Evaluation of perioperative high-sensitive cardiac troponin i as a predictive biomarker of major adverse cardiovascular events after noncardiac surgery

ABSTRACT Background: Various studies suggest that perioperative concentrations of high-sensitivity troponins are incremental and predictive factors of a major adverse cardiac event (MACE) and all-cause mortality. Objective: The objective of the study was to evaluate the predictive value of high-sensitivity cardiac troponin I (hs-cTnI) in the development of MACE and all-cause mortality, within 30-days and 1-year follow-up after noncardiac surgery. Methods: In this prospective cohort study, we included men ≥ 45 years and women ≥ 55 years with ≥ 2 cardiovascular risk factors and undergoing intermediate or high-risk noncardiac surgery. Demographic and clinical information was collected from clinical charts. We measured baseline hs-cTnI 24 h before surgery, and its post-operative concentration 24 h after surgery. Results: In the entire sample, 8 patients (8.6%) developed MACE at 30-days follow-up (4 deaths), 12 (12.9%) within the 1st year (7 deaths), and 17 (18.2%) after complete post-surgical follow-up (10 deaths). We observed higher baseline and post-operative concentrations in patients who presented MACE (12 pg/ml vs. 3.5 pg/ml; p = 0.001 and 18.3 pg/ml vs. 5.45 pg/ml; p = 0.009, respectively). The hazard ratios (HRs) calculated by Cox regression analysis between the hs-cTnI baseline concentration and the post-operative development of MACE at 30-days and 1-year were 5.70 (95% confidence interval [CI], 1.10-29.40) with hs-cTnI > 6.2 pg/ml and 12.86 (95% CI, 1.42-116.34) with hs-cTnI > 3.3 pg/ml, respectively. The estimated post-operative HR death risk at 1-year was 14.43 (95% CI, 1.37-151.61) with hs-cTnI > 4.5 pg/ml. Conclusions: Pre-operative hs-cTnI was an independent predictive risk factor for MACE at 30-days and 1-year after noncardiac surgery and for all-cause mortality at 1-year after noncardiac surgery.

The protective effects of sevoflurane at different anesthesia depths on periperative myocardial ischemia in coronary heart disease patients undergoing noncardiac surgery / 实用医学杂志

Objective To study the protective effects of sevoflurane at different anesthesia depths on periperative myocardial ischemia in coronary heart disease patients undergoing noncardiac surgery.Methods 96 patients with coronary undergoing noncardiac surgery were randomly divided into three groups:control group (Group C),high-concentration sevoflurane group (Group S 1) and low-concentration sevoflurane group (Group S2).Etomidate,Propofol,Cisatracurium Besilate and Fentanyl were used for intravenous anesthetic induction and maintenance of anesthesia.In addition,B ispectralindex (BIS) remained between 35 ～ 45 and 45 ～ 55 in groups S1 and S2,re spectively.BIS remained between 40 ～ 50 in group C.Perioperative hemodynamic changes,ECG ST-segment before induction of anesthesia,endotracheal immediate intubation and extubation were recorded.Plasma concentrations of cTnT,high sensitive cardiac troponin (hs-cTnT) and high sensitive ereaetive protein (hs-CRP) were detected with central venous blood before anesthesia induction and immediate extubation.Results Compared with group C,the incidences of hypertension,tachycardia,myocardial ischemia,proiosystole and atrial fibrillation were significantly reduced in groups S1 and S2 (P ＜ 0.05);The incidences of bradycardia and hypotension groups were significantly higher in group S1 (P ＜ 0.05).Compared with group S1,the incidences of hypotension,bradycardia,myocardial ischemia were significantly reduced in group S2 (P ＜ 0.05).Compared with group C,plasma concentrations of cTnT,hs-cTnT and hs-CRP were significantly reduced after endotracheal extubation in group S1 and S2 (P ＜ 0.05).Conclusion Myocardial protective effect is better and less risky for patients with coronary artery disease undergoing noncardiac surgery by inhalation of 1.0％ to 2.5％ sevoflurane to maintain BIS between 45 to 55.

