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Published on: March 27, 2018
Prevalence, phenotypes, and long-term outcomes of cardiac complications after arterial vascular surgery
Vanessa Thommen1, Danielle M Gualandro2, Christian Puelacher1
1Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.
Insights
Cardiac complications are common after arterial vascular surgery, with perioperative myocardial infarction/injury (PMI) occurring in 18.7% of patients. Specific causes like extra-cardiac PMI, postoperative acute heart failure (pAHF), and tachyarrhythmias significantly increase mortality and major adverse cardiac events (MACE).
Area of Science:
- Cardiology
- Vascular Surgery
- Critical Care Medicine
Background:
- Cardiac complications are a significant concern in patients undergoing arterial vascular surgery.
- High-risk patients undergoing these procedures have a substantial risk of perioperative myocardial infarction/injury (PMI) and major adverse cardiac events (MACE).
- Understanding the incidence, phenotypes, and prognostic implications of these complications is crucial for improving patient outcomes.
Purpose of the Study:
- To determine the incidence and phenotypes of cardiac complications following arterial vascular surgery.
- To investigate heterogeneity in cardiac complication types and their association with surgical procedures.
- To assess short- and long-term mortality and MACE rates based on different cardiac complication phenotypes.
Main Methods:
- A prospective diagnostic study involving high-risk patients (age >65 or with known cardiovascular disease) undergoing arterial vascular surgery between 2014 and 2019.
- Central adjudication of cardiac complications, including perioperative myocardial infarction/injury (PMI), by two independent physicians.
- Hierarchical classification of PMI aetiologies (extra-cardiac vs. cardiac subtypes: T1MI, tachyarrhythmia, pAHF, LT2MI) and assessment of 1-year mortality and MACE.
Main Results:
- PMI occurred in 18.7% of 2,265 patients, with significant variation based on surgical procedure (e.g., 42% after open aortic aneurysm repair vs. 11% after carotid endarterectomy).
- Within 1 year, 11.8% of patients died and 14.3% experienced MACE.
- Prognosis varied significantly by PMI aetiology: extra-cardiac PMI, T1MI, tachyarrhythmia, and pAHF were associated with substantially higher mortality and MACE rates compared to patients without PMI.
Conclusions:
- Cardiac complications, particularly PMI, are frequent after arterial vascular surgery and linked to high mortality and MACE.
- Extra-cardiac PMI, postoperative acute heart failure (pAHF), and tachyarrhythmias portend a particularly poor prognosis.
- There is an urgent need for improved diagnosis and targeted treatment strategies for cardiac complications in this patient population.
Objective:
The aim of this study prospective diagnostic study with central adjudication was to (1) determine the incidence and phenotypes of cardiac complications after arterial vascular surgery, (2) investigate possible heterogeneity, and (3) assess short- and long-term mortality and major adverse cardiac events (MACEs) according to different phenotypes of these cardiac complications.
Methods:
Consecutive high-risk patients (age >65 years or with known cardiovascular disease) undergoing arterial vascular surgery were included between 2014 and 2019. Cardiac complications including perioperative myocardial infarction/injury (PMI) were centrally adjudicated by two independent physicians. PMI etiologies were hierarchically classified into extracardiac if caused by a primarily extracardiac disease such as severe sepsis or pulmonary embolism, or cardiac, and further subtyped into type 1 MI, tachyarrhythmia, postoperative acute heart failure (pAHF), or likely type 2 MI. All-cause death and MACE, including acute MI, pAHF, life-threatening arrhythmia, and cardiovascular death, were assessed during 1-year follow-up.
Results:
Among 2'265 patients (median age 71 years, 27% female), PMI occurred in 423 (18.7%) with substantial heterogeneity. The highest incidence was seen after open thoracic, thoracoabdominal and abdominal aortic aneurysm repair (42%) and the lowest after carotid endarterectomy (11%). Open and endovascular peripheral revascularization procedures were associated with PMI rates of 17% and 14%, respectively. Within 1 year, 267/2'265 patients (11.8%) died and at least one MACE occurred in 325/2'265 patients (14.3%). Long-term outcomes differed substantially according to etiology: in patients with extracardiac PMI, type 1 MI, tachyarrhythmia, pAHF, and likely type 2 MI, 67%, 24%, 45%, 47%, and 18% died and 63%, 50%, 73%, 73%, and 20% had MACE within 1 year, respectively, in comparison with 8% and 10% (all P < .001) in patients without a PMI.
Conclusions:
The incidence of cardiac complications after arterial vascular surgery procedures is high and is associated with high rates of mortality and MACE, with extracardiac PMI, pAHF, and tachyarrhythmias being associated with a particularly poor prognosis, underscoring the urgent need for appropriate diagnosis and treatment.
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