR facilities and followed up 3 months later by telephone. At iCR (baseline), the Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls (SARC-F) questionnaire was used to identify sarcopenic patients. In addition, Katz-Index, Clinical Frailty Scale (CFS), handgrip strength (HGS), Short Physical Performance Battery (SPPB) and 6-minute walk distance (6MWD) measured functional capacity and frailty at baseline. Outcomes were prevalence of sarcopenia and the correlation of sarcopenia to functional capacity and frailty at baseline as well as the SARC-F score at follow-up. The Wilcoxon test was applied for pre-post-test analysis. Correlation between sarcopenia and 6MWD, SPPB score and HGS was tested with the eta coefficient with one-way ANOVA.

RESULTS

Complete assessments were collected from 101 patients (79.9 ± 4.0 years; 63% male). At baseline, the mean SARC-F score was 2.7 ± 2.1; 35% with sarcopenia. Other baseline results were Katz-Index 5.7 ± 0.9, CFS 3.2 ± 1.4, HGS 24.9 ± 9.9 kg, SPPB score 7.5 ± 3.3 and 6MWD 288.8 ± 136.5 m. Compared to baseline, fewer patients were sarcopenic (23% versus 35%) at follow-up. In the subgroup of sarcopenic patients at baseline (n = 35), pre-post comparison resulted in a significant SARC-F improvement (p = 0.017). There was a significant correlation between sarcopenia measured by SARC-F and poor results in the assessments of functional capacity (p < 0.001; r > 0.546).

CONCLUSIONS

The prevalence of sarcopenia in older patients at iCR after cardiac procedure is high (35%) and remains high at follow-up (23%). Sarcopenia screening is important since the diagnosis of sarcopenia in these patients correlates significantly with poor functional capacity. The results indicate that these patients may benefit from prehabilitation aimed at improving perioperative outcomes, increasing functional capacity and mitigating adverse effects.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS; http://www.drks.de ; DRKS00032256). Retrospectively registered on 13 July 2023.

Sarcopenia Adversely Affects Outcomes following Cardiac Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Sarcopenia is a degenerative condition characterised by the loss of skeletal muscle mass and strength. Its impact on cardiac surgery outcomes remains poorly investigated. This meta-analysis aims to provide a comprehensive synthesis of the available evidence to determine the effect of sarcopenia on cardiac surgery outcomes.

METHODS

A systematic review and meta-analysis followed PRISMA guidelines from inception to April 2023 in EMBASE, MEDLINE, Cochrane database, and Google Scholar. Twelve studies involving 2717 patients undergoing cardiac surgery were included. Primary outcomes were early and late mortality; secondary outcomes included surgical time, infection rates, and functional outcomes. Statistical analyses were performed using appropriate methods.

RESULTS

Sarcopenic patients (906 patients) had a significantly higher risk of early mortality (OR: 2.40, 95% CI: 1.44 to 3.99, p = 0.0007) and late mortality (OR: 2.65, 95% CI: 1.57 to 4.48, p = 0.0003) compared to non-sarcopenic patients (1811 patients). There were no significant differences in overall surgical time or infection rates. However, sarcopenic patients had longer ICU stays, higher rates of renal dialysis, care home discharge, and longer intubation times.

CONCLUSION

Sarcopenia significantly increases the risk of early and late mortality following cardiac surgery, and sarcopenic patients also experience poorer functional outcomes.

Sarcopenia and Cardiovascular Diseases

Sarcopenia is the loss of muscle strength, mass, and function, which is often exacerbated by chronic comorbidities including cardiovascular diseases, chronic kidney disease, and cancer. Sarcopenia is associated with faster progression of cardiovascular diseases and higher risk of mortality, falls, and reduced quality of life, particularly among older adults. Although the pathophysiologic mechanisms are complex, the broad underlying cause of sarcopenia includes an imbalance between anabolic and catabolic muscle homeostasis with or without neuronal degeneration. The intrinsic molecular mechanisms of aging, chronic illness, malnutrition, and immobility are associated with the development of sarcopenia. Screening and testing for sarcopenia may be particularly important among those with chronic disease states. Early recognition of sarcopenia is important because it can provide an opportunity for interventions to reverse or delay the progression of muscle disorder, which may ultimately impact cardiovascular outcomes. Relying on body mass index is not useful for screening because many patients will have sarcopenic obesity, a particularly important phenotype among older cardiac patients. In this review, we aimed to: (1) provide a definition of sarcopenia within the context of muscle wasting disorders; (2) summarize the associations between sarcopenia and different cardiovascular diseases; (3) highlight an approach for a diagnostic evaluation; (4) discuss management strategies for sarcopenia; and (5) outline key gaps in knowledge with implications for the future of the field.

