Presentation on theme: "Stenting Patients Needing Non-Cardiac Surgery"— Presentation transcript:
1 Stenting Patients Needing Non-Cardiac Surgery Davide Capodanno, MDUniversity of CataniaCardiology DepartmentFerrarotto Hospital - CataniaDirector: Prof. C. Tamburino
2 Yes Step 1 No Yes Step 2 No Yes Step 3 No Yes Step 4 No or unknown Perioperative surveillance and postoperative risk stratification and risk factor managementNeed for emergency noncardiac surgery?YesStep 1Operating roomNoActive cardiac conditions?YesEvaluate and treat per ACC/AHA guidelinesStep 2Consider operating roomNoLow risk surgeryYesStep 3Proceed with planned surgeryNoFunctional capacity greater than or equal to 4 MET, without symptomsYesStep 4Proceed with planned surgeryNo or unknownStep5Fleisher et al. ACC/AHA 2007
3 3 or more clinical risk factors Vascular surgery Step 53 or more clinical risk factorsVascular surgeryIntermediate risk surgery1-2 clinical risk factorsNo clinical risk factorsProceed with planned surgeryConsider testing if it will change managementProceed with planned surgery with HR control or consider non-invasive testing if it will change managementFleisher et al. ACC/AHA 2007 Perioperative Guidelines. JACC 2007;50:e
4 Prophylactic revascularization before non-cardiac surgery Proponents of ‘prophylactic’ coronary revascularization in selected patients argue that it improves both perioperative as well as long-term outcome
5 But the debate is open Opponents of this approach point out that: morbidity and mortality of PCI and CABG in high-risk elderly vascular patients are substantial and outweigh any benefit;recovery from such major morbidity substantially delays and even prevents the surgery for which the intervention was undertaken;it does not differentiate between young and old age and between patients with symptomatic CAD and those with CAD discovered by cardiac stress testing only;only survivors of coronary revascularization are included in the various reports
6 What do we know about perioperative myocardial ischemia (PMI)? Perioperative myocardial ischemia peaks during the early postoperative period. Intraoperative ischemia is less common.PMI is preceded almost exclusively by ST depression-type ischemia.MI is mostly silent (50%) and most often is a non-Q wave rather than Q-wave infarctionMortality is <10% to 15%, similar to in-hospital mortality of nonsurgical non-Q infarctionin contrast to earlier concerns, anesthesia per se, either general or regional, if administered without complications, is not a risk factor for the high-risk cardiac patient undergoing noncardiac surgery. Rather, it is postoperative stress (including emergence from anesthesia), which precipitates ischemia, infarction, and cardiac mortality.
8 Two types of PMIsPreoperative revascularization of severe stenoses may not reduce perioperative ischemic complications
9 Cardiac Outcomes After Higher-Risk Noncardiac Surgery Stratified by Coronary Status in the CASS Registry (n=1546) *30-Day OutcomeNo. of Diseased VesselsMedical RxPrior CABGPDeath14/278 (1%)4/191 (2%)NS28/170 (5%)2/314 (0.6%)0.000537/134 (5%)11/459 (2%)0.15MI5/278 (2%)3/191 (2%)6/170 (3.5%)0/314 (0%)0.0025/134 (4%)5/459 (1%)0.05* Higher-risk noncardiac surgery indicates vascular, thoracic, major abdominal, and head and neck surgeryEagle KA et al, Circulation 1997
10 Lessons from CASS Registry Patients who had CABG within the previous 5 years can be sent for surgery, if their clinical condition has remained unchanged since their last examination.Patients undergoing low-risk procedures are unlikely to derive benefit from CABG before low-risk surgery, differently from those with multivessel disease and severe angina undergoing high-risk surgeryThis analysis represents a unique opportunity to examine surgery-specific risk in patients with well-defined coronary artery disease. We have shown that vascular, thoracic, abdominal, and major head and neck surgery are those specific procedures associated with a higher risk of a myocardial infarction or death in the face of nonrevascularized coronary artery disease. Furthermore, any benefit conferred by coronary revascularization appears to be particularly suited for this higher-risk subcategory of noncardiac procedures
11 Balancing the potential risks versus benefits of CABG before vascular surgery Short term risk of CABGPerioperative risk of non-cardiac surgeryLong-term benefit of CABG
