Risk factors and outcomes of myocardial injury after non-cardiac surgery in high-risk patients who underwent radical cystectomy

Abstract

Radical cystectomy is considered the standard treatment for patients with muscle-invasive bladder tumors and has high postoperative complication rates among urological surgeries. High-risk patients, defined as those ≥45 years of age with history of coronary artery disease, stroke, or peripheral artery disease or those ≥65 years of age, can have a higher incidence of cardiac complications. Therefore, we evaluated the incidence, risk factors, and outcomes of myocardial injury after non-cardiac surgery (MINS) in high-risk patients who underwent radical cystectomy. This retrospective observational study analyzed 248 high-risk patients who underwent radical cystectomy. MINS was defined as serum troponin I concentration ≥0.04 mg/L within postoperative 3 days. The risk factors for MINS were evaluated by multivariate logistic regression analysis. Postoperative outcomes were evaluated. The 1-year survival after radical cystectomy was also compared between patients who developed MINS (MINS group) and those who did not (non-MINS group) by Kaplan–Meier analysis. MINS occurred in 35 patients (14.1%). Multivariate logistic regression analysis showed that early diastolic transmitral filling velocity (E)/early diastolic septal mitral annular velocity (E’) ratio (odds ratio = 1.102, 95% confidence interval [1.009–1.203], P = .031) and large volume blood transfusion (odds ratio = 2.745, 95% confidence interval [1.131–6.664], P = .026) were significantly associated with MINS in high-risk patients who underwent radical cystectomy. Major adverse cardiac events and 1-year mortality were significantly higher in the MINS group than in the non-MINS group (17.1% vs 6.1%, P = .035; 28.6% vs 12.7%, P = .021, respectively). Kaplan–Meier analysis showed significantly lower 1-year survival in the MINS group than in the non-MINS group ( P = .010). MINS occurred in 14.1% of patients. High E/E’ ratio and large volume blood transfusion were risk factors for MINS in high-risk patients who underwent radical cystectomy. Postoperative major adverse cardiac events and 1-year mortality were significantly higher in the MINS group than in the non-MINS group. Preoperative evaluation of risk factors for MINS may provide useful information to detect cardiovascular complications after radical cystectomy in high-risk patients.

Myocardial injury after major noncardiac surgery: A secondary analysis of a randomized controlled trial

“…5 In our study, the increased baseline troponin and pre and postoperative NT-proBNP levels in MINS patients reflected the impaired ventricular diastolic function associated with hypertension-induced ventricular hypertrophy and, in turn, with a reduced ability to adapt to acute volemic shifts and increased ventricular afterload. 2,20 In contrast with previous studies that focused on patient risk factors, for the first time, we identified procedure-related factors, namely prolonged surgery and need for transfusion, as important contributors to the development of MINS in the entire and matched cohorts. The higher postoperative weight gain and SIRS reflected the severity of surgery along with intense neuroendocrine and inflammatory responses to extensive tissue trauma.…”

“…In agreement with previous studies, MINS was associated with increased 60-day mortality and a higher incidence of MACEs. 1,4,6,20,22,23 Criteria for postoperative MI were met in only 5 patients, whereas 104 others exhibited transient elevations in cTnI/ TnT without ECG abnormalities or clinical signs of myocardial ischemia. In contrast with the short-term negative impact of MINS on clinical outcome, survival up to 30 months after surgery was related mainly to the presence cancer.…”

Long-term major adverse cardiovascular events following myocardial injury after non-cardiac surgery: meta-analysis

“…The majority of studies included all types of non-cardiac surgery in their eligibility criteria 2 , 15 , 22 , 30 , 33–35 , 37 , 38 , 40 , 43 , 44 , 46–49 , 51 , 56 , 58 , 60–62 , 65 . Seventeen studies focused on specific surgical subspecialties including vascular 28 , 39 , 41 , 42 , 45 , 52–54 , orthopaedic 29 , 31 , 32 , 50 , 55 , 59 , 64 , urology 36 , 63 and thoracic surgery 36 , 63 . Regarding surgical acuity, only two studies focused on emergency non-cardiac surgery 31 , 32 , whilst nine studies specifically included only patients undergoing elective surgery 28 , 35–38 , 52 , 53 , 58 , 63 .…”

Can we lower the rates of cystectomy complications by modifying risk factors? A review of the literature

“…A study by Parker et al [ 31 ] stated that approximately 25% of patients undergoing RC with PBT experience an infection within 30 days of surgery. Further reports demonstrated that myocardial injury occurred in 14.1% of patients with incidence of PBL and PBT during RC [ 32 ]. Due to the emerging role of PBL in RC complications, surgeons should be encouraged to cooperate closely with the anaesthesiologic unit and cautiously perform the surgeries, if possible, using available new technologies and haemostatic agents to decrease the rates of needless PBT.…”