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

Davide Capodanno, MD

University of CataniaCardiology Department

Ferrarotto Hospital - Catania

Director: Prof. C. Tamburino

Stenting Patients Needing Non-Cardiac Surgery

Ospedale Ferrarotto

Università di Catania

Need for emergency Need for emergency noncardiac surgery?noncardiac surgery? Operating roomOperating room

Perioperative surveillance and Perioperative surveillance and postoperative risk stratification postoperative risk stratification and risk factor managementand risk factor management

YesYes

Step 1Step 1

Active cardiac Active cardiac conditions?conditions?

Evaluate and treat per Evaluate and treat per ACC/AHA guidelinesACC/AHA guidelines Consider operating roomConsider operating room

YesYesStep 2Step 2

Low risk surgeryLow risk surgery Proceed with planned surgeryProceed with planned surgery

YesYesStep 3Step 3

NoNo

NoNo

Functional capacity greater Functional capacity greater than or equal to 4 MET, than or equal to 4 MET,

without symptomswithout symptomsProceed with planned surgeryProceed with planned surgery

YesYesStep 4Step 4

NoNo

Step5Step5

No or unknownNo or unknown

Fleisher et al. ACC/AHA 2007Fleisher et al. ACC/AHA 2007

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Proceed with planned surgery with HR control Proceed with planned surgery with HR control or consider non-invasive testing if it will or consider non-invasive testing if it will

change managementchange management

Consider Consider testing if it testing if it will change will change managemenmanagemen

tt

Fleisher et al. ACC/AHA 2007 Perioperative Guidelines. JACC 2007;50:e159-242 Fleisher et al. ACC/AHA 2007 Perioperative Guidelines. JACC 2007;50:e159-242

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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

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But the debate is openOpponents 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

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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

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Two types of PMIs

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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 Rx Prior CABG P

Death 1 4/278 (1%) 4/191 (2%) NS

2 8/170 (5%) 2/314 (0.6%) 0.0005

3 7/134 (5%) 11/459 (2%) 0.15

MI 1 5/278 (2%) 3/191 (2%) NS

2 6/170 (3.5%) 0/314 (0%) 0.002

3 5/134 (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

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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

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Balancing the potential risks versus benefits of CABG before vascular surgery

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Università di CataniaMcFalss 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

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CARP post hoc analysis of patients undergoing vascular surgery after revascularization (n = 222)

P = 0.497

P = 0.009

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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

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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 = 0.30 p = 0.48

OMT + Revasc

OMT

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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 perspective The surgeon’s perspective

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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

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Balloon angioplastyBARI post hoc

analysis

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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.

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What about stenting?

Ka GL et al, JACC 2000

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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

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Università di CataniaESC guidelines 2009

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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

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• 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

Documents

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