Prehabilitation in elective patients undergoing cardiac surgery: a randomised control trial (THE PrEPS TRIAL) - a study protocol

INTRODUCTION

Prehabilitation prior to surgery has been shown to reduce postoperative complications, reduce length of hospital stay and improve quality of life after cancer and limb reconstruction surgery. However, there are minimal data on the impact of prehabilitation in patients undergoing cardiac surgery, despite the fact these patients are generally older and have more comorbidities and frailty. This trial will assess the feasibility and impact of a prehabilitation intervention consisting of exercise and inspiratory muscle training on preoperative functional exercise capacity in adult patients awaiting elective cardiac surgery, and determine any impact on clinical outcomes after surgery.

METHODS AND ANALYSIS

PrEPS is a randomised controlled single-centre trial recruiting 180 participants undergoing elective cardiac surgery. Participants will be randomised in a 1:1 ratio to standard presurgical care or standard care plus a prehabilitation intervention. The primary outcome will be change in functional exercise capacity measured as change in the 6 min walk test distance from baseline. Secondary outcomes will evaluate the impact of prehabilitation on preoperative and postoperative outcomes including; respiratory function, health-related quality of life, anxiety and depression, frailty, and postoperative complications and resource use. This trial will evaluate if a prehabilitation intervention can improve preoperative physical function, inspiratory muscle function, frailty and quality of life prior to surgery in elective patients awaiting cardiac surgery, and impact postoperative outcomes.

ETHICS AND DISSEMINATION

A favourable opinion was given by the Sheffield Research Ethics Committee in 2019. Trial findings will be disseminated to patients, clinicians, commissioning groups and through peer-reviewed publication.

TRIAL REGISTRATION NUMBER

ISRCTN13860094.

Impact of Sarcopenia on Outcomes of Minimally Invasive Cardiac Surgery

Sarcopenia is an objective marker of poor outcome following cardiac surgery through median sternotomy. However, the clinical impact of sarcopenia after minimally invasive cardiac surgery (MICS) has not been well established. This study aimed to analyze the influence of sarcopenia on the early and late outcomes following MICS. We retrospectively examined 1248 patients who underwent MICS via right mini-thoracotomy or upper sternotomy between February 2009 and April 2020. Patients older than 65 years who underwent preoperative computed tomography were enrolled. Sarcopenia was defined as the lowest sex-specific quartile of the body surface area adjusted psoas muscle area. The early operative and late survival outcomes were compared, and the predictor of late composite outcome was analyzed using Cox proportional regression model. Early and late composite outcomes in both groups were also compared. A total of 367 patients were classified into the sarcopenia (n = 92) or non-sarcopenia (n = 275) group. Patients in the sarcopenia group were older, and had lower preoperative hemoglobin and albumin levels. They had higher estimated surgical mortality, but similar early mortality and major morbidity. The survival and late composite outcome were comparable between the two groups. Sarcopenia was neither an independent predictor of late death nor a composite outcome in the multivariable model. After MICS, patients with sarcopenia displayed comparable perioperative outcomes and survival. The clinical impact of sarcopenia on postoperative outcomes might be alleviated by MICS and early recovery protocol after MICS. MICS could be a reasonable approach for elderly patients with sarcopenia.

Endothelial Damage and Muscle Wasting in Cardiac Surgery Patients

This is a post-hoc analysis to assess the effect of anesthesia, surgical trauma, and extracorporeal circuit on endothelial integrity, microvascular permeability, and extracellular fluid balance, as well as on skeletal muscle catabolism, in patients undergoing elective cardiac surgery. We included 127 well-nourished patients undergoing "on-pump" elective cardiac surgery. One day prior to surgery (D0) and again on postoperative day 7 (POD7), body mass index, body composition assessment, hand-grip strength (HGS), and mid-upper arm muscle circumference (MAMC) were measured. Patients were assigned to early recovery (ER) and late recovery (LR) groups, depending on the duration of ICU stay (cut-off 48 hours). The magnitude of change (Δ) in all parameters studied was assessed in ER versus LR groups, regarding (i) epithelial tissue dysfunction (Δ-Extra-Cellular Water percentage (Δ-ECW%), Δ-Phase Angle (Δ-PhA)), (ii) skeletal muscle mass catabolism (Δ-Skeletal muscle mass reduction%, Δ-Hand Grip Strength (Δ-HGS) and Δ-Mid Upper-Arm Muscle Circumference (Δ-MAMC)). Baseline measurements were similar in both groups. A significant difference was observed in all Δ-parameters studied (Δ-ECW%, Δ-PhA and muscle catabolism, Δ-HGS, Δ-MAMC), the worse results being correlated to the LR group. The results raise the issue that patients with early recovery may silently have pathological conditions, continuing even on the day of discharge - further research should be planned.

