Association of prior metabolic and bariatric surgery with severity of coronavirus disease 2019 (COVID-19) in patients with obesity

BackgroundObesity is a risk factor for poor clinical outcomes in patients with coronavirus disease 2019 (COVID-19).ObjectivesTo investigate the relationship between prior metabolic surgery and the severity of COVID-19 in patients with severe obesity.SettingCleveland Clinic Health System in the United States.MethodsAmong 4365 patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between March 8, 2020 and July 22, 2020 in the Cleveland Clinic Health System, 33 patients were identified who had a prior history of metabolic surgery. The surgical patients were propensity matched 1:10 to nonsurgical patients to assemble a cohort of control patients (n = 330) with a body mass index (BMI) ≥ 40 kg/m² at the time of SARS-CoV-2 testing. The primary endpoint was the rate of hospital admission. The exploratory endpoints included admission to the intensive care unit (ICU), need for mechanical ventilation and dialysis during index hospitalization, and mortality. After propensity score matching, outcomes were compared in univariate and multivariate regression models.ResultsThe average BMI of the surgical group was 49.1 ± 8.8 kg/m² before metabolic surgery and was down to 37.2 ± 7.1 at the time of SARS-CoV-2 testing, compared with the control group’s BMI of 46.7 ± 6.4 kg/m². In the univariate analysis, 6 (18.2%) patients in the metabolic surgery group and 139 (42.1%) patients in the control group were admitted to the hospital (P = .013). In the multivariate analysis, a prior history of metabolic surgery was associated with a lower hospital admission rate compared with control patients with obesity (odds ratio, 0.31; 95% confidence interval, 0.11?0.88; P = .028). While none of the 4 exploratory outcomes occurred in the metabolic surgery group, 43 (13.0%) patients in the control group required ICU admission (P = .021), 22 (6.7%) required mechanical ventilation, 5 (1.5%) required dialysis, and 8 (2.4%) patients died.ConclusionPrior metabolic surgery with subsequent weight loss and improvement of metabolic abnormalities was associated with lower rates of hospital and ICU admission in patients with obesity who became infected with SARS-CoV-2. Confirmation of these findings will require larger studies.     

Perioperative- and long-term mortality rates after major vascular surgery: the relationship to preoperative testing in the medicare population.

Debate continues regarding the value of cardiovascular testing and coronary revascularization before major vascular surgery. Whereas recent guidelines have advocated selective preoperative testing, several authors have suggested that it is no longer necessary in an era of low perioperative cardiac morbidity and mortality. We used data from a random sample of Medicare beneficiaries to determine the mortality rate after vascular surgery, based on the use of preoperative cardiac testing. A 5% nationally random sample of the aged Medicare population for the final 6 mo of 1991 and first 11 mo of 1992 was used to identify a cohort of patients who underwent elective infrainguinal or abdominal aortic reconstructive surgery. Use within the first 6 mo of 1991 was reviewed to determine if preoperative noninvasive cardiovascular imaging or coronary revascularization was performed. Thirty-day (perioperative) and 1-yr mortalities were assessed. Perioperative mortality was significantly increased for aortic surgery (209 of 2865 or 7.3%), compared with infrainguinal surgery (232 of 4030 or 5.8%); however, 1-yr mortality was significantly increased for infrainguinal surgery (16.3% vs 11.3%, P < 0.05). Stress testing, with or without coronary revascularization, was associated with improved short-and long-term survival in aortic surgery. The use of stress testing with coronary revascularization was not associated with reduced perioperative mortality after infrainguinal surgery. Stress testing alone was associated with reduced long-term mortality in patients undergoing infrainguinal revascularization. IMPLICATIONS: Analysis of the Medicare Claims database suggests that vascular surgery is associated with substantial perioperative and long-term mortality. The reduced long-term mortality in patients who had previously undergone preoperative testing and coronary revascularization reinforces the need for a prospective evaluation of these practices.     