Effect of intrathecal blockade on postoperative myocardial infarction in noncardiac surgical patients: a meta-analysis / 临床麻醉学杂志

Objective A meta-analysis was conducted to figure out the effects of anesthetic methods on postoperative myocardial infarction in noncardiac surgery patients.Methods We searched PubMed, Embase, Ovid, Cochrane Library, Google scholar, CNKI, Wang-fang data and VIP Database (by September 2016) to identify relevant studies that focused on the effect of intrathecal blockade on postoperative myocardial infarction and mortality in non-cardiac surgery.Meta-analysis was performed using software of RevMan 5.3.Results A total of 21 859 patients from 10 RCTs were enrolled.The meta-analysis showed that there were no differences in myocardial infarction within 7 postoperative days (OR=0.44, 95%CI 0.13-1.46, P=0.18) or 30 days (OR=1.49, 95%CI 0.89-2.49, P=0.13) and all-cause mortality (OR=1.26, 95%CI 0.84-1.88, P=0.26) between epidural anesthesia combined with general anesthesia and general anesthesia.Furthermore, there were no differences in myocardial infarction within postoperative 7 days (OR=1.14, 95%CI 0.31-4.17, P=0.84) and all-cause mortality within postoperative 30 days (OR=0.88, 95%CI 0.43-1.79, P=0.73) between spinal anesthesia alone and general anesthesia alone.Conclusion Intrathecal blockade cannot affect the incidence of myocardial infarction and mortality in high-risk cardiac patients undergoing intermediate or high-risk non-cardiac surgery.

Comparison of dexmedetomidine versus sevoflurane to reduce perioperative myocardial ischemia in coronary heart disease patients undergoing noncardiac surgery / 临床麻醉学杂志

Objective To investigate the effect of dexmedetomidine versus sevoflurane to perioperative myocardial ischemia in coronary heart disease patients undergoing noncardiac surgery.Methods A total of 135 patients (90 males,45 females,aged 45-82 years,ASA grade Ⅱ or Ⅲ) with coronary heart disease,undergoing endoscopic thoracic and abdominal surgery,were divided into control group (group C),dexmedetomidine group (group D) and sevoflurane group (group S) by random number table.Anesthesia induction and maintenance were adopted by etomidate 0.2 mg/kg,propofol 0.5 mg/kg,atracuronium sulfonate 0.2-0.3 mg/kg and fentanyl 5.0-6.0 μg/kg.Dexmedetomidine was given the continuous injection from 10 min before the start of the operation to the end in group D.Equal volume of saline was given in group C.Sevoflurane was inhaled from the induction of anesthesia 30 min before the end of surgery.ST segment changes of electrocardiogram were recorded for diagnosis of myocardial ischemia during the operation and postoperative 72 hours.Results The incidence of myocardial ischemia in group C,group D and group S were 26.7% (12 cases),6.7% (3 cases),8.9% (4 cases) during the operation and 13.3% (6 cases),8.9% (4 cases) and 8.9% (4 cases) postoperative 72 hours.Conclusion Dexmedetomidine and sevoflurane can improve the balance of blood oxygen supply and demand to reduce cardiovascular complications of non-cardiac surgery in patients with coronary heart disease.

Risk factors of perioperative myocardial infarction in the patients undergoing noncardiac surgery / 中国介入心脏病学杂志

