Perioperative management of left ventricular diastolic dysfunction and heart failure: an anesthesiologist's perspective

Temporal trends and risk factors of perioperative cardiac events in patients over 80 years old with coronary artery disease undergoing noncardiac surgery: a high-volume single-center experience, 2014-2022

BACKGROUND

Temporal trends and risk factors of perioperative cardiac events (PCEs) in patients over 80 years old with coronary artery disease (CAD) undergoing noncardiac surgery are still unclear.

METHODS

We retrospectively reviewed 1478 patients over 80 years old, with known CAD undergoing selective noncardiac surgery in a single center (2014-2022). Patients were divided into three equal time groups based on the discharge date (2014-2016, 2017-2019, and 2020-2022), with 367, 473, and 638 patients in Groups 1-3, respectively. Perioperative clinical variables were extracted from the electronic medical records database. The primary outcome was the occurrence of PCEs intraoperatively or during hospitalization postoperatively, defined as any of the following events: myocardial infarction, heart failure, nonfatal cardiac arrest, and death.

RESULTS

PCEs occurred in 180 (12.2%) patients. Eight independent risk factors were associated with PCEs, including four clinical factors (body mass index < 22 kg/m2, history of myocardial infarction, history of heart failure, and general anesthesia) and four preoperative laboratory results (hemoglobin < 110 g/L, albumin < 40 g/L, creatinine > 120 μmol/L, and potassium <3.6 mmol/L). Significant rising trends were seen over the 9-year study period in the incidence of PCEs and independent risk factors including history of myocardial infarction, history of heart failure, general anesthesia, preoperative hemoglobin < 110 g/L, preoperative albumin < 40 g/L, and preoperative creatinine > 120 μmol/L (P for trend <0.05).

CONCLUSION

The incidence and independent risk factors of PCEs in patients over 80 years old with CAD undergoing noncardiac surgery showed significant rising trends over the last 9-year period.

Effect of Sevoflurane Anesthesia on Diastolic Function: A Prospective Observational Study

BACKGROUND

The effect of sevoflurane on left ventricular diastolic function is not well understood. We hypothesized that parameters of diastolic function may improve under sevoflurane anesthesia in patients with preexisting diastolic dysfunction compared to patients with normal diastolic function.

METHODS

This observational study included 60 patients undergoing breast surgery or laparoscopic cholecystectomy. Patients were assigned to diastolic dysfunction (n = 34) or normal (n = 26) groups of septal e' < 8 or ≥ 8.0 cm/s on the first thoracic echocardiography (TTE) performed before anesthesia. During anesthesia, sevoflurane was maintained at 1 to 2 minimum alveolar concentration (MAC) to maintain the bispectral index at 40 to 50. At the end of surgery, the second TTE was performed under 0.8 to 1 MAC of sevoflurane with the patient breathing spontaneously without ventilator support. Primary end point was the percentage change (Δ) of e' on 2 TTEs (Δe'). Secondary end points were ΔE/e', Δleft atrial volume index (ΔLAVI), and Δtricuspid regurgitation maximum velocity (ΔTR Vmax). These percentage changes (Δ) were compared between diastolic dysfunction and normal groups.

RESULTS

e' (Δe': 30 [6, 64] vs 0 [-18, 11]%; P < .001), mitral inflow E wave velocity (E), mitral inflow E/A ratio (E/A), and mitral E velocity deceleration time (DT) improved significantly in diastolic dysfunction group compared to normal group. LAVI decreased in diastolic dysfunction group but did not reach statistical significance between the 2 groups (ΔLAVI:-15 [-31, -3] vs -4 [-20, 10]%, P = .091). ΔE/e' was not different between the 2 groups (11 [-16, 26] vs 12 [-9, 22]%, P = .853) (all: median [interquartile range, IQR]). TR was minimal in both groups.

CONCLUSIONS

In this study, echocardiographic parameters of diastolic function, including septal e', E, E/A, and DT, improved with sevoflurane anesthesia in patients with preexisting diastolic dysfunction, but remained unchanged in patients with normal diastolic function.