Guidelines for Cardiac Management in Noncardiac Surgery Are Poorly Implemented in Clinical Practice: Results from a Peripheral Vascular Survey in The Netherlands

Background: The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery recommend an algorithm for a stepwise approach to preoperative cardiac assessment in vascular surgery patients. The authors' main objective was to determine adherence to the ACC/AHA guidelines on perioperative care in daily clinical practice.

Methods: Between May and December 2004, data on 711 consecutive peripheral vascular surgery patients were collected from 11 hospitals in The Netherlands. This survey was conducted within the infrastructure of the Euro Heart Survey Programme. The authors retrospectively applied the ACC/AHA guideline algorithm to each patient in their data set and subsequently compared observed clinical practice data with these recommendations.

Results: Although 185 of the total 711 patients (26%) fulfilled the ACC/AHA guideline criteria to recommend preoperative noninvasive cardiac testing, clinicians had performed testing in only 38 of those cases (21%). Conversely, of the 526 patients for whom noninvasive testing was not recommended, guidelines were followed in 467 patients (89%). Overall, patients who had not been tested, irrespective of guideline recommendation, received less cardioprotective medications, whereas patients who underwent noninvasive testing were significantly more often treated with cardiovascular drugs ([beta]-blockers 43% vs. 77%, statins 52% vs. 83%, platelet inhibitors 80% vs. 85%, respectively; all P < 0.05). Moreover, the authors did not observe significant differences in cardiovascular medical therapy between patients with a normal test result and patients with an abnormal test result.     

Incremental risk of obstructive sleep apnea on cardiac surgical outcomes

AIM: Obstructive sleep apnea (OSA) is not generally acknowledged as a perioperative risk factor. High incidence of Sleep disordered breathing has been noticed in patients with cardiovascular disease. The Sleep Heart Health Research Study Group found Apnea-Hypopnea indices (AHI) as modest as 1-10 to be associated with cardiovascular disease manifestations. Given the lack of data we chose to study the incremental risk of OSA in patients undergoing cardiac surgery. METHODS: We looked at 25 587 patients who underwent cardiac surgery at the Cleveland Clinic. Of these, 37 patients were also identified on the Cleveland Clinic Sleep center database as having OSA. Each of these 37 cases were propensity matched for multiple covariates with 5 controls within a distance of 0.001 units. An assumption was made that if the surgery was performed within two years of the diagnosis of OSA, the patient had OSA at the time of the surgery. RESULTS: Higher incidence of encephalopathy (p=0.008), postoperative infection (0.028) and increased ICU length of stay (p=0.031) were noted in the group with OSA after cardiac surgery. The difference in the rates of infection was mostly accounted for by the presence of mediastinitis (8.1% vs 1.6%). Differences in the rates of reintubation, tube time, and overall postoperative morbidity were not statistically significant. CONCLUSIONS:| Increased risk for postoperative complications is suggested in patients with OSA undergoing cardiac surgery. This risk is underestimated on account of lack of awareness about the incidence of OSA in the general population and the cardiovascular population in particular, difficulties in clinical suspicion and diagnosis and limited use of polysomnography.     

Preoperative cardiac risk assessment: an updated approach.

HYPOTHESIS: We provide an updated algorithm for approaching preoperative cardiac risk assessment in patients undergoing noncardiac surgery. DESIGN: A National Library of Medicine PubMed literature search was performed dating back to 1985 using the keywords "preoperative cardiac risk for noncardiac surgery." This search was restricted to English language articles involving human subjects. RESULTS: Patient-specific and operation-specific cardiac risk can be determined clinically. Patients with major cardiac risk factors have a high incidence of perioperative cardiac complications, whereas the risk is less than 3% for low-risk patients. For intermediate-risk patients, no prospective randomized studies demonstrate the efficacy of noninvasive stress testing (dipyridamole thallium or dobutamine echocardiography) or of subsequent coronary revascularization for preventing perioperative cardiac complications. Recent studies demonstrate that perioperative beta-blockade significantly reduces the adverse cardiac event rate in intermediate-risk patients. CONCLUSIONS: Most patients with high cardiac risk should proceed with coronary angiography. Patients with low cardiac risk can proceed to surgery without noninvasive testing. For intermediate-risk patients, consideration may be given to further stress testing prior to surgery; however, in most patients, proceeding to surgery with perioperative beta-blockade is an acceptable alternative.     

