Perioperative Predictors of Unfavorable Outcome of Vascular Surgery

Concurrent cardiac failure is an universally accepted risk factor in surgical patients undergoiing cardiac or non-cardiac surgery.

The aim of this study was to search for and identify factors or markers, which would permit to predict early (up to 30 days) or late (up to 1 year) adverse outcomes in patients with acute heart failure (AHF) in the vascular surgery.

Materials and Methods. A randomized, multicenter, prospective — retrospective study was performed. 89 patients who had signed the Informed Consent Form were randomized. Throughout the four stages of the study, the cardiac index (CI) and the left ventricle ejection fraction (LVEF) values were recorded. At the same stages, blood was sampled to be tested for the NT-proBNP level. The TnT level was tested only at the 3rd stage of the study. The required stay in the intensive care unit (ICU) and in the in-patient hospital, the incidence of infarctions and strokes during the early postoperative period (up to 30 days), the 30&day and one-year mortality rates were recorded.

Results. Different AHF prevention methods were used in patients included into this study in the postoperative period. Predictors of adverse events were studied in a combined population. The incidence of acute myocardial infarction (AMI) was 12% and that of stroke was 2%. The in-hospital mortality rate in the combined group was 2%; the one-year mortality was 10%. Patients stayed in the intensive care unit for 3 (2—4) days; the hospital stay was 11 (10—13) days; the composite adverse outcome of the surgical treatment was registered in 15% of patients. As a result, the Troponin T level was the only significant prognostic factor during the first 24 hours of the postoperative period. A study of the prognostic significance of different parameters in relation to their effect on the one-year mortality rate demonstrated a similar result. Vasoactive Inotropes Score (VIS) turned out to be the most significant criterion for prediction of possible treatment duration.

Conclusion. The study results confirmed the predictive value of early determination of TnT levels after reparative vascular surgeries in patients with decreased left ventricular ejection fraction. The diagnostic value of the VIS calculation needs further confirmation. 

1. Devereaux P.J., Sessler D.I. Cardiac complications in patients undergoing major noncardiac surgery. N. Engl. J. Med. 2015; 373 (23): 2258–2269. https://doi.org/10.1056/NEJMra1502824. PMID: 26630144