Objective To investigate the risk factors and prognosis of perioperative myocardial infarction in the patients undergoing noncardiac surgery. Methods Clinical data of 562 patients who had accepted non-cardiac surgery was collected and retrospectively analyzed. The risk factors, treatments and outcomes of all these patients were recorded and analyzed. Results A total of 19 out of the 562 patients had perioperative myocardial infarction ( PMI) . The incidence was 3. 4% . The mean occurrence time was (43. 5 ± 12. 7)h after operation. Eleven PMI patients (11 ∕ 19) were non-ST-segment elevation myocardial infarction and eight patients (8 ∕ 19) were ST-segment elevation myocardial infarction. Thirteen PMI patients were left coronary artery occlusion and six patients were right coronary artery occlusion. Advanced age, history of myocardial infarction, unstable angina, change of ST-T segment on electrocardiography (ECG), multivessel diseases, diabetes,hypertension,and high risk non-cardiac surgery were the risk factors of PMI and positively correlated to PMI. Sixteen PMI (16 ∕ 19) patients accepted PCI treatment and three patients (3 ∕ 19) accepted drug conservative treatment. Two patients had unstable angina attack after treatment and one patient had arrhythmia. The heart function in two patients decreased by one or more than one class within the follow up of 1 year. No patient had recurrent acute myocardial infarction or deceased during follow-up. Conclusions Many factors could lead to PMI. Making preoperative assessment, recognizing patients of high risks and dealing with patients who had PMI in time was necessary.

Perioperative management of patients with left ventricular assist devices undergoing noncardiac surgery.

Aim: The aim of this study was to describe our institutional experience, primarily with general anesthesiologists consulting with cardiac anesthesiologists, caring for left ventricular assist device (LVAD) patients undergoing noncardiac surgery. Materials and Methods: This is a retrospective review of the population of patients with LVADs at a single institution undergoing noncardiac procedures between 2009 and 2014. Demographic, perioperative, and procedural data collected included the type of procedure performed, anesthetic technique, vasopressor requirements, invasive monitors used, anesthesia provider type, blood product management, need for postoperative intubation, postoperative disposition and length of stay, and perioperative complications including mortality. Statistical Analysis: Descriptive statistics for categorical variables are presented as frequency distributions and percentages. Continuous variables are expressed as mean ± standard deviation and range when applicable. Results: During the study, 31 patients with LVADs underwent a total of 74 procedures. Each patient underwent an average of 2.4 procedures. Of the total number of procedures, 48 (65%) were upper or lower endoscopies. Considering all procedures, 81% were performed under monitored anesthesia care (MAC). Perioperative care was provided by faculty outside of the division of cardiac anesthesia in 62% of procedures. Invasive blood pressure monitoring was used in 27 (36%) procedures, and a central line, peripherally inserted central catheter or midline was in place preoperatively and used intraoperatively for 38 (51%) procedures. Vasopressors were not required in the majority (65; 88%) of procedures. There was one inhospital mortality secondary to multiorgan failure; 97% of patients survived to discharge after their procedure. Conclusion: At our institution, LVAD patients undergoing noncardiac procedures most frequently require endoscopy. These procedures can frequently be done safely under MAC, with or without consultation by a cardiac anesthesiologist.

Intraoperative goal directed hemodynamic therapy in noncardiac surgery: a systematic review and meta-analysis / Terapia hemodinâmica alvo-dirigida no intraoperatório de cirurgia não cardíaca: revisão sistemática e meta-análise

Abstract Background: The goal directed hemodynamic therapy is an approach focused on the use of cardiac output and related parameters as end-points for fluids and drugs to optimize tissue perfusion and oxygen delivery. Primary aim: To determine the effects of intraoperative goal directed hemodynamic therapy on postoperative complications rates. Methods: A meta-analysis was carried out of the effects of goal directed hemodynamic therapy in adult noncardiac surgery on postoperative complications and mortality using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A systematic search was performed in Medline PubMed, Embase, and the Cochrane Library (last update, October 2014). Inclusion criteria were randomized clinical trials in which intraoperative goal directed hemodynamic therapy was compared to conventional fluid management in noncardiac surgery. Exclusion criteria were trauma and pediatric surgery studies and that using pulmonary artery catheter. End-points were postoperative complications (primary) and mortality (secondary). Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by type of monitor, therapy, and hemodynamic goal), and predefined sensitivity analysis. Results: 51 RCTs were initially identified, 24 fulfilling the inclusion criteria. 5 randomized clinical trials were added by manual search, resulting in 29 randomized clinical trials in the final analysis, including 2654 patients. A significant reduction in complications for goal directed hemodynamic therapy was observed (RR: 0.70, 95% CI: 0.62-0.79, p < 0.001). No significant decrease in mortality was achieved (RR: 0.76, 95% CI: 0.45-1.28, p = 0.30). Quality sensitive analyses confirmed the main overall results. Conclusions: Intraoperative goal directed hemodynamic therapy with minimally invasive monitoring decreases postoperative complications in noncardiac surgery, although it was not able to show a significant decrease in mortality rate.