Coronary events in patients undergoing orthotopic liver transplantation: perioperative evaluation and management

Patients with advanced liver disease have a high prevalence of cardiac risk factors. The stress of liver transplant surgery predisposes these patients to major cardiac events, such as myocardial infarction or ventricular arrhythmias in addition to heart failure exacerbation. Liver transplant patients who experience coronary events in the perioperative period have a decreased five‐yr survival rate. Cardiovascular risk stratification prior to liver transplant can be accomplished by dobutamine stress echocardiography, stress myocardial perfusion imaging, cardiac computed tomography, and coronary angiography. Pre‐liver transplant management of cardiovascular pathology includes cardiovascular intervention like percutaneous coronary intervention, coronary bypass graft surgery, or medical management. Thorough screening and optimal management of underlying cardiovascular pathology and cardiovascular risk factors should decrease the incidence of new cardiac events in liver transplant recipients.     

Guidelines for cardiac management in noncardiac surgery are poorly implemented in clinical practice: results from a peripheral vascular survey in the Netherlands

BACKGROUND: The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery recommend an algorithm for a stepwise approach to preoperative cardiac assessment in vascular surgery patients. The authors' main objective was to determine adherence to the ACC/AHA guidelines on perioperative care in daily clinical practice. METHODS: Between May and December 2004, data on 711 consecutive peripheral vascular surgery patients were collected from 11 hospitals in The Netherlands. This survey was conducted within the infrastructure of the Euro Heart Survey Programme. The authors retrospectively applied the ACC/AHA guideline algorithm to each patient in their data set and subsequently compared observed clinical practice data with these recommendations. RESULTS: Although 185 of the total 711 patients (26%) fulfilled the ACC/AHA guideline criteria to recommend preoperative noninvasive cardiac testing, clinicians had performed testing in only 38 of those cases (21%). Conversely, of the 526 patients for whom noninvasive testing was not recommended, guidelines were followed in 467 patients (89%). Overall, patients who had not been tested, irrespective of guideline recommendation, received less cardioprotective medications, whereas patients who underwent noninvasive testing were significantly more often treated with cardiovascular drugs (beta-blockers 43% vs. 77%, statins 52% vs. 83%, platelet inhibitors 80% vs. 85%, respectively; all P < 0.05). Moreover, the authors did not observe significant differences in cardiovascular medical therapy between patients with a normal test result and patients with an abnormal test result. CONCLUSION: This survey showed poor agreement between ACC/AHA guideline recommendations and daily clinical practice. Only one of each five patients underwent noninvasive testing when recommended. Furthermore, patients who had not undergone testing despite recommendations received as little cardiac management as the low-risk population.     

Strategies in the high-risk cardiac patient undergoing non-cardiac surgery

The risk of perioperative myocardial infarction or cardiac death in patients undergoing non-cardiac surgery may be estimated by clinical risk factor analysis and by myocardial stress testing. While stress testing modalities accurately delineate reversible myocardial ischaemia, their positive predictive value is low, and it is not clear whether their implementation improves outcome when compared to risk stratification alone. Similarly, it remains to be shown that preoperative coronary revascularization is an effective strategy in reducing perioperative risk. Recent reports indicate that surgery undertaken in the first weeks after percutaneous coronary interventions may be associated with a significantly increased rate of major complications. Administration of β-blockers and α₂-adrenergic agonists to high-risk patients reduces surgical morbidity and mortality, and the benefits observed with β-blockers may extend long after the operative period. In high-risk patients undergoing major surgery, pulmonary artery catheter-guided haemodynamic optimization has not been associated with better outcomes, whereas use of regional anesthetic techniques decreases the incidence of postoperative pulmonary, but not cardiac, complications.     