Introducing a free-breathing MRI method to assess peri-operative myocardial oxygenation and function: A volunteer cohort study

BACKGROUND

Induction of general anaesthesia has many potential triggers for peri-operative myocardial ischaemia including the acute disturbance of blood gases that frequently follows alterations in breathing and ventilation patterns. Free-breathing oxygenation-sensitive cardiovascular magnetic resonance (OS-CMR) imaging may provide the opportunity to continuously quantify the impact of such triggers on myocardial oxygenation.

OBJECTIVE

To investigate the impact of breathing patterns that simulate induction of general anaesthesia on myocardial oxygenation in awake healthy adults using continuous OS-CMR imaging.

DESIGN

Prospective observational study.

SETTING

Single-centre university hospital. Recruitment from August 2020 to January 2022.

PARTICIPANTS

Thirty-two healthy volunteers younger than 45 years old were recruited. Data were analysed from n = 29 (69% male individuals).

INTERVENTION

Participants performed a simulated induction breathing manoeuvre consisting of 2.5 min paced breathing with a respiration rate of 14 breaths per minute, followed by 5 deep breaths, then apnoea for up to 60s inside a magnetic resonance imaging scanner (MRI). Cardiac images were acquired with the traditional OS-CMR sequence (OSbh-cine), which requires apnoea for acquisition and with two free-breathing OS-CMR sequences: a high-resolution single-shot sequence (OSfb-ss) and a real-time cine sequence (OSfb-rtcine).

MAIN OUTCOME MEASURES

Myocardial oxygenation response at the end of the paced breathing period and at the 30 s timepoint during the subsequent apnoea, reflecting the time of successful intubation in a clinical setting.

RESULTS

The paced breathing followed by five deep breaths significantly reduced myocardial oxygenation, which was observed with all three techniques (OSbh-cine -6.0 ± 2.6%, OSfb-ss -12.0 ± 5.9%, OSfb-rtcine -5.4 ± 7.0%, all P < 0.05). The subsequent vasodilating stimulus of apnoea then significantly increased myocardial oxygenation (OSbh-cine 6.8 ± 3.1%, OSfb-ss 8.4 ± 5.6%, OSfb-rtcine 15.7 ± 10.0%, all P < 0.01). The free-breathing sequences were reproducible and were not inferior to the original sequence for any stage.

CONCLUSION

Breathing manoeuvres simulating induction of general anaesthesia cause dynamic alterations of myocardial oxygenation in young volunteers, which can be quantified continuously with free-breathing OS-CMR. Introducing these new imaging techniques into peri-operative studies may throw new light into the mechanisms of peri-operative perturbations of myocardial tissue oxygenation and ischaemia.

VISUALABSTRACT

http://links.lww.com/EJA/A922.

Laparoscopic versus Open Inguinal Hernia Repair in Aging Patients: A Propensity Score Matching-Based Retrospective Study

Objective

Although laparoscopic repair has been widely carried out and promoted due to its minimally invasive advantages, open surgery is still popular compared to elderly patients. This study aims to compare the outcomes of laparoscopic (LIHR) vs open repair of inguinal hernias (OIHR) in elderly patients.

Methods

A retrospective analysis of the database was performed to identify elderly patients, from January 2021 through December 2022, who underwent surgery for an inguinal hernia. After a 1:1 propensity score matching (PSM) with a caliper of 0.1 was conducted to balance potential bias, binary logistic regressions were used for categorical and continuous outcomes.

Results

After PSM, 78 pairs of elderly patients were enrolled in this study, and there were no significant differences in baseline between LIHR and OIHR groups. Compared to OIHR, univariable and multivariable logistic regression analysis showed that LIHR was independently affected for reducing intraoperative hemorrhage (OR = 0.06, 95% CI: 0.02-0.18, P < 0.001) and shortening postoperative hospitalization time (OR = 0.29, 95% CI: 0.15-0.57, P < 0.001) in elderly patients. Furthermore, LIHR (OR = 0.28, 95% CI: 0.14-0.57, P < 0.001) and age (OR = 0.89, 95% CI: 0.82-0.96, P = 0.002) were independent affecting factors for relieving postoperative pain. Meanwhile, no obvious differences were detected in postoperative complications [LIHR 7.7% (6/78) vs OIHR 14.1% (11/78), P = 0.199].

