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Elevated troponin levels within 3 days of surgery, independent of the presence of symptoms, are strongly linked to increased risk of short- and long-term morbidity and mortality. However, the value of screening with troponin measurements is controversial. The Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery recommends measuring daily troponin for 48 to 72 hours after surgery in high-risk patients. Nevertheless, others doubt this recommendation, in part because postoperative elevated levels of troponin describe very little in terms of disease or event-specific pathogenesis and etiology, and thus, tailoring an intervention remains a challenge. This Pro-Con debate offers evidence-based data to stimulate physician understanding of daily practice and its significance in this matter, and assist in determining whether to use (Pro) or not to use (Con) this surveillance., (Copyright © 2022 International Anesthesia Research Society.)

Study Objective: Quantifying functional capacity is a core component of preoperative cardiovascular risk assessment. Lower metabolic equivalents (METs) are associated with higher morbidity/mortality in non-surgical and surgical populations. However, actually measuring METs preoperatively is rare. We sought to determine the correlation of self-reported METs using the questionnaire of the MET: REevaluation for Perioperative cArdIac Risk (MET-REPAIR) study and objectively measured METs by gold-standard cardiopulmonary exercise testing (CPET)., Design: Single-center prospective validation study., Setting: University hospital., Patients: We enrolled adult patients aged ≥45 undergoing out-patient cardiac rehabilitation., Intervention: Patients completed the MET-REPAIR Questionnaire and the Duke Activity Status Index (DASI), had blood samples drawn, and underwent undergoing routine CPET., Measurements: We compared measured METs by CPET to 1) self-reported METs (the MET-REPAIR Questionnaire), 2) the DASI score, 3) stand-alone questions, and 4) N-terminal pro-brain natriuretic peptide (NT-proBNP) concentrations., Main Results: 140 patients were recruited. Measured METs by CPET correlated with 1) self-reported METs by the MET-REPAIR Questionnaire (ρ = 0.489, "fair"), 2) self-reported physical activity by the DASI (ρ = 0.487, "fair"), 3) the self-reported continual stair climbing ability (one of the stand-alone questions; ρ = 0.587, "fair") and 4) NT-proBNP concentrations (ρ = -0.353, "poor"). The area under the receiver operating characteristic curve (AUROC) for the ability to perform more than 4 METs were: highest for flights of stairs (0.841 [95%CI 0.735-0.948], p < 0.05 to rest, optimum: 3 flights), not significantly different between MET-REPAIR Questionnaire and DASI (0.666 [95%CI 0.551-0.781], optimum: 6 METs vs. 0.704 [95%CI 0.578-0.829], optimum: 32.2 points or 6.7 METs, p = 0.405), and not significant for NT-proBNP: (0.623 [95%CI 0.483-0.763])., Conclusions: The MET-REPAIR Questionnaire correlates with measured METs; all utilized forms of self-reported physical activity overestimate measured METs. NT-proBNP correlates poorly with measured METs., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Aims: Primary graft dysfunction (PGD) is a feared complication after heart transplantation (HTX). HTX patients frequently receive veno-arterial extracorporeal membrane oxygenation (VA-ECMO) until graft recovery. Long-term mortality of patients weaned from VA-ECMO after HTX is comparable with non-ECMO patients. However, impact on quality of life is unknown. This study investigated days alive and out of hospital (DAOH) as patient-centred outcome in HTX patients at 1 year after surgery., Methods and Results: This retrospective single-centre cohort study included patients who underwent HTX at the University Hospital Düsseldorf, Germany, from 2010 to 2020. Main exposure was VA-ECMO due to PGD. VA-ECMO and non-VA-ECMO patients were compared regarding the primary endpoint DAOH at 1 year after HTX. Subgroup analysis for patients weaned from VA-ECMO was performed. In total, 144 patients were included into analysis; 1 year mortality was significantly lower in non-ECMO patients [non-ECMO 14.3% (14/98) vs. VA-ECMO 34.8% (16/46), adjusted hazard ratio: 0.32, 95% confidence interval: 0.15-0.74; P = 0.002]. Mortality did not differ significantly between patients weaned from VA-ECMO and non-ECMO patients [non-ECMO 14.3% (14/98) vs. VA-ECMO (weaned) 18.9% (7/37), adjusted hazard ratio: 0.72, 95% confidence interval: 0.27-1.90; P = 0.48]. DAOH were significantly higher in non-ECMO patients compared with VA-ECMO patients and patients weaned from VA-ECMO [non-ECMO vs. VA-ECMO: median 310 (inter-quartile range 277-327) days vs. 243 (0-288) days; P < 0.0001; non-ECMO vs. VA-ECMO (weaned): 310 (277-327) days vs. 253 (208-299) days; P < 0.0001]. These results were still significant after multivariable adjustment with forced entry of predefined covariables., Conclusions: Despite similar survival rates, VA-ECMO due to PGD has a relevant life impact as defined by DAOH in the first year after HTX. As a more patient-centred endpoint, DAOH may contribute to a more comprehensive assessment of outcome in HTX patients., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: Preliminary data suggest that preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) may improve risk prediction in patients undergoing noncardiac surgery., Objective: To determine whether preoperative NT-proBNP has additional predictive value beyond a clinical risk score for the composite of vascular death and myocardial injury after noncardiac surgery (MINS) within 30 days after surgery., Design: Prospective cohort study., Setting: 16 hospitals in 9 countries., Patients: 10 402 patients aged 45 years or older having inpatient noncardiac surgery., Measurements: All patients had NT-proBNP levels measured before surgery and troponin T levels measured daily for up to 3 days after surgery., Results: In multivariable analyses, compared with preoperative NT-proBNP values less than 100 pg/mL (the reference group), those of 100 to less than 200 pg/mL, 200 to less than 1500 pg/mL, and 1500 pg/mL or greater were associated with adjusted hazard ratios of 2.27 (95% CI, 1.90 to 2.70), 3.63 (CI, 3.13 to 4.21), and 5.82 (CI, 4.81 to 7.05) and corresponding incidences of the primary outcome of 12.3% (226 of 1843), 20.8% (542 of 2608), and 37.5% (223 of 595), respectively. Adding NT-proBNP thresholds to clinical stratification (that is, the Revised Cardiac Risk Index [RCRI]) resulted in a net absolute reclassification improvement of 258 per 1000 patients. Preoperative NT-proBNP values were also statistically significantly associated with 30-day all-cause mortality (less than 100 pg/mL [incidence, 0.3%], 100 to less than 200 pg/mL [incidence, 0.7%], 200 to less than 1500 pg/mL [incidence, 1.4%], and 1500 pg/mL or greater [incidence, 4.0%])., Limitation: External validation of the identified NT-proBNP thresholds in other cohorts would reinforce our findings., Conclusion: Preoperative NT-proBNP is strongly associated with vascular death and MINS within 30 days after noncardiac surgery and improves cardiac risk prediction in addition to the RCRI., Primary Funding Source: Canadian Institutes of Health Research.