Evaluation and treatment of patients with cardiac disease undergoing bariatric surgery

BackgroundBariatric surgery is a proven tool in reducing the co-morbidities associated with morbid obesity. The aim of the present review was to assess the current data and discuss the strategies for preoperative evaluation, preoperative treatment, and intraoperative management of the obese patient with cardiac disease seeking bariatric surgery, including those who have undergone previous angiographic intervention with coronary stenting and/or antiplatelet therapy. The setting was a university hospital in the United States.MethodsA search of the English-language reports using the keywords morbid obesity, bariatric surgery, perioperative risk assessment, coronary artery disease, coronary stents, and antiplatelet therapy was conducted.ResultsThe methods of preoperative cardiac risk assessment found in the published studies included the use of certain criteria, stress echocardiography, and single-photon emission computed tomography. Preoperative medical treatment optimization with β-blockers and statins is recommended. Perioperative antiplatelet therapy in the form of aspirin 81 mg can be safely continued, but clopidogrel should be stopped and reinitiated with caution.ConclusionPreoperative assessment of morbidly obese patients with coexisting cardiac issues presents unique challenges. Safe patient care and good clinical outcomes can be achieved with adherence to evidence-based practice.     

A new model to predict acute kidney injury after cardiac surgery in patients with renal insufficiency

ObjectiveTo establish a simple model for predicting postoperative acute kidney injury (AKI) requiring renal replacement therapy (RRT) in patients with renal insufficiency (CKD stages 3–4) who underwent cardiac surgery.MethodsA total of 330 patients were enrolled. Among them, 226 were randomly selected for the development group and the remaining 104 for the validation group. The primary outcome was AKI requiring RRT. A nomogram was constructed based on the multivariate analysis with variables selected by the application of the least absolute shrinkage and selection operator. Meanwhile, the discrimination, calibration, and clinical power of the new model were assessed and compared with those of the Cleveland Clinic score and Simplified Renal Index (SRI) score in the validation group. Results: The rate of RRT in the development group was 10.6% (n = 24), while the rate in the validation group was 14.4% (n = 15). The new model included four variables such as postoperative creatinine, aortic cross‐clamping time, emergency, and preoperative cystatin C, with a C-index of 0.851 (95% CI, 0.779–0.924). In the validation group, the areas under the receiver operating characteristic curves for the new model, SRI score, and Cleveland Clinic score were 0.813, 0.791, and 0.786, respectively. Furthermore, the new model demonstrated greater clinical net benefits compared with the Cleveland Clinic score or SRI score.ConclusionsWe developed and validated a powerful predictive model for predicting severe AKI after cardiac surgery in patients with renal insufficiency, which would be helpful to assess the risk for severe AKI requiring RRT.     

Transthoracic Dobutamine Stress Echocardiography in Patients Undergoing Bariatric Surgery

BACKGROUND: The feasibility and value of transthoracic dobutamine stress echocardiography (DSE) in patients scheduled for bariatric surgery has not been investigated. METHODS: We evaluated 611 patients (86.6% female, 42 +/- 10 years, 136 +/- 18 kg, BMI 48.0 +/- 6.1 kg/m2) referred for DSE prior to surgery between February 2000 and July 2005. Mortality and major cardiovascular events (cardiac death, acute coronary syndrome, and urgent revascularization) were recorded 30-days postoperatively and at 6 months. RESULTS: Adequate baseline imaging quality was achieved in 590 patients (96.6%), with use of echocardiographic contrast agents in 426 patients (72.2%); the remaining 21 patients (3.4%) were referred for alternative preoperative testing. There were no serious adverse events during DSE, which was negative in 545 patients (92.4%). The test was inconclusive in 38 patients (6.4%), requiring alternative investigations, and positive in 7 patients (1.2%). Eventually, 595 patients proceeded to surgery: 539 with DSE-based risk stratification and 56 with risk stratification based on alternative testing. Laparoscopic procedures were employed in 77.0% of patients. There were 3 perioperative deaths, all attributed to sepsis (perioperative mortality 0.50%), but no major cardiovascular events at 30-days. One patient (evaluated prior to surgery with alternative testing) experienced an acute coronary syndrome during the following 6 months (event rate 0.17%). CONCLUSION: Transthoracic DSE is feasible and safe in morbidly obese patients undergoing bariatric surgery; implementation of echocardiographic contrast agents allows for adequate imaging quality in the majority of these patients. However, the very low risk of contemporary bariatric procedures questions the need for routine preoperative stress testing in asymptomatic patients.     