Conclusion

LIHR was closely associated with reducing intraoperative hemorrhage and shortening postoperative hospitalization time. Whilst LIHR and age were independently affecting factors for relieving postoperative pain.

The effect of physical activity level on the severity of diastolic dysfunction

BACKGROUND

Diastolic dysfunction (DD) is a risk factor for cardiovascular events in patients undergoing non-cardiac surgeries. Investigators aimed to assess the effect of physical activity level on the diastolic function of the left ventricle (LV) in patients attending the preoperative visit.

METHODS

This analytic cross-sectional study was conducted on 228 patients referred to Poursina hospital from November 2021 to March 2022. To define the physical activity level, we used the short form of the International Physical Activity Questionnaire (IPAQ). We categorized patients into inactive, minimally active, and health-enhancing physical activity groups. We also divided participants into three groups based on their daily sitting time. Also, echocardiographic parameters were calculated. The diastolic function of LV was evaluated, and its grading was defined from mild (grade1) to severe (grade 3).

RESULTS

Results showed that patients with DD had significantly higher age and lower levels of education (P < 0.001 and P = 0.005, respectively). After assessing echocardiographic parameters, we found that E/e', TR Velocity, left atrial volume index, and pulmonary artery pressure had a statistically significant inverse relationship with physical activity level (P < 0.001 for all). Comparing physical activity level of subgroups showed that in HEPA (health-enhancing physical activity), the chance of developing grade 2 or 3 DD was reduced by 97% compared to the inactive group (OR = 0.03, P < 0.001). Still, there was no significant difference between the inactive and minimally active groups (P = 0.223).

CONCLUSIONS

This study showed an inverse relationship between physical activity level and DD of the LV in a sample of 228 individuals attending the Anesthesia Clinic, independent of potentially confounding variables.Therefore, due to lower rate of DD in patients who are physically active, we can expect lower occurrence rate of cardiovascular events during surgery.

Association between intraoperative pulmonary artery pressure and cardiovascular complications after off-pump coronary artery bypass surgery: a single-center observational study

BACKGROUND

The impact of intraoperative pulmonary hemodynamics on prognosis after off-pump coronary artery bypass (OPCAB) surgery remains unknown. In this study, we examined the association between intraoperative vital signs and the development of major adverse cardiovascular events (MACE) during hospitalization or within 30 days postoperatively.

METHODS

This retrospective study analyzed data from a university hospital. The study cohort comprised consecutive patients who underwent isolated OPCAB surgery between November 2013 and July 2021. We calculated the mean and coefficient of variation of vital signs obtained from the intra-arterial catheter, pulmonary artery catheter, and pulse oximeter. The optimal cut-off was defined as the receiver operating characteristic curve (ROC) with the largest Youden index (Youden index = sensitivity + specificity - 1). Multivariate logistic regression analysis ROC curves were used to adjust all baseline characteristics that yielded P values of < 0.05.

RESULTS

In total, 508 patients who underwent OPCAB surgery were analyzed. The mean patient age was 70.0 ± 9.7 years, and 399 (79%) were male. There were no patients with confirmed or suspected preoperative pulmonary hypertension. Postoperative MACE occurred in 32 patients (heart failure in 16, ischemic stroke in 16). The mean pulmonary artery pressure (PAP) was significantly higher in patients with than without MACE (19.3 ± 3.0 vs. 16.7 ± 3.4 mmHg, respectively; absolute difference, 2.6 mmHg; 95% confidence interval, 1.5 to 3.8). The area under the ROC curve of PAP for the prediction of MACE was 0.726 (95% confidence interval, 0.645 to 0.808). The optimal mean PAP cut-off was 18.8 mmHg, with a specificity of 75.8% and sensitivity of 62.5% for predicting MACE. After multivariate adjustments, high PAP remained an independent risk factor for MACE.