Resumo Justificativa: A terapia hemodinâmica alvo-dirigida (THAD) é uma abordagem focada no uso do débito cardíaco (DC) e parâmetros relacionados, como desfechos para fluidos e medicamentos para aprimorar a perfusão tecidual e o fornecimento de oxigênio. Objetivo primário: determinar os efeitos da THAD sobre as taxas de complicações no pós-operatório. Métodos: Metanálise dos efeitos da THAD em cirurgias não cardíacas de adultos sobre as complicações pós-operatórias e mortalidade, com a metodologia PRISMA. Uma busca sistemática foi feita no Medline PubMed, Embase e Biblioteca Cochrane (última atualização, outubro de 2014). Os critérios de inclusão foram estudos clínicos randômicos (ECRs) nos quais a THAD no intraoperatório foi comparada com a terapia convencional de reposição de líquidos em cirurgia não cardíaca. Os critérios de exclusão foram traumatismo e estudos de cirurgia pediátrica e aqueles que usaram cateter de artéria pulmonar. Os desfechos, primário e secundário, foram complicações pós-operatórias e mortalidade, respectivamente. Os estudos que atenderam aos critérios de inclusão foram examinados na íntegra e submetidos à análise quantitativa, análise de subgrupo pré-definido (estratificada por tipo de monitor, terapia e objetivo hemodinâmico) e análise de sensibilidade pré-definida. Resultados: 51 ECRs foram identificados inicialmente, 24 atenderam aos critérios de inclusão. Cinco ECRs foram adicionados por busca manual, resultando em 29 ECRs para análise final, incluindo 2.654 pacientes. Uma redução significativa das complicações para a THAD (RR: 0,70, IC de 95%: 0,62-0,79, p < 0,001). Nenhuma diminuição significativa na mortalidade foi observada (RR: 0,76, IC de 95%: 0,45-1,28, p = 0,30). Análises de sensibilidade qualitativa confirmaram os principais resultados gerais. Conclusões: THAD no intraoperatório com monitoração minimamente invasiva diminui as complicações no pós-operatório de cirurgia não cardíaca, embora não tenha mostrado uma redução significativa da taxa de mortalidade.

N-terminal pro B type natriuretic peptide in high cardiovascular-risk patients for noncardiac surgery: What is the current prognostic evidence.

As millions of surgical procedures are performed worldwide on an aging population with multiple comorbidities, accurate and simple perioperative risk stratification is critical. The cardiac biomarker, brain natriuretic peptide (BNP), has generated considerable interest as it is easy to obtain and appears to have powerful predictive and prognostic capabilities. BNP is currently being used to guide medical therapy for heart failure and has been added to several algorithms for perioperative risk stratification. This review examines the current evidence for the use of BNP in the perioperative period in patients who are at high‑cardiovascular risk for noncardiac surgery. In addition, we examined the use of BNP in patients with pulmonary embolism and left ventricular assist devices. The available data strongly suggest that the addition of BNP to perioperative risk calculators is beneficial; however, whether this determination of risk will impact outcomes, remains to be seen.

Fontan’s circulation with dextrocardia, recent pulmonary embolism, and inferior vena cava filter: Anesthetic challenges for urgent hysterectomy.