Correlation between prior coronary revascularization and perioperative cardiac events in patients for noncardiac surgery

We evaluated the influence of interval between prior coronary revascularization and subsequent noncardiac surgery on perioperative cardiac events. We retrospectively identified 162 consecutive patients with previous revascularization procedures who had undergone noncardiac surgery. Postoperative cardiac complications occurred in 10 (6.2%) patients, cardiac death in 1 patient, and significant arrhythmia in 3 patients. These patients had higher rates of unstable angina, myocardial infarction within 3 months, cerebrovascular disease, peripheral vascular disease, renal dysfunction (Cr > or = 1.9 mg.dl-1) and higher preoperative risk scores as described by the Cleveland Clinic (P < 0.05). Also, the incidence of cardiac complications increased when noncardiac surgery was performed within 1 week of previous percutaneous transluminal coronary angioplasty (PTCA) and in more than 5 years after coronary artery bypass grafting or PTCA (P < 0.05). Although PTCA is widely accepted, especially in Japan, early lesion progression was observed during the first several days and atherosclerotic progression was apparent in more than 5 years after the procedure. Therefore, the time between coronary revascularization and noncardiac surgery, as well as atherosclerotic risk factors, is important in evaluating patients with history of previous revascularization procedures.     

Older bariatric surgery candidates: is there greater psychological risk than for young and midlife candidates?

BackgroundAlthough severe obesity is dramatically increasing in older adults, many bariatric programs use age cutoffs due to concerns about greater perioperative morbidity and mortality risks. More recently, surgical outcomes have been reported in older adults. However, a paucity of data is available on the psychological risks of older bariatric candidates. Our objective is to examine psychiatric risk factors and weight loss outcomes in older (≥65 yr) versus midlife (40–55 yr) versus young adult (18–29 yr) patients.MethodsOlder, midlife, and young adults (n = 608) who underwent weight loss surgery (74.6% women, 75.6% white, mean body mass index 48.07 ± 9.61 kg/m²) at the Cleveland Clinic Bariatric and Metabolic Institute completed a psychiatric diagnostic interview, and the Minnesota Multiphasic Personality Inventory-2-Restructured Form, Binge Eating Scale, and Cleveland Clinic Behavioral Rating Scale before surgery. The data gathered from follow-up visits and weight loss outcomes at 1, 3, 6, 9, 12, and 18 months after surgery were measured.ResultsYoung adults had a greater reduction in excess body mass index than those at midlife in the first 6 months but no age differences were noted in the following year. Older patients were less likely to have a suicide history but the groups were equivalent on other psychiatric variables and self-report measures. Psychologist evaluators rated older adults less favorably on the capacity to consent and realistic nature of expectations.ConclusionAlthough medical risks may cause concern, older adults do not demonstrate any increased psychological risk factors compared with midlife or young adult surgical candidates and evidenced equivalent weight loss. However, concerns with lower ratings on consent and expectations warrant additional research.     