CONCLUSIONS

Our findings provide the first evidence that intraoperative borderline pulmonary hypertension may affect the prognosis of patients undergoing OPCAB surgery. Future large-scale prospective studies are needed to verify the present findings.

Selected Transesophageal Echocardiographic Parameters of Left Ventricular Diastolic Function Predict Length of Stay Following Coronary Artery Bypass Graft-A Prospective Observational Study

(1) Importance: Abnormal left ventricular (LV) diastolic function, with or without a diagnosis of heart failure, is a common finding that can be easily diagnosed by intra-operative transesophageal echocardiography (TEE). The association of diastolic function with duration of hospital stay after coronary artery bypass (CAB) is unknown. (2) Objective: To determine if selected TEE parameters of diastolic dysfunction are associated with length of hospital stay after coronary artery bypass surgery (CAB). (3) Design: Prospective observational study. (4) Setting: A single tertiary academic medical center. (5) Participants: Patients with normal systolic function undergoing isolated CAB from September 2017 through June 2018. (6) Exposures: LV function during diastole, as assessed by intra-operative TEE prior to coronary revascularization. (7) Main Outcomes and Measures: The primary outcome was duration of postoperative hospital stay. Secondary intermediate outcomes included common postoperative cardiac, respiratory, and renal complications. (8) Results: The study included 176 participants (mean age 65.2 ± 9.2 years, 73% male); 105 (60.2%) had LV diastolic dysfunction based on selected TEE parameters. Median time to hospital discharge was significantly longer for subjects with selected parameters of diastolic dysfunction (9.1/IQR 6.6−13.5 days) than those with normal LV diastolic function (6.5/IAR 5.3−9.7 days) (p < 0.001). The probability of hospital discharge was 34% lower (HR 0.66/95% CI 0.47−0.93) for subjects with diastolic dysfunction based on selected TEE parameters, independent of potential confounders, including a baseline diagnosis of heart failure. There was a dose−response relation between severity of diastolic dysfunction and probability of discharge. LV diastolic dysfunction based on those selected TEE parameters was also associated with postoperative cardio-respiratory complications; however, these complications did not fully account for the relation between LV diastolic dysfunction and prolonged length of hospital stay. (9) Conclusions and Relevance: In patients with normal systolic function undergoing CAB, diastolic dysfunction based on selected TEE parameters is associated with prolonged duration of postoperative hospital stay. This association cannot be explained by baseline comorbidities or common post-operative complications. The diagnosis of diastolic dysfunction can be made by TEE.

Secondary left heart failure occurred during VA-ECMO assistance for severe residual pulmonary hypertension after pulmonary endarterectomy: a case report

Background

In patients of chronic thromboembolic pulmonary hypertension undergoing pulmonary endarterectomy, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides full haemodynamic support. However, during a rescue treatment of VA-ECMO for patients with difficulty weaning from cardiopulmonary bypass, a significantly increase left ventricular afterload through retrograde infusion of arterialized blood into the descending aorta may occur.

Case presentation

We report a 70-year-old man who suffered severe residual pulmonary hypertension following pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Preoperative echocardiogram showed a dilated and poorly functioning right ventricle, as well as a small left heart with normal function (TAPES9.6 mm, LVEF64%, average E/E′11.94, lateral E′12.1 cm/s, tricuspid regurgitation velocity 2.5 m/s), while postoperative echocardiography revealed a significant decrease of whole ventricular function on postoperative day 1(TAPES4mm, LVEF28%, average E/E′15, lateral E′6.7 cm/s, tricuspid regurgitation velocity 4.1 m/s), indicating the patient developed severe secondary left ventricular dysfunction on the basis of right ventricular dysfunction, during VA-ECMO support. Then comprehensive measures were adopted, such as down-regulating VA-ECMO flow rate, adjusting respiratory parameters, using vasoactive drugs, as well as prostacyclin. Eventually, the pulmonary hypertension decreased to moderate degree, and the heart function improved gradually.