12 Long-Term Survival among Patients Randomized to Undergo Coronary-Artery Revascularization or No Coronary-Artery Revascularization before Elective Major Vascular SurgeryCARP trialMcFalss et al, NEJM 2004
13 CARP post hoc analysis of patients undergoing vascular surgery after revascularization (n = 222)
14 Incidence of perioperative myocardial infarction and death CARP post hoc analysis of patients undergoing vascular surgery after revascularization (n = 222)Incidence of perioperative myocardial infarction and deathWard et al, Ann Thorac Surg 2006
15 Incidence of All-Cause Death or Myocardial Infarction During 1-Year Follow-Up According to the Allocated Strategy in Patients With 3 or More Cardiac Risk Factors With Extensive Stress-Induced IschemiaDECREASE VOMT + RevascOMTRandomized studies are not sized. Patients undergoing elective noncardiac procedures who are found to have prognostic high-risk coronary anatomy and in whom long-term outcome would likely be improved bycoronary bypass grafting should generally undergo coronary revascularization before a noncardiac elective vascular surgical procedure or noncardiac operative proceduresof intermediate or high riskp = 0.30p = 0.48
16 When stents meet non-cardiac surgery The cardiologist’s perspectiveThe surgeon’s perspectiveStents in patients needing non-cardiac surgeryProphylactic PCI: who?To stent or not to stent?Which stent, if any?Non-cardiac surgery in patients with stentHow to manage antiplatelet therapy?
17 Prophylactic PCI Unstable active CAD (UA/NSTEMI, STEMI) according to current guidelines: YesRecurrent ischemia after CABG: YesAsymptomatic ischemia or CCS I-II: NoStable angina but CCS III: Uncertain, probably notLeft main: poor outcome with PCI, consider CABGIn summary: PCI is of no value in preventing perioperative cardiac eventsm except in those patients in whom PCI is independently indicated for an acute coronary syndromeFleisher et al, JACC 2007
19 Issues with balloon PTCA Delaying noncardiac surgery for more than 8 weeks increases the chance of restenosis. Performing the surgical procedure too soon after the PCI procedure might also be hazardous.Delaying surgery for at least 2 to 4 weeks after balloon angioplasty to allow for healing of the vessel injury at the balloon treatment site is the optimal approachDaily aspirin antiplatelet therapy should be continued perioperatively. The risk of stopping the aspirin should be weighed against the benefit of reduction in bleeding complications from the planned surgery.Arterial recoil or acutethrombosis at the site of balloon angioplasty is most likely tooccur within hours to days after balloon coronary angioplasty.
21 No apparent ambiguities from guidelines It is recommended that patients with previous CABG in the last5 years be sent for non-cardiac surgery without further delay (class I C)It is recommended that non-cardiac surgery be performed in patients with recent bare metal stent implantation after a minimum 6 weeks and optimally 3 months following the intervention (class I B)It is recommended that non-cardiac surgery be performed inpatients with recent drug-eluting stent implantation nosooner than 12 months following the intervention (class I B)Consideration should be given to postponing non-cardiacsurgery in patients with recent balloon angioplasty until atleast 2 weeks following the intervention (class IIa B)ESC guidelines 2009
23 Unplanned surgeryThe need for surgery in relation to its timing and the specific pathology (e.g. malignant tumour, vascular aneurysm repair) should be balanced against the excessive risk of stent thrombosis during the first year following DES implantation and a careful ‘case-by-case’ consideration is advisable.Discussion between the surgeon, the anaesthesiologist, and the treating cardiologist about this matter is recommended in order to achieve a reasonable expert consensus
24 ConclusionsSuccessful perioperative evaluation and management of high- risk cardiac patients undergoing noncardiac surgery requires careful teamwork and communication between surgeon, anesthesiologist, the patient’s primary caregiver, and the consultant.The use of both noninvasive and invasive preoperative testing should be limited to those circumstances in which the results of such tests will clearly affect patient managementFor many patients noncardiac surgery represents their first opportunity to receive an appropriate assessment of both short- and long-term cardiac risk.