Prevalence and prognostic value of preexisting sarcopenia in patients with mechanical ventilation: a systematic review and meta-analysis

BACKGROUND

Sarcopenia is defined as age-related loss of muscle mass, strength, and/or function in the context of aging. Mechanical ventilation (MV) is one of the most frequently used critical care technologies in critically ill patients. The prevalence of preexisting sarcopenia and the clinical impact of its prognostic value on patients with MV are unclear. This review sought to identify the prevalence and prognostic value of preexisting sarcopenia on MV patient health outcomes.

METHODS

Relevant studies were identified by searching MEDLINE, Embase, and the Cochrane library and were searched for all articles published as of December 2021. The prevalence of sarcopenia was determined using the authors' definitions from the original studies. Comparisons were made between patients who did and did not have sarcopenia for prognostic outcomes, including mortality, the number of days of MV, the length of intensive care unit stay, and the length of hospital stay. Odds ratios (ORs) and weighted mean differences with 95% confidence intervals (CIs) were used for pooled analyses of the relationships between sarcopenia and prognostic outcomes.

RESULTS

The initial search identified 1333 studies, 17 of which met the eligibility criteria for the quantitative analysis, including 3582 patients. The pooled prevalence was 43.0% (95% CI 34.0-51.0%; I2 = 96.7%). The pooled analyses showed that sarcopenia was related to increased mortality (OR 2.13; 95% CI 1.70, 2.67; I2 = 45.0%), longer duration of MV (MD = 1.22; 95% CI 0.39, 2.05; I2 = 97.0%), longer days of ICU stay (MD = 1.31; 95% CI 0.43, 2.19; I2 = 97.0%), and hospital stay (MD 2.73; 95% CI 0.58, 4.88; I2 = 98.0%) in patients with MV.

CONCLUSION

The prevalence of sarcopenia is relatively high in patients with MV, and it will have a negative impact on the prognosis of patients. However, further, large-scale, high-quality prospective cohort studies are required.

Prevalence and Impact of Sarcopenia in Heart Failure: A Cross-Sectional Study

Background:

Abnormal structure and function of cardiac muscles in heart failure (HF) may lead to decreased muscle mass and muscle strength, including low physical performance. This may play an important role in the development of sarcopenia.

Objective:

The objectives of this study were to determine the prevalence of sarcopenia among patients with HF and to explore the association between sarcopenia and HF.

Methods:

A cross-sectional study of 152 patients with HF was conducted in Thammasat University Hospital and Central Chest Institute of Thailand. Sarcopenia was defined according to the Asian Working Group for Sarcopenia. Participants were requested to perform handgrip strength, gait speed, and muscle mass. Logistic regression analysis was used to examine the association between sarcopenia occurrence and HF.

Results:

The prevalence of sarcopenia in patients with HF was 19.8% (14.0% in men and 31.1% in women). Participants with sarcopenia had a significantly lower body mass index (BMI) than those without sarcopenia (p<0.001). In addition, patients with sarcopenia had significantly lower respiratory muscle strength than those without sarcopenia (p<0.01). Sarcopenia was found to be significantly associated with age, sex, BMI, and left ventricular ejection fraction (LVEF) (p<0.05). In addition, age, sex, BMI, and LVEF predicted skeletal muscle mass index (SMI) accounted for 76.8% of the variance.

Conclusion:

The prevalence of sarcopenia among patients with HF was similar to that reported in previous studies. Regarding risk factors, age, sex, BMI, and LVEF were related to sarcopenia in the female sex, advanced age, low BMI, and low LVEF.

Association of phase angle with hospital-acquired functional decline in older patients undergoing cardiovascular surgery

OBJECTIVE

The aim of this study was to examine whether preoperative phase angle (PhA) measured by bioelectrical impedance analysis was associated with a hospital-acquired functional decline in older patients undergoing cardiovascular surgery.

METHODS

This was an observational study of prospectively collected data of 114 patients (>65 y of age) with cardiovascular disease who underwent elective cardiovascular surgery between September 2019 and August 2020. Patients were classified into tertiles based on PhA levels. Factors associated with the occurrence of hospital-acquired functional decline (postoperative recovery to preoperative physical function was not possible) were analyzed using univariate and multivariate analyses.

RESULTS

Patients in the low PhA group were significantly older than those in the middle and high PhA groups; were predominantly women; had higher New York Heart Association cardiovascular and EuroSCORE severity scores; and had significantly lower levels of body mass index, Geriatric Nutritional Risk Index, hemoglobin, and albumin. There was a significant correlation between PhA and nutrition and physical function. The incidence of hospital-acquired functional decline occurred in 26.3% of all patients, with a significantly higher incidence in patients in the low PhA group. Multivariate analysis showed that PhA was extracted as a factor for the hospital-acquired functional decline in all the models.

CONCLUSIONS

PhA was associated with hospital-acquired functional decline in older patients undergoing cardiovascular surgery. PhA is likely to be a comprehensive indicator of physical health that indicates nutritional status, physical function, and geriatric syndrome (frailty/sarcopenia), and is an important predictor of hospital-acquired functional decline in this group of older patients.