Atrial fibrillation after cardiac surgery: A systematic review and meta-analysis

ObjectiveNew-onset postoperative atrial fibrillation (POAF) after cardiac surgery is common, with rates up to 60%. POAF has been associated with early and late stroke, but its association with other cardiovascular outcomes is less known. The objective was to perform a meta-analysis of the studies reporting the association of POAF with perioperative and long-term outcomes in patients with cardiac surgery.MethodsWe performed a systematic review and a meta-analysis of studies that presented outcomes for cardiac surgery on the basis of the presence or absence of POAF. MEDLINE, EMBASE, and the Cochrane Library were assessed; 57 studies (246,340 patients) were selected. Perioperative mortality was the primary outcome. Inverse variance method and random model were performed. Leave-one-out analysis, subgroup analyses, and metaregression were conducted.ResultsPOAF was associated with perioperative mortality (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.58-2.33), perioperative stroke (OR, 2.17; 95% CI, 1.90-2.49), perioperative myocardial infarction (OR, 1.28; 95% CI, 1.06-1.54), perioperative acute renal failure (OR, 2.74; 95% CI, 2.42-3.11), hospital (standardized mean difference, 0.80; 95% CI, 0.53-1.07) and intensive care unit stay (standardized mean difference, 0.55; 95% CI, 0.24-0.86), long-term mortality (incidence rate ratio [IRR], 1.54; 95% CI, 1.40-1.69), long-term stroke (IRR, 1.33; 95% CI, 1.21-1.46), and longstanding persistent atrial fibrillation (IRR, 4.73; 95% CI, 3.36-6.66).ConclusionsThe results suggest that POAF after cardiac surgery is associated with an increased occurrence of most short- and long-term cardiovascular adverse events. However, the causality of this association remains to be established.     

Dobutamine stress echocardiography as a predictor of cardiac events associated with aortic surgery.

Two-dimensional echocardiography can detect regional wall motion abnormalities resulting from myocardial ischemia produced by dobutamine infusion. In 60 patients undergoing elective aortic surgery (27 with aneurysms, 33 with occlusive disease), we evaluated the ability of dobutamine stress echocardiography to predict perioperative cardiac events. Echo images were obtained at rest and during incremental dobutamine infusion to a peak dose of 50 micrograms/kg/min, unless another test end point was reached (angina, heart rate greater than or equal to 85% of age-predicted maximum, significant ST segment depression, or new stress-induced wall motion abnormalities). Dobutamine stress echocardiography results were stratified as follows: group I, no wall motion abnormalities; group II, resting wall motion abnormalities unchanged with stress; group III, stress-induced worsening of resting wall motion abnormalities; group IV, new-onset wall motion abnormalities with stress. Twelve cardiac events occurred within the first 30 postoperative days: three cardiac deaths (5%), six nonfatal myocardial infarctions (10%), two patients with unstable angina (3.3%), and one patient with asymptomatic elevation of creatine phosphokinase MB isoenzymes without electrocardiographic changes (1.7%). Eleven events occurred in the 38 patients with an abnormal dobutamine stress echocardiograph (groups II to IV); in contrast, only one of 22 patients with a normal dobutamine stress echocardiograph (group I) had a cardiac event. These event rates (29% vs 4.6%) differed significantly (p less than 0.025). Dobutamine stress echocardiography is a new, safe, rapid, relatively low cost, noninvasive, nonexercise cardiac stress test for risk stratification before major vascular surgery.     

Chest pain in patients recovering from noncardiac surgery: A retrospective analysis