Conclusions

In the face of severe residual pulmonary hypertension and sencondary left ventricular dysfunction associated with VA-ECMO, comprehensive measures described above may facilitate recovery. ECMO flow titration to maintain relatively low flow rate is very important to not only maintain systemic perfusion, but also reduce left ventricular afterload and ensure pulsatile perfusion of pulmonary artery.

The effect of different anaesthetics on echocardiographic evaluation of diastolic dysfunction in a heart failure with preserved ejection fraction model

Heart failure with preserved ejection fraction (HFpEF) is currently untreated. Therapeutics development demands effective diagnosis of diastolic dysfunction in animal models mimicking human pathology, which requires appropriate anaesthetics. Here, we investigated which anaesthetic, ketamine/xylazine or isoflurane, could be used to reveal diastolic dysfunction in HFpEF-diseased obese ZSF1 rats by echocardiography. First, diastolic dysfunction was confirmed by pressure-volume loops in obese compared to lean control ZSF1 rats. In echocardiography, ketamine/xylazine, unlike isoflurane, was able to demonstrate impaired relaxation in obese ZSF1 rats, as reflected by impaired early (E) and late (A) filling peak velocities, decreased E/A ratio, and a prolonged deceleration and isovolumic relaxation time. Interestingly, ketamine/xylazine induced a wider separation of both tissue and pulsed wave Doppler-derived echocardiographic waves required for diastolic dysfunction diagnosis, potentially by reducing the heart rate (HR), while isoflurane resulted in merged waves. To assess whether HR-lowering alone explained the differences between the anaesthetics, echocardiography measurements under isoflurane with and without the HR-lowering drug ivabradine were compared. However, diastolic dysfunction could not be diagnosed in ivabradine-treated obese ZSF1 rats. In summary, ketamine/xylazine compared to isoflurane is the anaesthetic of choice to detect diastolic dysfunction by echocardiography in rodent HFpEF, which was only partly mediated by HR-lowering.

Perioperative Cardiac Complications in Patients Over 80 Years of Age with Coronary Artery Disease Undergoing Noncardiac Surgery: The Incidence and Risk Factors

Purpose

Ever-increasing noncardiac surgeries are performed in patients aged 80 years or over with coronary artery disease (CAD). The objective of the study was to explore the incidence and risk factors of perioperative cardiac complications (PCCs) for the oldest-old patients with CAD undergoing noncardiac surgery, which have not been evaluated previously.

Patients and Methods

A total of 547 patients, aged over 80 years, with a history of CAD who underwent noncardiac surgery were enrolled in this retrospective study. Perioperative clinical variables were extracted from the electronic medical records database. The primary outcome was the occurrence of PCCs intraoperatively or within 30 days postoperatively, defined as any of the following complications: acute coronary syndrome, heart failure, new-onset severe arrhythmia, nonfatal cardiac arrest, and cardiac death. Multivariate logistic regression analysis and multivariate Cox regression model were both performed to estimate the risk factors of PCCs. The incidence of PCCs overtime was illustrated by the Kaplan-Meier curve with a stratified Log-rank test.

Results

One hundred six (19.4%) patients developed at least one PCC, and 15 (2.7%) patients developed cardiac death. The independent risk factors contributing to PCCs were age ≧85 years; body mass index ≧30 kg/m²; the history of angina within 6 months; metabolic equivalents <4; hypertension without regular treatment; preoperative ST-T segment abnormality; anesthesia time >3 h and drainage ≧200 mL within 24 h postoperatively.

Conclusion

The incidence of PCCs in elderly patients over 80 years with CAD who underwent noncardiac surgery was high. Comprehensive preoperative evaluation, skilled surgical technique, and regular postoperative monitoring may help to reduce the occurrence of PCCs in this high-risk population.

Effect of Heart Failure With Preserved Ejection Fraction on Perioperative Outcomes in Patients Undergoing Hip Fracture Surgery

INTRODUCTION

Heart failure is a leading cause of morbidity and mortality in hip fracture surgery. The impact of heart failure with preserved ejection fraction (HFpEF) is poorly understood in this population. We designed a study to evaluate national perioperative outcomes in hip fracture for patients with HFpEF.

