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Perioperative Cardiac Events in Endovascular Repair of Complex Aortic Aneurysms and Association With Preoperative Studies
Study Questions:
What is the association between preoperative evaluation and cardiac events in patients undergoing endovascular repair of thoracoabdominal (TAA) and juxtarenal aortic aneurysms?
Methods:
A total of 395 patients who underwent endovascular repair of TAA and complex abdominal aneurysms were retrospectively reviewed. Exclusion criteria included lack of perioperative troponin assessment or preoperative cardiac workup. Cardiac events included myocardial infarction (MI), atrial fibrillation (AF), ventricular arrhythmia (VA), or cardiac-related death.
Results:
A total of 246 patients were assessed (82% male). Of these, 78% had a history of coronary artery disease (CAD), 38% had prior coronary revascularization, and 16% required home O2 therapy for chronic obstructive pulmonary disease. Overall event rates were as follows: MI 7.1%, AF 9%, VA 3%, and 30-day cardiac-related mortality 6%. Preoperative evaluation of CAD included cardiac catheterization in 49 (20%), cardiologist clearance in 18 (7%), and preoperative stress testing in 179 (73%). Of the 179 patients who had stress testing, 27 (15%) were positive for ischemia. Of those with a positive stress study, 22 underwent diagnostic catheterization and 8 patients underwent percutaneous coronary intervention prior to endovascular repair. Of these 8 patients, 2 (7.4% of 27) had a perioperative MI. There was no perioperative MI in those with positive stress studies who had a catheterization and continued medical therapy or were cleared by a cardiologist. Of the 152 patients with a negative stress test, 9 (6%) sustained a perioperative MI. VAs were independently associated with left atrial area, but not left ventricular (LV) ejection fraction or LV mass. There were no echocardiographic parameters associated with the development of postoperative AF.
Conclusions:
In this high-risk cohort of patients, the cardiac event rate is high, and close monitoring is required in the perioperative period. However, the outcome of preoperative cardiac testing and intervention did not appear to be associated with the risk of perioperative cardiac events.
Perspective:
Perioperative management and the utility of preoperative evaluation in high-risk patients with vascular disease have been debated. It is difficult to comment on the efficacy of preoperative testing in this small, nonrandomized study. However, these data are congruous with the CARP and most recent DECREASE trials that suggest preoperative evaluation of and intervention on coronary disease in stable patients is not associated with improved outcomes. Aggressive medical therapy is as good as medical therapy with preoperative screening for CAD ± revascularization is associated with lower cost burden to the health care system.
Keywords: Pulmonary Disease, Chronic Obstructive, Coronary Artery Disease, Myocardial Infarction, Cardiac Catheterization, Catheterization, Perioperative Period, Atrial Fibrillation, Aortic Aneurysm, Abdominal, Percutaneous Coronary Intervention
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