Study objectiveChest pain is relatively common postoperatively. Myocardial infarction (MI) is one cause of chest pain after surgery, but chest pain also results from less severe conditions. Because of its potential severity, chest pain usually prompts the activation of Rapid Response Systems (RRS). While chest pain is a cardinal symptom of myocardial ischemia in the non-surgical setting, the significance and relevance of chest pain after noncardiac surgery remains unclear.DesignWe conducted a retrospective analysis of noncardiac surgical inpatients for whom postoperative chest pain triggered our multidisciplinary RRS.SettingSurgical wards at Cleveland Clinic, Cleveland, OH.PatientsPostsurgical patients after noncardiac surgery in whom the RSS system was activated for chest pain.InterventionsRRS specified interventions like ECG readings, troponin measurements, transfer to ICU.MeasurementsOur primary outcome was MI. Secondary outcomes included the proportion of patients who had an ECG performed, troponin measurements, echocardiography, cardiac catheterization, and were admitted to the Intensive Care Unit (ICU).Main results5850 surgical patients experienced postoperative chest pain and triggered an RRS activation between 2009 and 2019. A total of 3110 patients had troponin T measured within 6 h after RRS activation, and 538 of them (17%) had elevated troponin, meeting the Fourth Universal Definition criteria for MI. Additionally, 2 patients had ST-segment elevation infarction (STEMI) without troponin measurement. Among the 540 patients with MI, only 19 (3.5%) were diagnosed with a STEMI by ECG, 388 (72%) had echocardiography, 43 patients (8%) had cardiac catheterization, 8 patients (1.5%) required emergent cardiac surgery, and 424 (79%) were admitted to an ICU.ConclusionChest pain is a serious clinical sign, often indicating a postoperative myocardial infarction, and therefore should be taken seriously. Troponin screening should be routinely considered in postsurgical patients who report chest pain.     

Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial

OBJECTIVES: This prospective, randomized, placebo-controlled, double-blind clinical trial was performed to analyze the effect of atorvastatin compared with placebo on the occurrence of a 6-month composite of cardiovascular events after vascular surgery. Cardiovascular complications are the most important cause of perioperative morbidity and mortality among patients undergoing vascular surgery. Statin therapy may reduce perioperative cardiac events through stabilization of coronary plaques. METHODS: One hundred patients were randomly assigned to receive 20 mg atorvastatin or placebo once a day for 45 days, irrespective of their serum cholesterol concentration. Vascular surgery was performed on average 30 days after randomization, and patients were prospectively followed up over 6 months. The cardiovascular events studied were death from cardiac cause, nonfatal myocardial infarction, unstable angina, and stroke. RESULTS: Fifty patients received atorvastatin, and 50 received placebo. During the 6-month follow-up primary end points occurred in 17 patients, 4 in the atorvastatin group and 13 in the placebo group. The incidence of cardiac events was more than three times higher with placebo (26.0%) compared with atorvastatin (8.0%; P =.031). The risk for an event was compared between the groups with the Kaplan-Meier method, as event-free survival after vascular surgery. Patients given atorvastatin exhibited a significant decrease in the rate of cardiac events, compared with the placebo group, within 6 months after vascular surgery (P =.018). CONCLUSION: Short-term treatment with atorvastatin significantly reduces the incidence of major adverse cardiovascular events after vascular surgery.     

Dobutamine stress echocardiography for the preoperative evaluation of patients undergoing lung volume reduction surgery.

BACKGROUND: Lung volume reduction surgery has been proposed as a bridge to lung transplantation and as definitive therapy for advanced chronic obstructive lung disease. However, patient selection criteria and optimal preoperative assessment have not been clearly defined. OBJECTIVE: We investigated the feasibility, safety, and value of dobutamine stress echocardiography as a predictor of major early cardiac events in patients who underwent lung volume reduction surgery. METHODS: The study population consisted of 46 patients (21 men and 25 women, mean age 59 +/- 9 years) who underwent dobutamine stress echocardiography (maximum dose 40 microg. kg(-1). min(-1) plus atropine if needed) 180 days or less before lung volume reduction surgery. Adverse cardiac events were prospectively defined and tabulated during hospitalization after the operation and at subsequent outpatient visits. RESULTS: Dobutamine stress echocardiography was interpretable in 45 of 46 (98%) patients. There were no adverse events during testing. The studies revealed normal left ventricular systolic function at rest in all patients and normal right ventricular function in all patients but one. Thirteen patients had right ventricular enlargement. Estimated right ventricular systolic pressure was mildly elevated (>40 mm Hg) in 5 patients. Four patients (9%) had stress tests positive for ischemia. There were no perioperative deaths. Follow-up was available for 44 of 45 patients at a duration of 20.0 +/- 7.0 months. Two major adverse cardiac events occurred in the same patient in whom the results of dobutamine stress echocardiography were positive for ischemia (positive predictive value 25%, 95% confidence interval 0% to 83%; negative predictive value 100%, 95% confidence interval 90 to 100%). CONCLUSION: Despite end-stage chronic obstructive lung disease and poor ultrasound windows, dobutamine stress echocardiography is feasible and safe in patients undergoing evaluation for lung volume reduction surgery. It yields important information on right and left ventricular function and has an excellent negative predictive value for early and late adverse cardiac events.     