METHODS

Patients with hip fracture undergoing total hip arthroplasty, hemiarthroplasty, or open/closed reduction with internal and external fixation from January 2005 to December 2013 were identified using the Nationwide Inpatient Sample. Inpatient outcomes during the index hospitalization were compared between patients without heart failure and with HFpEF. Heart failure with reduced ejection fraction was included as a secondary comparator. Perioperative major adverse cardiovascular and cerebrovascular events (MACCEs), defined as in-hospital all-cause death, acute myocardial infarction, and in-hospital cardiac arrest or acute ischemic stroke, were evaluated.

RESULTS

Among 2,020,712 hospitalizations for hip fracture surgery, perioperative MACCE occurred in 67,554 hospitalizations (3.3%), corresponding to an annual incidence of approximately 7,506 events after applying sample weights. Compared with patients without heart failure, patients with HFpEF experienced increased odds of MACCE, adjusted odds ratio [aOR], 1.69; 95% confidence interval (CI), 1.51 to 1.89. In comparison, the aOR of experiencing a MACCE event in the heart failure with reduced ejection fraction group was 1.75 (95% CI, 1.57 to 1.96). HFpEF was also associated with increased odds of acute respiratory failure (aOR, 1.71; 95% CI, 1.53 to 1.91) and acute renal failure (aOR, 1.52; 95% CI, 1.41 to 1.64).

CONCLUSION

HFpEF confers a significant perioperative risk of MACCE in patients undergoing hip fracture surgery.

The Impact of Perioperative Factors on Changes in Diastolic Function after Kidney Transplantation: A Retrospective Analysis

PURPOSE

Cardiac changes in end-stage renal disease are the most common causes of death after kidney transplantation (KT). Chronic kidney disease presents a major risk factor for the development and progression of diastolic dysfunction. The purpose of this study was to identify the association between changes in left ventricular (LV) diastolic function and perioperative clinical factors in patients with preserved ejection fraction following KT.

MATERIALS AND METHODS

We reviewed 115 patients who underwent KT between January 2011 and December 2015 with both preand post-transplant echocardiograms; patients with LV systolic dysfunction were excluded. LV diastolic function was measured using the ratio of early transmitral flow velocity to early diastolic velocity of the mitral annulus (E/e').

RESULTS

Patients with normal pre-operative LV systolic function (n=97) showed improvement in E/e' after KT (11.9±4.4 to 10.5±3.8, p=0.023). Additionally, post-KT estimated glomerular filtration ratio was associated with changes in E/e' (odds ratio, -0.056; 95% confidence interval, -0.014 to -0.007; p=0.026). Among patients with preexisting diastolic dysfunction (20/97 patients), the amount of intraoperative fluid administration was related to E/e' changes (odds ratio, 0.003; 95% confidence interval, 0.000 to 0.005; p=0.029).

CONCLUSION

KT is associated with improved diastolic function. Post-KT renal function was significantly related to changes in LV diastolic function. The amount of intraoperative fluid was a risk factor for worsening diastolic function after KT in patients with preexisting diastolic dysfunction.

Preoperative cardiac evaluation with transthoracic echocardiography before non-cardiac surgery

Transthoracic echocardiography has become increasingly popular in clinical practice. It is used for the functional evaluation of patients with various cardiovascular diseases. Its use has been extended further in routine screening for cardiovascular health and in preoperative risk assessment before non-cardiac surgery because it is non-invasive, easy to perform, reproducible, and cost-effective. When the results of preoperative echocardiography contain abnormalities, the findings must be interpreted to determine clinical relevance. However, when the results of preoperative echocardiography are apparently normal, many physicians and surgeons readily think that the patient will not have any cardiovascular events in the future, or at least in the perioperative period. In this review, we will cover 1) current guidelines for preoperative echocardiographic assessment, 2) specific cardiac conditions for which the non-cardiac surgery should be delayed, 3) commonly encountered echocardiographic findings before non-cardiac surgeries, 4) application of stress echocardiography, and 5) clinical perspectives of focused transthoracic echocardiography before non-cardiac surgery.