Fontan’s circulation is a unique challenge for the anesthesiologist. Venous pressure is the only source of blood flow for the pulmonary circulation. Patients with such circulation are extremely sensitive to progression of cyanosis (decreased pulmonary blood flow) or circulatory failure. Any major venous compression can compromise the pulmonary blood flow worsening cyanosis; simultaneously, an increased afterload can precipitate circulatory failure. We present a rare patient of surgically corrected Ivemark syndrome with Fontan’s physiology with dextrocardia who developed a large uterine fibroid compressing inferior vena cava (IVC). As a result of compression, not only the pulmonary circulation was compromised but she also developed stasis‑induced venous thrombosis in the lower limbs that lead to pulmonary embolism (PE) (increased afterload). In addition to oral anticoagulation an IVC filter was inserted to prevent ongoing recurrent PE. Further, to prevent both circulatory compromise and deep venous thrombosis an urgent myomectomy/ hysterectomy was planned. In the present case, we discuss the issues involved in the anesthetic management of such patients and highlight the lacunae in the present guidelines for managing perioperative anticoagulation these situations.

Perioperative management of patient with intracoronary stent presenting for noncardiac surgery.

As the number of percutaneous coronary interventions increase annually, patients with intracoronary stents (ICS) who present for noncardiac surgery (NCS) are also on the rise. ICS is associated with stent thrombosis (STH) and requires mandatory antiplatelet therapy to prevent major adverse cardiac events. The risks of bleeding and ischemia remain significant and the management of these patients, especially in the initial year of ICS is challenging. The American College of Cardiologists guidelines on the management of patients with ICS recommend dual antiplatelet therapy (DAT) for minimal 14 days after balloon angioplasty, 30 days for bare metal stents, and 365 days for drug‑eluting stents. Postponement of elective surgery is advocated during this period, but guidelines concerning emergency NCS are ambiguous. The risk of STH and surgical bleeding needs to be assessed carefully and many factors which are implicated in STH, apart from the type of stent and the duration of DAT, need to be considered when decision to discontinue DAT is made. DAT management should be a multidisciplinary exercise and bridging therapy with shorter acting intravenous antiplatelet drugs should be contemplated whenever possible. Well conducted clinical trials are needed to establish guidelines as regards to the appropriate tests for platelet function monitoring in patients undergoing NCS while on DAT.

Aspirina no perioperatório de cirurgias não cardíacas: o dilema entre manter ou suspender / Aspirin perioperatively in noncardiac surgery: the dilemma between keeping or suspend

JUSTIFICATIVA E OBJETIVOS: É crescente o número de pacientes em uso de aspirina que serão submetidos a procedimentos cirúrgicos, situação que contribui para o dilema entre suspensão ou manutenção da medicação. Se por um lado a manutenção da aspirina durante o perioperatório está associada a um aumento no número de complicações hemorrágicas, por outro a sua interrupção está associada a graves complicações trombóticas. O objetivo deste estudo foi revisar de forma não sistemática as bases de dados Medline, Cochrane, Google Scholar e LILACS quanto aos efeitos da suspensão ou manutenção da aspirina no perioperatório de operações não cardíacas.CONTEÚDO: Os pacientes em uso de aspirina devem ser avaliados individualmente e a antiga recomendação de suspender a medicação de 7 a 10 dias antes de todo procedimento cirúrgico deve ser revista em razão dos comprovados efeitos prejudiciais. A aspirina deve ser mantida naqueles pacientes em prevenção secundária na maioria das situações, com exceção das cirurgias em cavidades fechadas e da prostatectomia transuretral, onde os riscos associados ao sangramento mostraram-se elevados. Os pacientes com stent coronariano também devem manter o uso da aspirina indefinidamente e a realização de procedimentos cirúrgicos eletivos deve ser postergada enquanto o uso concomitante do clopidogrel estiver indicado. CONCLUSÃO: A decisão sobre a manutenção da aspirina no perioperatório deve levar em conta riscos aterotrombóticos associados à sua suspensão e riscos de sangramento inerentes ao procedimento cirúrgico proposto. As evidências disponíveis apontam a favor de uma relação risco-benefício favoráveis à manutenção da aspirina na maioria das situações, embora estudos mais definitivos sejam necessários.(AU)