The impact of a cardioprotective protocol on the incidence of cardiac complications after aortic abdominal surgery

We analyzed a local database including 468 consecutive patients who underwent elective aortic abdominal surgery over an 8-yr period in a single institution. A new cardioprotective perioperative protocol was introduced in January 1997, and we questioned whether perioperative cardiac outcome could be favorably influenced by the application of a stepwise cardiovascular evaluation based on the American College of Cardiology/American Heart Association guidelines and by the use of antiadrenergic drugs. Clonidine was administered during surgery, and beta-blockers were titrated after surgery to achieve heart rates less than 80 bpm. We compared data of two consecutive 4-yr periods (1993-1996 [control period] versus 1997-2000 [intervention period]). Implementation of American College of Cardiology/American Heart Association guidelines was associated with increased preoperative myocardial scanning (44.3% vs 20.6%; P < 0.05) and coronary revascularization (7.7% vs 0.8%; P < 0.05). During the intervention period, there was a significant decrease in the incidence of cardiac complications (from 11.3% to 4.5%) and an increase in event-free survival at 1 yr after surgery (from 91.3% to 98.2%). Multivariate regression analysis showed that the combined administration of clonidine and beta-blockers was associated with a decreased risk of cardiovascular events (odds ratio, 0.3; 95% confidence interval, 0.1-0.8), whereas major bleeding, renal insufficiency, and chronic obstructive pulmonary disease were predictive of cardiac complications. In conclusion, cardiac testing was helpful to identify a small subset of high-risk patients who might benefit from coronary revascularization. Sequential and selective antiadrenergic treatments were associated with improved postoperative cardiac outcome. IMPLICATIONS: Implementation of American College of Cardiology/American Heart Association guidelines and use of antiadrenergic drugs were associated with better cardiac outcomes after major vascular surgery.     

Mid-term Results of Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass in Adolescent Patients

The prevalence and severity of obesity in children and adolescents has been increasing in recent years at an unprecedented rate. Morbidly obese children will almost certainly develop severe comorbidities as they progress to adulthood, and bariatric surgery may provide the only alternative for achieving a healthy weight. The aim of this study was to assess the long-term outcomes and safety of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) as new treatment modalities for morbidly obese adolescents. We conducted a retrospective review of a prospectively collected database of all adolescent patients who underwent LSG and RYGB under IRB protocol at the Bariatric and Metabolic Institute in Cleveland Clinic Florida between 2002 and 2011. Patients were also contacted by phone, adhering to HIPAA regulations, and were asked to answer a survey. Eighteen adolescents had a bariatric procedure performed at this institution. The mean age was 17.5 years, the average weight was 293.1 lbs, and the average BMI was 47.2 kg/m². The mean follow-up period consisted of 55.2 months. The postoperative weight at 55 months follow-up was 188.4 lbs and average BMI was 30.1 kg/m². Fifteen of the patients were available for follow-up. Thirteen out of 16 (81 %) comorbidities in patients available for follow-up were in remission following rapid weight loss. The long-term follow-up and perioperative morbidity shown in this study suggest that LSG and LRYGB appear to be safe and effective operations in morbidly obese adolescents.