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Davide Capodanno, MD University of Catania Cardiology Department Ferrarotto Hospital - Catania Director: Prof. C. Tamburino Stenting Patients Needing Non-Cardiac.

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Presentation on theme: "Davide Capodanno, MD University of Catania Cardiology Department Ferrarotto Hospital - Catania Director: Prof. C. Tamburino Stenting Patients Needing Non-Cardiac."— Presentation transcript:

1 Davide Capodanno, MD University of Catania Cardiology Department Ferrarotto Hospital - Catania Director: Prof. C. Tamburino Stenting Patients Needing Non-Cardiac Surgery

2 Ospedale Ferrarotto Università di Catania Need for emergency noncardiac surgery? Operating room Perioperative surveillance and postoperative risk stratification and risk factor management Yes Step 1 Active cardiac conditions? Evaluate and treat per ACC/AHA guidelines Consider operating room Yes Step 2 Low risk surgery Proceed with planned surgery Yes Step 3 No No Functional capacity greater than or equal to 4 MET, without symptoms Proceed with planned surgery Yes Step 4 No Step5Step5 No or unknown Fleisher et al. ACC/AHA 2007

3 Ospedale Ferrarotto Università di Catania Step 5 3 or more clinical risk factors Vascular surgery Intermediate risk surgery 1-2 clinical risk factors Vascular surgery Intermediate risk surgery No clinical risk factors Proceed with planned surgery Proceed with planned surgery with HR control or consider non-invasive testing if it will change management Consider testing if it will change management Fleisher et al. ACC/AHA 2007 Perioperative Guidelines. JACC 2007;50:e

4 Ospedale Ferrarotto Università di Catania Proponents of ‘prophylactic’ coronary revascularization in selected patients argue that it improves both perioperative as well as long-term outcome Prophylactic revascularization before non-cardiac surgery

5 Ospedale Ferrarotto Università di Catania But the debate is open Opponents of this approach point out that: 1)morbidity and mortality of PCI and CABG in high- risk elderly vascular patients are substantial and outweigh any benefit; 2)recovery from such major morbidity substantially delays and even prevents the surgery for which the intervention was undertaken; 3)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; 4)only survivors of coronary revascularization are included in the various reports

6 Ospedale Ferrarotto Università di Catania What do we know about perioperative myocardial ischemia (PMI)? 1)Perioperative myocardial ischemia peaks during the early postoperative period. Intraoperative ischemia is less common. 2)PMI is preceded almost exclusively by ST depression-type ischemia. 3)MI is mostly silent (50%) and most often is a non-Q wave rather than Q-wave infarction 4)Mortality is <10% to 15%, similar to in-hospital mortality of nonsurgical non-Q infarction

7 Ospedale Ferrarotto Università di Catania

8 Ospedale Ferrarotto Università di Catania Two types of PMIs

9 Ospedale Ferrarotto Università di Catania Cardiac Outcomes After Higher-Risk Noncardiac Surgery Stratified by Coronary Status in the CASS Registry (n=1546) * 30-Day Outcome No. of Diseased Vessels Medical RxPrior CABGP Death14/278 (1%)4/191 (2%)NS 28/170 (5%)2/314 (0.6%) /134 (5%)11/459 (2%)0.15 MI15/278 (2%)3/191 (2%)NS 26/170 (3.5%)0/314 (0%) /134 (4%)5/459 (1%)0.05 * Higher-risk noncardiac surgery indicates vascular, thoracic, major abdominal, and head and neck surgery Eagle KA et al, Circulation 1997

10 Ospedale Ferrarotto Università di Catania 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 surgery Lessons from CASS Registry

11 Ospedale Ferrarotto Università di Catania Balancing the potential risks versus benefits of CABG before vascular surgery Short term risk of CABG Perioperative risk of non-cardiac surgery Long-term benefit of CABG

12 Ospedale Ferrarotto Università di Catania McFalss et al, NEJM 2004 Long-Term Survival among Patients Randomized to Undergo Coronary-Artery Revascularization or No Coronary-Artery Revascularization before Elective Major Vascular Surgery CARP trial

13 Ospedale Ferrarotto Università di Catania CARP post hoc analysis of patients undergoing vascular surgery after revascularization (n = 222) P = P = 0.009

14 Ospedale Ferrarotto Università di Catania CARP post hoc analysis of patients undergoing vascular surgery after revascularization (n = 222) Incidence of perioperative myocardial infarction and death Ward et al, Ann Thorac Surg 2006

15 Ospedale Ferrarotto Università di Catania 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 Ischemia DECREASE V p = 0.30p = 0.48 OMT + Revasc OMT

16 Ospedale Ferrarotto Università di Catania When stents meet non-cardiac surgery Stents in patients needing non-cardiac surgery 1)Prophylactic PCI: who? 2)To stent or not to stent? 3)Which stent, if any? Non-cardiac surgery in patients with stent 1)How to manage antiplatelet therapy? The cardiologist’s perspectiveThe surgeon’s perspective

17 Ospedale Ferrarotto Università di Catania Prophylactic PCI  Unstable active CAD (UA/NSTEMI, STEMI) according to current guidelines: Yes  Recurrent ischemia after CABG: Yes  Asymptomatic ischemia or CCS I-II: No  Stable angina but CCS III: Uncertain, probably not  Left main: poor outcome with PCI, consider CABG Fleisher et al, JACC 2007

18 Ospedale Ferrarotto Università di Catania Balloon angioplasty BARI post hoc analysis

19 Ospedale Ferrarotto Università di Catania 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 approach Daily 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.

20 Ospedale Ferrarotto Università di Catania What about stenting? Ka GL et al, JACC 2000

21 Ospedale Ferrarotto Università di Catania No apparent ambiguities from guidelines It is recommended that patients with previous CABG in the last 5 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 in patients with recent drug-eluting stent implantation no sooner than 12 months following the intervention (class I B) Consideration should be given to postponing non-cardiac surgery in patients with recent balloon angioplasty until at least 2 weeks following the intervention (class IIa B) ESC guidelines 2009

22 Ospedale Ferrarotto Università di Catania ESC guidelines 2009

23 Ospedale Ferrarotto Università di Catania The 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 Unplanned surgery

24 Ospedale Ferrarotto Università di Catania Successful 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 management For many patients noncardiac surgery represents their first opportunity to receive an appropriate assessment of both short- and long-term cardiac risk. Conclusions


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