Beta-blockers improve in-hospital and long-term survival in patients with severe left ventricular dysfunction undergoing major vascular surgery.

OBJECTIVES: To study whether beta-blockers reduce in-hospital and long-term mortality in patients with severe left ventricular dysfunction (LVD) undergoing major vascular surgery. DESIGN: Observational cohort study. MATERIALS: Five hundred and eleven patients with severe LVD (ejection fraction<30%) undergoing major non-cardiac vascular surgery. METHODS: In all patients, cardiac risk factors, medication (including beta-blockers), and dobutamine stress echocardiography (DSE) results were noted prior to surgery. DSE was evaluated for rest and stress-induced new wall motion abnormalities. Endpoint was in-hospital and long-term mortality. Propensity scores for beta-blockers were calculated and regression models were used to analyse the relation between beta-blockers and mortality. RESULTS: Mean age was 64+/-11 years and 383 patients (75%) were male. 139 patients (27%) used beta-blockers. Stress-induced ischemia occurred in 82 patients (16%). Median follow-up was 7 years (interquartile range: 3-10). In-hospital and long-term mortality was observed in 64 (13%) and 171 (33%) patients, respectively. After adjusting for clinical variables, DSE results and propensity scores, beta-blockers were significantly associated with reduced in-hospital and long-term mortality (OR: 0.18, 95% CI: 0.04-0.74 and HR: 0.38, 95% CI: 0.22-0.65, respectively). CONCLUSION: In patients with severe LVD undergoing major vascular surgery, the use of beta-blockers is associated with a reduced incidence of in-hospital and long-term postoperative mortality.     

Preoperative cardiac assessment in patients undergoing major vascular surgery

The aim of this study was to evaluate the effectiveness of a preoperative standardized cardiac assessment in patients undergoing major vascular surgery. From January 2005 to December 2006, 1446 elective interventions for major vascular diseases (carotid stenosis, CS; abdominal aortic aneurysm, AAA; peripheral arterial obstructive disease, PAOD) were performed; 1090 out of these patients underwent preoperative diagnostic assessment on an outpatient basis. Thirty-day results in terms of cardiac mortality and morbidity rates were recorded. Patients suffered from a CS in 578 cases (53%), an AAA in 303 cases (27.8%) and a PAOD in 209 cases (19.2%). Four hundred thirty-two patients (39.6%) underwent further evaluation of cardiac functional capacity with non-invasive stress testing. Sixteen patients were successfully treated prior to vascular surgery. Thirty-day cardiac mortality and morbidity rates were 0.2% and 3.9%, respectively. A positive preoperative non-invasive stress testing did not affect 30-day cardiac outcomes. In conclusion, the use of an accurate preoperative cardiac assessment allowed us to obtain satisfactory perioperative results in patients undergoing major vascular surgery. Routine preoperative evaluation with non-invasive stress testing did not seem to improve perioperative cardiac results.     

Levosimendan for patients with impaired left ventricular function undergoing cardiac surgery

The efficacy of levosimendan treatment for a low cardiac output status following cardiac surgery has not been established. Here, we review our initial experiences of the perioperative use of levosimendan. This study is a retrospective uncontrolled trial. Nine patients who underwent cardiac surgery, and developed a low cardiac output status resistant to conventional inotropic support, were given levosimendan. The mean preoperative ejection fraction was 35.2+/-3.4%. All patients were on concomitant inotropic agents and had previously undergone intra-aortic balloon pumping. Cardiac index increased immediately from 2.14+/-0.33 l/min/m(2) at baseline to 2.41+/-0.31 (P=0.02) at 1 h, rising to 2.67+/-0.43 (P<0.001) at 4 h after the loading dose was started. Similarly, the systemic vascular resistance index decreased from 2350+/-525 dynes/s/cm(-5)/m(2) at baseline to 1774+/-360 (P=0.002) at 4 h. In the case of all but one of the patients, either the dose of the concomitant inotropic support or the balloon pumping could be weaned down within 24 h after completion of the levosimendan infusion. No withdrawal of levosimendan was required. Levosimendan could constitute a new therapeutic option for postoperative low cardiac output.     

Perioperative risk stratification in cardiac patients undergoing noncardiac surgery

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Intra-aortic balloon counterpulsation in high-risk cardiac patients undergoing noncardiac surgery

Patients undergoing noncardiac general surgical procedures after coronary artery bypass surgery have reduced mortality compared with those operated on without prior revascularization. The urgency of the noncardiac procedure and the potential reconstructability of the coronary artery anatomy may mitigate against timely revascularization. We report the successful outcome of prophylactic intra-aortic balloon counterpulsation in three patients with coronary artery disease and impaired left ventricular function undergoing noncardiac surgical procedures. Intra-aortic balloon counterpulsation may provide myocardial protection in high-risk cardiac patients requiring noncardiac surgery initially. A review of the literature is discussed.     