BACKGROUND AND OBJECTIVES: The number of patients taking aspirin who will undergo invasive surgical procedures is increasing. This clinical situation contributes to the dilemma between maintaining or withdraws the medication. In one hand, the maintenance during the perioperative periodis associated with an increased number of bleeding complications;on the other its discontinuation is associated with severe thrombotic complications. The purpose of this article was a non-systematic review of databases Medline, Cochrane Library, Google Scholar and LILACS as to the effects of the suspension or maintenance of aspirin perioperatively in noncardiac operations. CONTENTS: Patients taking aspirin must be evaluated individually and the former recommendation to discontinue the medication 7-10 days prior to any procedure should be reviewed because of the proven harmful effects. Aspirin should be maintained in patients in secondary prevention in most situations, except in closed space surgeries and transurethral prostatectomy, situations where the risk of bleeding appeared to be high. Patients with coronary stenting should also keep aspirin indefinitely and the holding of elective surgeries must be postponed while the concomitant use of clopidogrel is indicated. CONCLUSION: The decision on the maintenance of aspirin in the perioperative period should consider the atherothrombotic risks associated with suspension and bleeding risks inherent of the proposed surgical procedure. The available evidence points in favor of a risk-benefit ratio favorable to the maintenance of aspirin in most situations, although more definitive studies are needed.(AU)

C-Reactive protein predicts acute myocardial infarction during high-risk noncardiac and vascular surgery

BACKGROUND: High-sensitivity C-reactive protein predicts cardiovascular events in a wide range of clinical contexts. However, the role of high-sensitivity C-reactive protein as a predictive marker for perioperative acute myocardial infarction during noncardiac surgery is not yet clear. The present study investigated high-sensitivity C-reactive protein levels as predictors of acute myocardial infarction risk in patients undergoing high-risk noncardiac surgery. METHODS: This concurrent cohort study included patients aged >50 years referred for high-risk noncardiac surgery according to American Heart Association/ACC 2002 criteria. Patients with infections were excluded. Electrocardiograms were performed, and biomarkers (Troponin I or T) and/or total creatine phosphokinase and the MB fraction (CPK-T/MB) were evaluated on the first and fourth days after surgery. Patients were followed until discharge. Baseline high-sensitivity C-reactive protein levels were compared between patients with and without acute myocardial infarction. RESULTS: A total of 101 patients undergoing noncardiac surgery, including 33 vascular procedures (17 aortic and 16 peripheral artery revascularizations), were studied. Sixty of the patients were men, and their mean age was 66 years. Baseline levels of high-sensitivity C-reactive protein were higher in the group with perioperative acute myocardial infarction than in the group with non-acute myocardial infarction patients (mean 48.02 vs. 4.50, p = 0.005). All five acute myocardial infarction cases occurred in vascular surgery patients with high CRP levels. CONCLUSIONS: Patients undergoing high-risk noncardiac surgery, especially vascular surgery, and presenting elevated baseline high-sensitivity C-reactive protein levels are at increased risk for perioperative acute myocardial infarction.

Anesthetic management for a patient with Eisenmenger syndrome undergoing dacryocystorhinostomy: A case report

Eisenmenger syndrome is defined as pulmonary hypertension at or close to systemic values, with an intracardiac or aortopulmonary communication resulting a bidirectional or right-to-left shunt.Patients with Eisenmenger syndrome require a close monitoring while undergoing non-cardiac surgery because these patients are very vulnerable to alteration in hemodynamics induced by anesthetics or surgery.Therefore we report the successful management of a patient with Eisenmenger syndrome undergoing a dacryocystorhinostomy under desflurane and ketamine based general anesthesia.

Acute, fatal postoperative myocardial infarction after laparoscopic cholecystectomy in a cardiac patient: A case report / 대한마취과학회지

This report presents the case of a 63-year-old man who had a myocardial infarction leading to coronary artery bypass graft 2 years earlier who subsequently underwent elective laparoscopic cholecystectomy. After an uneventful operation, the patient developed an acute postoperative myocardial infarction in the recovery room and died 19 days postoperatively. Anesthesiologists should be aware of the rare possibility of acute, fatal postoperative myocardial infarction and consider this complication when they perform the preoperative risk evaluation, anesthesia, and postoperative care for cardiac patients undergoing noncardiac surgery.