Background: Myocardial injury after noncardiac surgery (MINS) is a mostly asymptomatic condition that is strongly associated with 30-day mortality; however, it remains mostly undetected without systematic troponin T monitoring. We evaluated the cost and consequences of postoperative troponin T monitoring to detect MINS., Methods: We conducted a model-based cost-consequence analysis to compare the impact of routine troponin T monitoring versus standard care (troponin T measurement triggered by ischemic symptoms) on the incidence of MINS detection. Model inputs were based on Canadian patients enrolled in the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) study, which enrolled patients aged 45 years or older undergoing inpatient noncardiac surgery. We conducted probability analyses with 10 000 iterations and extensive sensitivity analyses., Results: The data were based on 6021 patients (48% men, mean age 65 [standard deviation 12] yr). The 30-day mortality rate for MINS was 9.6%. We determined the incremental cost to avoid missing a MINS event as $1632 (2015 Canadian dollars). The cost-effectiveness of troponin monitoring was higher in patient subgroups at higher risk for MINS, e.g., those aged 65 years or more, or with a history of atherosclerosis or diabetes ($1309)., Conclusion: The costs associated with a troponin T monitoring program to detect MINS were moderate. Based on the estimated incremental cost per health gain, implementation of postoperative troponin T monitoring seems appealing, particularly in patients at high risk for MINS.

Objective: Normative values of left ventricular (LV) end-diastolic area and diameter (EDA and EDD) for intraoperative transoesophageal echocardiography (TEE) have not been established. We aimed to define the ranges of LV EDA and EDD for intraoperative TEE examinations in patients undergoing coronary artery bypass graft (CABG) surgery., Methods: A MEDLINE search for studies reporting LV EDA and EDD in CABG patients was performed. Individual-level dataset from 333 anaesthetised and mechanically ventilated patients with preserved LV function (study population) were received from 8 studies. EDA and calculated EDD values in the study population were compared with summary mean EDD values obtained by transthoracic echocardiography (TTE) in 2 studies of 500 awake patients with coronary artery disease (CAD). Further, the influence of prespecified factors on EDD was evaluated through a multivariate regression model., Results: LV EDA and EDD values measured by TEE in anaesthetised CABG patients were 16.7±4.7 cm 2 and 4.6±0.6 cm, respectively. EDD values measured by TEE in anaesthetised patients were 10% to 13% less those measured by TTE in 2 studies of awake patients (p<0.001). Body surface area, age and fractional area change but not sex were factors that affected LV EDD., Conclusion: LV EDD values measured by intraoperative TEE in anaesthetised and mechanically ventilated CABG patients were 10% to 13% less than those measured by TTE in awake CAD patients. This finding indicates that independent normative values specific for intraoperative TEE should be established for guiding intraoperative clinical decisions., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

Objectives: To determine the proportion of noncardiac surgery patients exceeding the published 99th percentile or change criteria with the high sensitivity Troponin T (hs-TnT) assay., Design and Methods: We measured hs-TnT preoperatively and postoperatively on days 1, 2 and 3 in 325 adults., Results: Postoperatively 45% (95% CI: 39-50%) of patients had hs-TnT≥14ng/L and 22% (95% CI:17-26%) had an elevation (≥14ng/L) and change (>85%) in hs-TnT., Conclusion: Further research is needed to inform the optimal hs-TnT threshold and change in this setting., (Copyright © 2011 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.)

All patients should undergo surgical procedures in the most stable and favourable condition with a continuation of chronic medication. Accordingly, this medication should be continued until the day before surgery in most patients. The preoperative period should be used to evaluate the completeness and quality of the medical treatment. Are all patient with cardiological indications for beta-receptor blocking agents, ACE-inhibitors and statins treated with these drugs? Is diabetes being adequately treated? Are the doses of the medication for the treatment of thyroid dysfunction within the optimal range? If there is room for improvement, adjustments should be done cautiously and well in advance. In contrast, there are no recognised situations in which a medication should be started preoperatively in the absence of a pre-established chronic indication. Management of antiplatelet agents and cumarins requires careful consideration. The hazards of continuing and withholding treatment must be evaluated. In patients who have suffered a cardiovascular event and/or have undergone (coronary) revascularisation, elective surgery must be delayed for weeks or months depending on the circumstances and the devices used.