β受体阻滞剂与非心脏手术围术期心脏并发症

β受体阻滞剂越来越多地在围术期得到预防性应用,现就β受体阻滞剂临床应用现状、作用机制、应用标准、注意事项以及对非心脏手术患者围术期心脏并发症的影响等方面作一综述。     

Aortic valve surgery in patients with left ventricular dysfunction

Patient with advanced left ventricular dysfunction and heart failure symptoms, either secondary to severe aortic stenosis and a low transvalvular gradient, or chronic aortic insufficiency are sometimes referred for cardiac transplantation. Now, with improvements in both myocardial protection and better valve prostheses, aortic valve surgery for patients with even the most advanced ventricular dysfunction can be performed with low risk.     

Heart rate and outcome in patients with cardiovascular disease undergoing major noncardiac surgery

There is an increasing awareness that an elevated resting heart rate is associated with increased all-cause mortality in the general population and that this may be an independent coronary risk factor This review was undertaken to determine whether heart rate is predictive of increased mortality and major morbidity in noncardiac surgical patients and whether heart rate manipulation improves perioperative outcome. A search of Medline from 1966 until October 2007 was conducted using the terms "heart rate", "surgery", "cardiac", "morbidity", "mortality" and "perioperative". The main findings were that an elevated perioperative heart rate, an absolute increase in heart rate and heart rate lability are independent predictors of both short- and long-term adverse outcomes in patients at cardiovascular risk undergoing major noncardiac surgery. Although prospective nonrandomised and retrospective data suggest heart rate control improves perioperative outcome, there is conflicting evidence from randomised trials that perioperative heart rate control improves outcome. This may be because drug-associated bradycardia influences mortality in the perioperative period. Further studies reporting the absolute heart rate, the absolute change of heart rate and the time period of the observations are needed to identify 'early warning systems', which may allow earlier triage and improved outcome. Enthusiasm for this approach must be tempered by the appreciation that a J-shaped relationship probably exists between heart rate and morbidity, particularly following bradycardic therapy. Therefore, any bradycardic manipulation of heart rate in the perioperative period must be accompanied by simultaneous attention to other physiological variables associated with increased morbidity and mortality.     

Preoperative evaluation using asialoscintigraphy in patients undergoing cardiac surgery with noncardiac liver cirrhosis

Objective Liver cirrhosis is recognized as one of the risk factors for severe complications after cardiac surgery. However, there are no established methods for risk stratification of the patients with liver cirrhosis (LC) regarding cardiac surgery. We present our experience of preoperative evaluation of liver function using asialoscintigraphy. Methods Between April 1999 and December 2005, we evaluated preoperative liver function using asialoscintigraphy with technetium-99m galactosyl human serum albumin in four cirrhotic patients undergoing coronary artery bypass grafting (n = 2) and valve replacement (n = 2), whose etiologies of LC were alcoholabuse (n = 1) and hepatitis C virus infection (n = 3). They also underwent other tests for preoperative evaluation of liver function, including the indocyanine green (ICG) test. Results Asialoscintigraphy revealed that the receptor index and the index of blood clearance in each patient were 0.81/0.73, 0.95/0.5, 0.82/0.62, and 0.97/0.57, respectively. These values closely correlated with the results of the ICG test. All patients were discharged alive from hospital after surgery. However, although one patient who underwent off-pump bypass had an uneventful course, three patients had major complications: pleural effusion (n = 1) and wound infection (n = 2). Conclusion Asialoscintigraphy is a practical, reliable method that can replace the ICG test for estimating hepatic function for risk stratification of cirrhotic patients undergoing cardiac surgery, whose mortality and morbidity are still high.     