2. Botto F., Alonso-Coello P., Chan M.T., Villar J.C., Xavier D., Srinathan S., Guyatt G., Cruz P., Graham M., Wang C.Y., Berwanger O., Pearse R.M., Biccard B.M., Abraham V., Malaga G., Hillis G.S., Rodseth R.N., Cook D., Polanczyk C.A., Szczeklik W., Sessler D.I., Sheth T., Ackland G.L., Leuwer M., Garg A.X., Lemanach Y., Pettit S., Heels-Ansdell D., Luratibuse G., Walsh M., Sapsford R., Schünemann H.J., Kurz A., Thomas S., Mrkobrada M., Thabane L., Gerstein H., Paniagua P., Nagele P., Raina P., Yusuf S., Devereaux P.J., Devereaux P.J., Sessler D.I., Walsh M., Guyatt G., McQueen M.J., Bhandari M., Cook D., Bosch J., Buckley N., Yusuf S., Chow C.K., Hillis G.S., Halliwell R., Li S., Lee V.W., Mooney J., Polanczyk C.A., Furtado M.V., Berwanger O., Suzumura E., Santucci E., Leite K., Santo J.A., Jardim C.A., Cavalcanti A.B., Guimaraes H.P., Jacka M.J., Graham M., McAlister F., McMurtry S., Townsend D., Pannu N., Bagshaw S., Bessissow A., Bhandari M., Duceppe E., Eikelboom J., Ganame J., Hankinson J., Hill S., Jolly S., Lamy A., Ling E., Magloire P., Pare G., Reddy D., Szalay D., Tittley J., Weitz J., Whitlock R., Darvish Kazim S., Debeer J., Kavsak P., Kearon C., Mizera R., O’Donnell M., McQueen M., Pinthus J., Ribas S., Simunovic M., Tandon V., Vanhelder T., Winemaker M., Gerstein H., McDonald S., O’Bryne P., Patel A., Paul J., Punthakee Z., Raymer K., Salehian O., Spencer F., Walter S., Worster A., Adili A., Clase C., Cook D., Crowther M., Douketis J., Gangji A., Jackson P., Lim W., Lovrics P., Mazzadi S., Orovan W., Rudkowski J., Soth M., Tiboni M., Acedillo R., Garg A., Hildebrand A., Lam N., Macneil D., Mrkobrada M., Roshanov P.S., Srinathan S.K., Ramsey C., John P.S., Thorlacius L., Siddiqui F.S., Grocott H.P., McKay A., Lee T.W., Amadeo R., Funk D., McDonald H., Zacharias J., Villar J.C., Cortés O.L., Chaparro M.S., Vásquez S., Castañeda A., Ferreira S., Coriat P., Monneret D., Goarin J.P., Esteve C.I., Royer C., Daas G., Chan M.T., Choi G.Y., Gin T., Lit L.C., Xavier D., Sigamani A., Faruqui A., Dhanpal R., Almeida S., Cherian J., Furruqh S., Abraham V., Afzal L., George P., Mala S., Schünemann H., Muti P., Vizza E., Wang C.Y., Ong G.S., Mansor M., Tan A.S., Shariffuddin I.I., Vasanthan V., Hashim N.H., Undok A.W., Ki U., Lai H.Y., Ahmad W.A., Razack A.H., Malaga G., Valderrama Victoria V., Loza Herrera J.D., De Los Angeles Lazo M., Rotta Rotta A., Szczeklik W., Sokolowska B., Musial J., Gorka J., Iwaszczuk P., Kozka M., Chwala M., Raczek M., Mrowiecki T., Kaczmarek B., Biccard B., Cassimjee H., Gopalan D., Kisten T., Mugabi A., Naidoo P., Naidoo R., Rodseth R., Skinner D., Torborg A., Paniagua P., Urrutia G., Maestre M.L., Santaló M., Gonzalez R., Font A., Martínez C., Pelaez X., De Antonio M., Villamor J.M., García J.A., Ferré M.J., Popova E., Alonso Coello P., Garutti I., Cruz P., Fernández C., Palencia M., Díaz S., Del Castillo T., Varela A., de Miguel A., Muñoz M., Piñeiro P., Cusati G., Del Barrio M., Membrillo M.J., Orozco D., Reyes F., Sapsford R.J., Barth J., Scott J., Hall A., Howell S., Lobley M., Woods J., Howard S., Fletcher J., Dewhirst N., Williams C., Rushton A., Welters I., Leuwer M., Pearse R., Ackland G., Khan A., Niebrzegowska E., Benton S., Wragg A., Archbold A., Smith A., McAlees E., Ramballi C., Macdonald N., Januszewska M., Stephens R., Reyes A., Paredes L.G., Sultan P., Cain D., Whittle J., Del Arroyo A.G., Sessler D.I., Kurz A., Sun Z., Finnegan P.S., Egan C., Honar H., Shahinyan A., Panjasawatwong K., Fu A.Y., Wang S., Reineks E., Nagele P., Blood J., Kalin M., Gibson D., Wildes T.; Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Writing Group, on behalf of The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Investigators; Appendix 1. The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Study Investigators Writing Group; Appendix 2. The Vascular events In noncardiac Surgery patIents cOhort evaluatioN Operations Committee; Vascular events In noncardiac Surgery patIents cOhort evaluatioN VISION Study Investigators. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study estab- lishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology. 2014; 120 (3): 564–578. https://doi.org/10.1097/ ALN.0000000000000113. PMID: 24534856

3. Landesberg G., Beattie W.S., Mosseri M., Jaffe A.S., Alpert J.S. Perioperative myocardial infarction. Circulation. 2009; 119 (22): 2936–2944. https://doi.org/10.1161/CIRCULATIONAHA.108.828228. PMID: 19506125

4. Badner N.H., Knill R.L., Brown J.E., Novick T.V., Gelb A.W. Myocardial infarction after noncardiac surgery. Anesthesiology. 1998; 88 (3): 572–578. https://doi.org/10.1097/00000542- 199803000-00005. PMID: 9523798

