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Prognostic value of extended cardiac risk assessment before elective open abdominal aortic surgery

Prognostischer Wert der erweiterten kardialen Risikobeurteilung vor elektiver offener Bauchaortenchirurgie

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Abstract

Background

Major vascular surgery is associated with a high perioperative risk and significant mortality. Despite advances in risk stratification, monitoring, and management of perioperative complications, cardiac complications are still common. Stress echocardiography is well established in coronary artery disease diagnostics; however, its prognostic value before high-risk aortic surgery is unknown. This prospective, single-center study compared the outcome of patients undergoing extended cardiac risk assessment before open abdominal aortic surgery with the outcome of patients who had received standard preoperative assessment.

Methods

The study included patients undergoing elective open abdominal aortic surgery. Patients who underwent standard preoperative assessment before the start of a dedicated protocol were compared with patients who had extended cardiac risk assessment, including dobutamine stress echocardiography, as part of a stepwise interdisciplinary cardiovascular team approach. The combined primary endpoint was cardiovascular death, myocardial infarction, emergency coronary revascularization, and life-threatening arrhythmia within 30 days. The secondary endpoint was acute renal failure and severe bleeding.

Results

In total, 77 patients (mean age 68.1 ± 8.1 years, 70% male) were included: 39 underwent standard and 38 underwent cardiac risk assessment. The combined primary endpoint was reached significantly more often in patients before than after implementation of the extended cardiac stratification procedure (15% vs. 0%, p = 0.025). The combined secondary endpoint did not differ between the groups.

Conclusions

Patients with extended cardiac risk assessment undergoing elective open abdominal aortic surgery had better 30-day outcomes than did those who had standard preoperative assessment.

Zusammenfassung

Hintergrund

Größere Gefäßoperationen gehen mit einem hohen perioperativen Risiko und erheblicher Mortalität einher. Trotz Fortschritten in der Risikostratifizierung, im Monitoring und Management perioperativer Komplikationen sind kardiale Komplikationen immer noch häufig. Die Stressechokardiographie ist ein etabliertes diagnostisches Verfahren für die koronare Herzkrankheit, jedoch ist ihr prognostischer Wert vor einer Hochrisikoaortenoperation bisher nicht bekannt. In der vorliegenden prospektiven Einzelzentrumstudie wurden die Ergebnisse von Patienten mit erweiterter kardialer Risikobeurteilung vor offener Bauchaortenoperation mit den Ergebnisse von Patienten mit der präoperativen Standardeinschätzung verglichen.

Methoden

In diese Studie wurden Patienten aufgenommen, bei denen eine elektive offene Bauchaortenoperation durchgeführt wurde. Patienten, bei denen die präoperative Standardeinschätzung vor dem Beginn eines festgelegten Ablaufs erfolgte, wurden mit Patienten verglichen, bei denen als Teil eines stufenweise ablaufenden Ansatzes mit einem interdisziplinären kardiovaskulären Team eine erweiterte kardiale Risikobeurteilung durchgeführt wurde, einschließlich Dobutaminstressechokardiographie. Der kombinierte primäre Endpunkt bestand aus Tod aus kardiovaskulärer Ursache, Myokardinfarkt, Notfallkoronarrevaskularisation und lebensbedrohlicher Arrhythmie innerhalb von 30 Tagen. Akutes Nierenversagen und schwere Blutung bildeten den sekundären Endpunkt.

Ergebnisse

Es wurden insgesamt 77 Patienten in die Studie eingeschlossen (Durchschnittsalter 68,1 ± 8,1 Jahre, 70 % m.): Die Standardeinschätzung durchliefen 39 und die kardiale Risikobeurteilung 38 Patienten. Der kombinierte primäre Endpunkt wurde bei den Patienten vor Einführung der erweiterten kardialen Stratifizierung signifikant häufiger erreicht als danach (15 vs. 0 %, p = 0,025). Der kombinierte sekundäre Endpunkt unterschied sich nicht zwischen den Gruppen.

Schlussfolgerung

Patienten mit erweiterter kardialer Risikobeurteilung, bei denen eine elektive offene Bauchaortenoperation erfolgte, wiesen bessere 30-Tage-Ergebnisse auf als Patienten mit der präoperativen Standardeinschätzung.

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Authors and Affiliations

  1. Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1–3, 68167, Mannheim, Germany

    Martin Sigl MD, Stefan Baumann MD, Ann-Sophie Könemann, Daniel Dürschmied MD & Stephanie Rosenkaimer MD

  2. Division of Vascular Surgery, Department of Surgery, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany

    Michael Keese MD, Kay Schwenke MD & Andreas L. H. Gerken MD

  3. European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany

    Michael Keese MD & Daniel Dürschmied MD

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  1. Martin Sigl MD
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  2. Stefan Baumann MD
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  3. Ann-Sophie Könemann
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  4. Michael Keese MD
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  5. Kay Schwenke MD
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  6. Andreas L. H. Gerken MD
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  8. Stephanie Rosenkaimer MD
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Contributions

MS conceived the study, approved the statistical analysis and prepared the initial manuscript draft. SB conceived the study and made a decisive contribution to completion of the manuscript. AK collected and helped to analyze the data. MK, KS, AG and DD provided critical revisions for intellectual content. SR co-designed the study and performed a majority of the ultrasound examinations.

Corresponding author

Correspondence to Martin Sigl MD.

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Conflict of interest

M. Sigl, S. Baumann, A.‑S. Könemann, M. Keese, K. Schwenke, A.L.H. Gerken, D. Dürschmied and S. Rosenkaimer declare that they have no competing interests.

The study was carried out according to the principles of the Helsinki Declaration of 1964 and all subsequent revisions, and it was approved by the Medical Ethics Commission II of the Faculty of Medicine Mannheim, University of Heidelberg, Germany. Informed consent forms were signed by all patients who were enrolled in this study.

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Data availability statement

The data can be obtained from the corresponding author upon reasonable request.

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Sigl, M., Baumann, S., Könemann, AS. et al. Prognostic value of extended cardiac risk assessment before elective open abdominal aortic surgery. Herz 49, 210–218 (2024). https://doi.org/10.1007/s00059-023-05209-y

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  • DOI: https://doi.org/10.1007/s00059-023-05209-y

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