Multicenter study of cardiac events and anesthetic management of patients with ischemic heart diseases undergoing noncardiac surgery

We designed a joint research project to investigate the incidence of ischemic heart diseases in patients undergoing noncardiac surgery and to define the risk of perioperative cardiac complications in these patients. Of the 8358 surgical patients in the 8 departments of anesthesiology between March 1997 and June 1997, 328 (3.9%) had ischemic heart diseases. Among the 328 patients, 54 (16.4%) developed perioperative cardiac events, including myocardial infarction (3 patients) and either lethal or potentially dangerous dysrhythmias (51 patients). Preoperative cardiac assessments were performed while the anesthetic techniques including intensive monitoring and perioperative prophylactic therapy were also employed. Patients with ischemic heart diseases received various types of preoperative evaluation to identify the degree of coronary artery disease and to assess the overall cardiac function. The patients were monitored using a multilead electrocardiogram, an arterial line, a central venous catheter, a pulmonary artery catheter, and by transesophageal echocardiography intraoperatively. Therapeutically, isosorbide, nitroglycerin, beta-blockers, calcium channel blockers, and/or nicorandil were administered to prevent perioperative ischemia. So far, no generally accepted management strategies have been established in patients with cardiovascular disorders based on large-scale outcome trials in Japan. Therefore, nationwide large multicenter trials are awaited with interest in order to establish helpful guidelines to improve the perioperative management and to reduce ischemia in cardiac patients undergoing noncardiac surgery.     

心脏手术后的认知功能障碍

大脑功能障碍是指智力下降等不同程度脑功能改变。随着心脏外科的发展，有关中枢神经系统并发症日益受到重视。 1 危险因素 术前已有中风、主动脉近端硬化、贫血与老龄化、高血压和糖尿病等均可使体外循环后中风风险增加。术中发生中风的主要风险因子是体外循环时间和反复地钳夹主动脉。其他如围术期心律失常、低心排综合征等情况也会使体外循环后认知功能障碍增加。     

Early and midterm clinical outcome in patients with severe left ventricular dysfunction undergoing coronary artery surgery

BACKGROUND: Patients presenting with severe left ventricular (LV) dysfunction undergoing coronary artery surgery are at increased risk of perioperative morbidity and mortality. The present study investigated early and midterm outcomes in a consecutive series of patients with severe LV dysfunction undergoing coronary surgery at our institution. METHODS: Data on 5,195 consecutive patients undergoing coronary artery bypass grafting (CABG) alone (in-hospital mortality 1.35%) from April 1996 to August 2002 were prospectively recorded in the Patient Analysis and Tracking System. Two hundred and fifty patients (median age 65 years [interquartile range, 57 to 70]) with preoperative left ventricular ejection fraction less than 30% (74 off pump; 29.6%) were identified and early and midterm clinical outcomes analyzed. Propensity scores were used to take account of the imbalance in the distribution of prognostic factors between the on-pump and off-pump groups. RESULTS: Patients undergoing on-pump surgery were less likely to have current congestive heart failure, insulin-dependent diabetes, a history of hypertension, have had gastrointestinal tract surgery or an ulcer, or unstable angina. They had on average lower Parsonnet scores and New York Heart Association and Canadian Cardiovascular Score ratings. However they were more likely to have more extensive coronary artery heart disease and to require more grafts than those undergoing off-pump surgery. After adjustment for consultant team and propensity scores no differences between groups with regard to in-hospital mortality and morbidity were found. The only in-hospital outcome to show a significant difference after adjustment was the need for intraoperative inotropic support, which was higher in the on-pump group (odds ratio 5.1; 95% confidence interval 2.55 to 10.2; p < 0.001)). The median follow-up times for the on- and off-pump groups were 3.4 years and 1.4 years respectively. Three-year survival was higher with on-pump surgery (87% on-pump versus 73% off-pump) but this difference did not reach statistical significance after adjustment for prognostic variables (hazard ratio 0.54, 95% confidence interval 0.22 to 1.26, p = 0.16). CONCLUSIONS: In-hospital mortality and morbidity in patients presenting with severe LV dysfunction is low with comparable results with both on- and off-pump coronary artery surgery. Midterm clinical outcome is encouraging and seems to justify surgical revascularization for this high-risk group of patients.     

Changes in heart rate variability in elderly patients undergoing major noncardiac surgery under spinal or general anesthesia.

BACKGROUND AND OBJECTIVES: Heart rate variability (HRV), widely used as an indicator of activity of the autonomic nervous system, has been reported to decrease during and after both spinal and general anesthesia in patients without cardiovascular disease. We evaluated the changes in HRV bands in 40 patients with a high risk of ischemic heart disease. METHODS: The patients were randomly assigned to receive either spinal (SA) or general anesthesia (GA) for elective total hip arthroplasty or peripheral vascular surgery. Anesthetic techniques and perioperative fluid administration were standardized. Holter monitoring was started preoperatively and continued until the third postoperative day. Three HRV frequency bands were analyzed. RESULTS: A significant decrease was seen in very low frequency (VLF) and low frequency (LF) bands during GA but not during SA. Also the LF/high frequency (HF) ratio decreased during GA but not during SA. A decrease in all HRV frequency bands was seen after both types of anesthesia. None of the frequency bands returned back to the preoperative level during the 3-day trial. Postoperatively circadian variation was found only in the VLF band after SA. CONCLUSIONS: The sympathovagal balance (LF/HF) is more stable during SA than during GA in patients with a high risk of ischemic heart disease. The postoperative decrease in HRV bands, however, is independent of the anesthetic technique.     

