The Role of Frailty in Failure to Rescue After Cardiovascular Surgery

Dewan, Krish C.; Navale, Suparna M.; Hirji, Sameer; Koroukian, Siran M.; Dewan, Karan S.; Svensson, Lars G.; Gillinov, A. Marc; Roselli, Eric E.; Johnston, Douglas R.; Bakaeen, Faisal G.; Soltesz, Edward G.

doi:10.1016/j.athoracsur.2020.06.065

Cited by 24 publications

(13 citation statements)

References 19 publications

(23 reference statements)

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“…21 In our experience, frailty assessment has been especially useful in picking a potential therapy for patients with severe aortic valve stenosis (treatment choices are nonsurgical management, surgical aortic valve replacement, and TAVR) and patients with coronary artery disease (treatment choices are percutaneous coronary intervention, medical therapy, or surgical revascularization). [21][22][23][24][25] Frailty scoring also directs the management of heart failure patients (medical management vs mechanical support vs heart transplantation). 26 Some evidence suggests that a frail patient's outcomes are improved when cardiac surgery is performed at a high-volume center.…”

Section: Managementmentioning

confidence: 99%

Pre-Habilitation of Cardiac Surgical Patients, Part 2: Frailty, Malnutrition, Respiratory disease, Alcohol/Smoking cessation and Depression

Subramanian

Knight

Sultan

et al. 2022

Semin Cardiothorac Vasc Anesth

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The concept of “pre-habilitation” comprises screening for and identification of pre-existing disorders followed by medical optimization. This is performed for many types of surgeries, but may have profound impacts on outcomes, particularly in cardiac surgery given the multiple comorbidities typically carried by these patients. Components of pre-habilitation include direct medical intervention by preoperative specialists as well as significant care coordination and shared decision-making. In this second part of a two-part review, the authors describe existing evidence to support the optimization of various preoperative problems and present a few institutional protocols utilized at out center for cardiac presurgical care. This second installment will focus on alcohol and smoking cessation and the management of frailty, malnutrition, respiratory disease, and depression.

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Section: Managementmentioning

confidence: 99%

Pre-Habilitation of Cardiac Surgical Patients, Part 2: Frailty, Malnutrition, Respiratory disease, Alcohol/Smoking cessation and Depression

Subramanian

Knight

Sultan

et al. 2022

Semin Cardiothorac Vasc Anesth

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show abstract

“…Our findings suggest that the selection of frailty instrument could be tailored to specific outcomes and follow-up durations to better inform patient-centered decision-making, preoperative optimization, and health resource planning. Frailty is associated with operative and long-term mortality, 4,8,52 cardiac resuscitation, 37,53 failure to rescue, 52,54 prolonged hospital and intensive care unit stay, 4,53 surgical site infection, 4 nonhome discharge, 52,54 and readmission, 37 all of which contribute to poor quality of life and increased health care resource utilization.…”

Section: Jama Network Open | Surgerymentioning

confidence: 99%

Comparison of Multidimensional Frailty Instruments for Estimation of Long-term Patient-Centered Outcomes After Cardiac Surgery

et al. 2022

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IMPORTANCELittle is known about the performance of available frailty instruments in estimating patient-relevant outcomes after cardiac surgery. OBJECTIVE To examine how well the Johns Hopkins Adjusted Clinical Groups (ACG) frailty indicator, the Hospital Frailty Risk Score (HFRS), and the Preoperative Frailty Index (PFI) estimate long-term patient-centered outcomes after cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted in Ontario, Canada, among residents 18 years and older who underwent coronary artery bypass grafting or aortic, mitral or tricuspid valve, or thoracic aorta surgery between October 2008 and March 2017.Long-term care residents, those with discordant surgical encounters, and those receiving dialysis or dependent on a ventilator within 90 days were excluded. Statistical analysis was conducted from July 2021 to January 2022. MAIN OUTCOMES AND MEASURESThe primary outcome was patient-defined adverse cardiovascular and noncardiovascular events (PACE), defined as the composite of severe stroke, heart failure, long-term care admission, new-onset dialysis, and ventilator dependence. Secondary outcomes included mortality and individual PACE events. The association between frailty and PACE was examined using cause-specific hazard models with death as a competing risk, and the association between frailty and death was examined using Cox models. Areas under the receiver operating characteristic curve (AUROC) were determined over 10 years of follow-up for each frailty instrument. RESULTSOf 88 456 patients (22 924 [25.9%] female; mean [SD] age, 66.3 [11.1] years), 14 935 (16.9%) were frail according to ACG criteria, 63 095 (71.3%) according to HFRS, and 76 754 (86.8%) according to PFI. Patients with frailty were more likely to be older, female, and rural residents; to have lower income and multimorbidity; and to undergo urgent surgery. Patients meeting ACG criteria (hazard ratio [HR], 1.66; 95% CI, 1.60-1.71) and those with higher HFRS scores (HR per 1.0-point increment, 1.10; 95% CI, 1.09-1.10) and PFI scores (HR per 0.1-point increment, 1.75; 95% CI, 1.73-1.78) had higher rates of PACE. Similar magnitudes of association were observed for each frailty instrument with death and individual PACE components. The HFRS had the highest AUROC for estimating PACE during the first 2 years and death during the first 4 years, after which the PFI had the highest AUROC. CONCLUSIONS AND RELEVANCEThese findings could help to tailor the use of frailty instruments by outcome and follow-up duration, thus optimizing preoperative risk stratification, patient-centered decision-making, candidate selection for prehabilitation, and personalized monitoring and health resource planning in patients undergoing cardiac surgery.

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“…Frail patients can expect better outcomes with lower costs at cardiac surgical centers of excellence that can adequately manage postoperative outcomes. 1 During cardiopulmonary bypass (CPB), hypoperfusion of the gut exists, which leads to increased intestinal permeability, allowing endotoxins to enter the portal circulation, endotoxin was found in the pericardial shed blood. The endotoxin levels were found higher after induction of anesthesia, immediately after the start of CPB, and after the release of the cross-clamp.…”

Section: Minimally Invasive Extracorporeal Circulation and Toraymyxin...mentioning

confidence: 99%

Minimally invasive extracorporeal circulation and toraymyxin, option for frail patient

Condello¹,

Nasso²,

Fiore³

et al. 2022

Journal of Cardiac Surgery

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The Role of Frailty in Failure to Rescue After Cardiovascular Surgery

Cited by 24 publications

References 19 publications

Pre-Habilitation of Cardiac Surgical Patients, Part 2: Frailty, Malnutrition, Respiratory disease, Alcohol/Smoking cessation and Depression

Pre-Habilitation of Cardiac Surgical Patients, Part 2: Frailty, Malnutrition, Respiratory disease, Alcohol/Smoking cessation and Depression

Comparison of Multidimensional Frailty Instruments for Estimation of Long-term Patient-Centered Outcomes After Cardiac Surgery

Minimally invasive extracorporeal circulation and toraymyxin, option for frail patient

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