Endothelial dysfunction and myocardial injury after major emergency abdominal surgery: a prospective cohort study

Abstract

Background: Preoperative endothelial dysfunction is a predictor of myocardial injury and major adverse cardiac events. Non-cardiac surgery is known to induce acute endothelial changes. The aim of this explorative cohort study was to assess the extent of systemic endothelial dysfunction after major emergency abdominal surgery and the potential association with postoperative myocardial injury.Methods: Patients undergoing major emergency abdominal surgery were included in this prospective cohort study. The primary outcome was the change in endothelial function expressed as the reactive hyperemia index from 4-24 h after surgery until postoperative day 3-5. The reactive hyperemia index was assessed by non-invasive digital pulse tonometry. Secondary outcomes included changes in biomarkers of nitric oxide metabolism and bioavailability. All assessments were performed at the two separate time points in the postoperative period. Clinical outcomes included myocardial injury within the third postoperative day and major adverse cardiovascular events within 30 days of surgery. Results: Between October 2016 and June 2017, 83 patients were included. The first assessment of the endothelial function, 4-24 h, was performed 15.8 (SD 6.9) hours after surgery and the second assessment, postoperative day 3-5, was performed 83.7 (SD 19.8) hours after surgery. The reactive hyperemia index was suppressed early after surgery and did not increase significantly; 1.64 (95% CI 1.52-177) at 4-24 h after surgery vs. 1.75 (95% CI 1.63-1.89) at postoperative day 3-5, p = 0.34. The L-arginine/ADMA ratio, expressing the nitric oxide production, was reduced in the perioperative period and correlated significantly with the reactive hyperemia index. A total of 16 patients (19.3%) had a major adverse cardiovascular event, of which 11 patients (13.3%) had myocardial injury. The Larginine/ADMA ratio was significantly decreased at 4-24 h after surgery in patients suffering myocardial injury.Conclusion: This explorative pathophysiological study showed that acute systemic endothelial dysfunction was present early after major emergency abdominal surgery and remained unchanged until day 3-5 after the procedure. Early postoperative disturbances in the nitric oxide bioavailability might add to the pathogenesis of myocardial injury. This pathophysiological link should be confirmed in larger studies. Trial registration: clinicaltrials.gov no. NCT03010969.

Patient perceptive focus on recovery: An exploratory study on follow‐up after major emergency abdominal surgery

“…This study reports a secondary outcome from a prospective protocol (ClinicalTrials no. NCT03010969), and the primary outcome has earlier been reported 18,19 . Data were collected from the Department of Surgery at Zealand University Hospital, Denmark.…”

“…NCT03010969), and the primary outcome has earlier been reported. 18,19 Data were collected from the Department of Surgery at Zealand University Hospital, Denmark. The protocol was approved by the Danish Local Ethics Committee (no.…”

The effect of remote ischaemic preconditioning on endothelial function after hip fracture surgery

“…We have previously shown that RHI and data variation depend on the type of surgery and population. 3,5,11 The pilot endothelial assessments were performed within the structure of the larger PIXIE trial in order to guide sample size calculations for a future trial with endothelial function as a main outcome. For this pilot sub-study, 20 patients were included in each group.…”

“…While pre‐operative endothelial dysfunction has been associated with the risk of developing perioperative major adverse cardiovascular events 8‐10 the clinical consequences of endothelial dysfunction in the perioperative period remain to be established. Endothelial dysfunction early after surgery may play a role in the pathophysiology of myocardial injury 11 …”

“…Endothelial dysfunction early after surgery may play a role in the pathophysiology of myocardial injury. 11 Remote ischaemic preconditioning (RIPC) is a non-invasive procedure with reversible episodes of ischaemia and reperfusion…”