Preoperative evaluation and management of patients with ischemic heart disease undergoing noncardiac surgery

The evaluation and management of patients with coronary artery disease (CAD) undergoing noncardiac surgery are becoming important medical issues in modern society with the aging of the population and prevalence of CAD. For patients with CAD, medical therapy (beta-blockers, statins), percutaneous coronary artery intervention (PCI) with/without stenting, and coronary artery bypass grafting have been the modalities for management. Although balloon angioplasty is effective in selected patients, bare-metal stents (BMS) require post-PCI antiplatelet therapy for 4-6 weeks delaying noncardiac procedures As recently reported patients with drug-eluting stents (DES) experienced late stentthrombosis due to discontinuation of antiplatelet therapy in the long-term period before noncardiac surgery, suggesting the need for life-long anticoagulant therapy after DES placement. Recently, offpump coronary artery bypass (OPCAB) has become a safe and effective procedure for direct coronary revascularization. OPCAB, without cardiopulmonary bypass and its adverse effects, can be performed simultaneously with noncardiac surgery such as carotid endoarterectomy, abdominal aortic aneurysm resection, and peripheral arterial reconstruction. OPCAB is a promising option as a simultaneous or staged procedure for patients with CAD and noncardiac disease.     

缺血性心脏行非心脏手术患者围手术期的处理新观念

心血管病是引起麻醉及术后死亡的首要原因.为了降低围术期并发症的风险性,识别潜在冠脉疾病以启动适当治疗策略很重要.最新发现按简单、安全、精确以及经济有效原则将围手术期风险进行分级.利尿肽有望成为围手术期新的风险标记物.β受体阻断剂的抗缺血特性已被证实,在临床实践中,使用足够剂量的β受体阻断剂,加强围手术期心率控制及术后持续的β受体阻断剂使用或许成为抗缺血的重要因素.他汀类虽然有望成为围手术期具心肌保护特性的药物,但还需要更多临床试验验证.现就探讨围术期治疗领域的新理念,以运用于临床实践或促进更深远研究作一综述.     

血栓前状态预测老年冠心病非心脏手术患者围术期心脏事件的价值

目的 评价血栓前状态(PTS)预测老年冠心病非心脏手术患者围术期心脏事件的价值.方法 择期全麻下行腹部手术的冠心病老年患者128例,年龄65 ～ 75岁,性别不限,ASA分级Ⅰ或Ⅱ级,NYHA分级Ⅰ或Ⅱ级.采用全凭静脉麻醉.术前采集静脉血样,测定血浆D-二聚体、血栓前体蛋白及P-选择素的浓度,根据此3项指标判断是否存在PTS.根据术中和术后3d内是否发生心脏事件分为非心脏事件组和心脏事件组.记录患者一般资料及术中情况各指标,将组间差异有统计学意义的因素进行logistic回归分析,筛选心脏事件的危险因素.结果 29例患者发生心脏事件,与非心脏事件组比较,心脏事件组年龄、肥胖、糖尿病比率、手术时间和PTS比率差异有统计学意义(P＜ 0.05或0.01);logistic回归结果显示:高龄、糖尿病、手术时间长和PTS是心脏事件的独立危险因素(P＜O.O1).结论 PTS对老年冠心病非心脏手术围术期心脏事件的发生有一定的预测价值.     

Anesthetic considerations in the patient with valvular heart disease undergoing noncardiac surgery

Valvular heart disease can be an important finding in patients presenting for noncardiac surgery. Valvular heart disease and resulting comorbidity, such as heart failure or atrial fibrillation, significantly increase the risk for perioperative adverse events. Appropriate preoperative assessment, adequate perioperative monitoring, and early intervention, should hemodynamic disturbances occur, may help prevent adverse events and improve patient outcome. This review article aims to guide the practitioner in the various aspects of anesthetic management in the perioperative care of patients with valvular heart disease. The pharmacological approach to optimization of patient outcome with drugs, such as betablockers and lipid-lowering medications (statins), is an evolving field, and recent developments are discussed in this article.