Jorge Kasper

Randomized Comparison of Sevoflurane Versus Propofol to Reduce Perioperative Myocardial Ischemia in Patients Undergoing Noncardiac Surgery

Background— Volatile anesthetics provide myocardial preconditioning in coronary surgery patients. We hypothesized that sevoflurane compared with propofol reduces the incidence of myocardial ischemia in patients undergoing major noncardiac surgery. Methods and Results— We enrolled 385 patients at cardiovascular risk in 3 centers. Patients were randomized to maintenance of anesthesia with sevoflurane or propofol. We recorded continuous ECG for 48 hours perioperatively, measured troponin T and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) on postoperative days 1 and 2, and evaluated postoperative delirium by the Confusion Assessment Method. At 6 and 12 months, we contacted patients by telephone to assess major adverse cardiac events. The primary end point was a composite of myocardial ischemia detected by continuous ECG and/or troponin elevation. Additional end points were postoperative NT-proBNP concentrations, major adverse cardiac events, and delirium. Patients and outcome assessors were blinded. We tested dichotomous end points by &khgr;2 test and NT-proBNP by Mann–Whitney test on an intention-to-treat basis. Myocardial ischemia occurred in 75 patients (40.8%) in the sevoflurane and 81 (40.3%) in the propofol group (relative risk, 1.01; 95% confidence interval, 0.78–1.30). NT-proBNP release did not differ across allocation on postoperative day 1 or 2. Within 12 months, 14 patients (7.6%) suffered a major adverse cardiac event after sevoflurane and 17 (8.5%) after propofol (relative risk, 0.90; 95% confidence interval, 0.44–1.83). The incidence of delirium did not differ (11.4% versus 14.4%; P=0.379). Conclusions— Compared with propofol, sevoflurane did not reduce the incidence of myocardial ischemia in high-risk patients undergoing major noncardiac surgery. The sevoflurane and propofol groups did not differ in postoperative NT-proBNP release, major adverse cardiac events at 1 year, or delirium. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00286585.

Troponin T and B-Type Natriuretic Peptide After On-Pump Cardiac Surgery Prognostic Impact on 12-Month Mortality and Major Cardiac Events After Adjustment for Postoperative Complications

Background— The independent predictive value of troponin T (TNT) after on-pump cardiac surgery was established in several studies. However, adjustment was limited to preoperative risk factors without considering perioperative complications. Data on the prognostic value of postoperative B-type natriuretic peptide (BNP) are scarce. Our aim was to assess the independent value of TNT and BNP to predict 12-month outcome after cardiac surgery with adjustment for preoperative risk estimates and postoperative complications and to report risk stratification gains when considering the European System for Cardiac Operative Risk Evaluation (EuroSCORE) combined with postoperative biomarkers. Methods and Results— This prospective cohort study included consecutive patients undergoing on-pump cardiac surgery between 2007 and 2010. We evaluated postoperative TNT and BNP, the EuroSCORE, and postoperative complications as predictors of adverse events using Cox regression. The primary end point was death or major adverse cardiac events within 1 year after surgery. We calculated the net reclassification index of TNT and BNP in addition to the EuroSCORE. We enrolled 1559 patients, of whom 176 (11.3%) experienced an event. The adjusted hazard ratio of TNT >0.8 &mgr;g/L was 2.13 (95% confidence interval, 1.47–3.15) and of BNP >790 ng/L was 2.44 (95% confidence interval, 1.65–3.62). The net reclassification index of the addition of TNT and BNP to the EuroSCORE was 0.276 (95% confidence interval, 0.195–0.348). Conclusions— Postoperative TNT and BNP are strong predictors of 1-year events after on-pump cardiac surgery independent of preoperative risk factors and postoperative complications. Updating the preoperative EuroSCORE risk with postoperative TNT and BNP after surgery allows for improved prediction of 1-year death or major adverse cardiac events.

Additional Cross-sectional Transesophageal Echocardiography Views Improve Perioperative Right Heart Assessment

Background:Right heart failure is an important cause of perioperative morbidity and mortality, and transesophageal echocardiography (TEE) is crucial for its diagnosis. However, only four of the 20 cross-sectional views recommended in current guidelines for intraoperative TEE focus on the right heart. This study analyzed whether incorporating additional views into the standard TEE examination improves assessment of the right heart. Methods:Sixty patients underwent standard TEE examination after induction of anesthesia. In addition, five views focusing on the right heart were acquired. Offline analysis tested: (1) whether the additional TEE views can be acquired as reliably as standard views including parts of the right heart; whether incorporating additional views improves the assessment of (2) eight or more right ventricular wall segments based on a predefined nine-segment model; (3) the tricuspid or pulmonary valve in two or more planes; and (4) transvalvular tricuspid and pulmonary flow in orthograde fashion. Results:Additional views could be imaged as reliably (88%) as standard views (90%). Incorporating some of the additional views allowed the assessment of eight or more right ventricular segments in 59 (98%) versus 18 patients (30%) by the standard views alone, and of the pulmonary valve in two or more planes in 60 (100%) versus 15 patients (25%). Several additional views improved orthograde assessment of transvalvular pulmonary flow, but not of tricuspid flow. Conclusions:The additional TEE views focusing on the right heart can be acquired as reliably as standard views. Incorporating three of them into the standard TEE examination improves comprehensive assessment of the right heart.

12-Month Outcome After Cardiac Surgery: Prediction by Troponin T in Combination With the European System for Cardiac Operative Risk Evaluation

BACKGROUND The prognostic value of troponin T for midterm outcome in cardiac surgery is insufficiently known. We aimed to assess the value of troponin T to predict 12-month outcome after cardiac surgery, as a single predictor and in combination with the European system for cardiac operative risk evaluation (EuroSCORE). METHODS This cohort study included consecutive patients undergoing on-pump cardiac surgery between January 2005 and December 2006. We evaluated postoperative troponin T (TNT) on days 1 and 2 and the EuroSCORE as predictor variables. The primary composite endpoint was all-cause mortality or any major adverse cardiac event (MACE) at 12 months. Logistic regression was used to study the prognostic effect of TNT in a univariate analysis and after adjustment for EuroSCORE. The area under the receiver-operator curve (AUC) was calculated to report the discriminatory performance of the models. RESULTS Seven hundred forty-one patients were available for analysis. Within 12 months after surgery, 92 (12.4%) patients had a MACE, 48 (6.5%) of whom died. A multivariate model of continuous TNT and the continuous logistic EuroSCORE showed a significant independent association between TNT and the composite endpoint (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.02 to 1.04 per 0.1 microg/L increase in TNT). The AUC for the prediction of the composite endpoint of the model combining TNT and the EuroSCORE was 0.72; when based on EuroSCORE alone it was 0.64 (p < 0.0001). CONCLUSIONS Postoperative TNT increase (per 0.1 microg/L) is a strong independent predictor of 12-month outcome after on-pump cardiac surgery. Updating the preoperative EuroSCORE risk with postoperative TNT allows for better prediction of 12-month MACE and all-cause mortality.

Response to Letters Regarding Article, “Randomized Comparison of Sevoflurane Versus Propofol to Reduce Perioperative Myocardial Ischemia in Patients Undergoing Noncardiac Surgery”

We thank the authors of the letters for their interest in our publication.1 Their comments focused on the following issues: (1) hypothesized effect; (2) study end points, including methods and duration of the ischemia assessment; (3) factors potentially masking the preconditioning effect of sevoflurane (eg, opioids), and (4) inclusion of patients undergoing orthopedic surgery.