Variance of Brain Natriuretic Peptide in Aged Patients after Noncardiac Surgery and Its Significance / 中国康复理论与实践

@#Objective To explore the variance of plasma brain natriuretic peptide (BNP) concentrations in the aged patients after noncardiac surgery and its significance. Methods 101 patients undergoing elective noncardiac surgery were divided into two groups based on the BNP concentrations before surgery: group A: BNP≤100 ng/L，n=61; group B: BNP>100 ng/L，n=40. The BNP concentrations before and after noncardiac surgery and the incidence of cardiac events in both groups were compared. Results There was no significant difference （P>0.05） of BNP concentrations before and after noncardiac surgery in group A, which were (58.2±28.7) ng/L and (53.7±25.9) ng/L respectively, but was significant difference （P<0.05） in group B, which were (147.3±72.1) ng/L and (341.5±92.4) ng/L respectively. There was significant difference （P<0.05） between group A, in which no patient happened cardiac event, and group B, in which 14 patients happened. Conclusion The plasma BNP concentration would be increased significantly in the aged patients with a BNP concentration>100 ng/L before surgery, which may cause more cardiac events.

Prediction of B-type Natriuretic Peptide for Cardiac Events after Noncardiac Surgery in Aged Patients / 中国康复理论与实践

@# Objective To explore the value of B-type natriuretic peptide (BNP) predicting cardiac events after noncardiac surgery in the aged patients. Methods The level of BNP， the score of Goldman analysis and the cardiac risk grade of ACC/AHA guideline were analyzed in 274 aged patients for cardiac outcome after noncardiac surgery. Results Preoperative BNP concentration>100 pg/ml，score of Goldman≥13，and the high or moderate risk grade by ACC/AHA guideline were related with cardiac events. There was no significant difference in the index such as sensitivity，specificity, accuracy，positive predictive value and negative predictive value for cardiac events between BNP level and cardiac risk grade. Compared with the score of Goldman, BNP was more sensitive （100% vs 55.6%）and negatively predictive （100% vs 96.3%） for cardiac events. Conclusion The risk of cardiac events after noncardiac surgery could be predicted with the level of BNP before operation in the aged patient.

Very late stent thrombosis of DES implanted patient during noncardiac surgery: A case report / 대한마취과학회지

Very late stent thrombosis after implantation of drug eluting stent is rare, but its consequences are potentially fatal. Stent thrombosis may be occurred in perioperative period because of interruption of anticoagulation therapy and intraoperative hypercoagulability. We report a case of very late stent thrombosis in a 49-year-old male patient during total gastrectomy. ST-segment elevation in lead II occurred during the surgery and followed by cardiac arrest. After external cardiac massage and electrocardioversion, normal sinus rhythm was restored. Postoperative 12 lead ECG showed ST-segment elevation in leads II, III, aVF and serum cardiac enzymes such as CPK, CK-MB, and Troponin T were markedly elevated. Postoperative coronary angiography showed complete occlusion of the right coronary artery stent. Emergency percutaneous transluminal coronary angioplasty was performed and the patient recovered uneventfully.

Coronary Stent Thrombosis during Noncardiac Surgery: A case report / 대한마취과학회지

We report a 62-year-old man who expired due to intraoperative stent thrombosis. He presented for radical cystectomy because of a bladder cancer. Before a surgery, coronary stent intervention was performed at left anterior descending (LAD) artery. And then he received dual antiplatelet medication for three weeks. Four weeks later, he had an operation for bladder cancer. During the surgery, arrhythmias were developed. After the surgery, the patient suffered from a ST segment elevation myocardial infarction, which was caused by total occlusion of the stent. Additional stent implantation was performed but immediately after the procedure, uncontrolled ventricular arrhythmias developed. It seems that patients with stents may be at heightened risk of stent occlusion during and after surgery. They should be required safe waiting period, titrated anticoagulatory therapy and exact monitoring of myocardial ischemia during the entire perioperative period.