5. Devereaux P.J., Xavier D., Pogue J., Guyatt G., Sigamani A., Garutti I., Leslie K., Rao Melacini P., Chrolavicius S., Yang H., Macdonald C., Avezum A., Lanthier L., Hu W., Yusuf S.; POISE (PeriOperative ISchemic Evaluation) Investigators. Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study. Ann. Intern. Med. 2011; 154 (8): 523–528. https://doi.org/10.7326/0003-4819-154-8-201104190-00003.PMID: 21502650

6. Likhvantsev V.V., Ubasev Y.V., Skripkin Y.V., Zabelina T.S., Sungurov V.A., Lomivorotov V.V., Marchenko D.N. Preoperative prevention of heart failure in noncardiac surgery. Obshchaya Reanimatologiya = General Reanimatology. 2016; 12 (3): 48–61. https://doi.org/ 10.15360/1813-9779-2016-3-48-61 [In Russ., In Engl.]

7. Hammill B.G., Curtis L.H., Bennett Guerrero E., O’Connor C.M., Jollis J.G., Schulman K.A., Hernandez A.F. Impact of heart failure on patients under- going major noncardiac surgery. Anesthesiology. 2008; 108 (4): 559–567. https://doi.org/10.1097/ALN.0b013e31816725ef. PMID: 18362586

8. van Diepen S., Bakal J.A., McAlister F.A., Ezekowitz J.A. Mortality and readmission of patients with heart failure, atrial fibrillation, or coro- nary artery disease undergoing noncardiac surgery: an analysis of 38 047 patients. Circulation. 2011; 124 (3): 289–296. https://doi.org/ 10.1161/CIRCULATIONAHA.110.011130.PMID: 21709059

9. Kristensen S.D., Knuuti J., Saraste A., Anker S., Bøtker H.E., Hert S.D., Ford I., Gonzalez-Juanatey J.R., Gorenek B., Heyndrickx G.R., Hoeft A., Huber K., Iung B., Kjeldsen K.P., Longrois D., Lüscher T.F., Pierard L., Pocock S., Price S., Roffi M., Sirnes P.A., Sousa Uva M., Voudris V., Funck-Brentano C.; Authors/Task Force Members. 2014 ESC/ESA guidelines on non-cardiac surgery: cardiovascular assessment and man- agement: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur. Heart J. 2014; 35 (35): 2383–2431. https://doi.org/10.1093/eurheartj/ ehu282. PMID: 25086026

10. Likhvantsev V.V., Marchenko D.N., Grebenchikov O.A., Ubasev Yu.V., Zabelina T.S., Timoshin S.S. Prevention of heart failure in non-cardiac surgery in patients with a reduced fraction of left ventricular ejection: levosimendan or anesthetic cardioprotection? (randomized multicen- tre study). Vestnik Anesteziologii i Reanimatologii. 2016; 13 (3): 74–79. https://doi.org/ 10.21292/2075-1230-2016-13-3-74-80. [In Russ.]

11. Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators, Devereaux P.J., Chan M.T., Alonso-Coello P., Walsh M., Berwanger O., Villar J.C., Wang C.Y., Garutti R.I., Jacka M.J., Sigamani A., Srinathan S., Biccard B.M., Chow C.K., Abraham V., Tiboni M., Pettit S., Szczeklik W., LuratiBuse G., Botto F., Guyatt G., Heels Ansdell D., Sessler D.I., Thorlund K., Garg A.X., Mrkobrada M., Thomas S., Rodseth R.N., Pearse R.M., Thabane L., McQueen M.J., VanHelder T., Bhandari M., Bosch J., Kurz A., Polanczyk C., Malaga G., Nagele P., LeManach Y., Leuwer M., Yusuf S. Association between post- operative troponin levels and 30-day mortality among patients under- going noncardiac surgery. JAMA. 2012; 307 (21): 2296–2304. https://doi.org/10.1001/jama.2012.5502. PMID: 22706835

12. Kornienko A.N., Dobrushina O.R., Zinina E.P. Differentiated prevention of cardiac complications of extracardiac surgery. Obshchaya Reanimatologiya = General Reanimatology. 2011; 7 (5): 57–66. http://dx.doi.org/10.15360/1813-9779-2011-5-57. [In Russ., In Engl.]