Comparation of VSG-CRI score and modificated VSG-CRI score sensitivity in estimation of a cardial risk in abdominal aortic surgery

[I. Đokić]

110 str.

Medicina - Kardiologija / Medicine - Cardiology

Uvod. Hirurgija abdominalne aorte nosi visok hiruški rizik za razvoj kardijalnih komplikacija. Glavni neželjeni kardijalni događaji (engl. Major adverse cardiac events, MACEs) kod bolesnika podrazumevaju nastanak poremećaja ritma, infarkta miokarda i srčane insuficijencije i povezani su sa značajnim morbiditetom i mortalitetom. Indeks kardijalnog rizika vaskularne studije grupe (engl. Vascular Study Group Cardiac Risk Index, VSG-CRI) se izdvojio se kao standardni index za predikciju kardijalnog rizika u vaskularnoj hirurgiji. Iako su dosadašnja istraživanja ukazala na potencijalnu prediktivnu vrednost ehokardiografskih parametara ejekcione frakcije LV (engl. left ventricular ejection fraction, LVEF) i segmentnih ispada u kinetici zida leve komore (engl. left ventricular wall motion abnormalities LVWMAs), VSG-CRI ih nije uključio kao varijable prediktore. Cilj rada. Cilj ove studije je bio da ispita uticaj preoperativne LVEF i LVWMAs na poboljšanje diskriminatorne sposobnosti VSG-CRI u predikciji MACEs u hirurgiji abdominalne aorte. Metode. U opservacionu prospektivnu studiju uključen je 271 bolesnik podvrgnut hirurškoj rekonstruktivnoj hirurgiji abdominalne aorte, od čega je 200 bolesnika podvrgnuto otvorenoj hirurškoj rekonstrukciji aneurizme abdominalne aorte (OAAA) a 71 bolesnik aortofemoralnom ili aortoilijakalnom bajpasu. Za sve bolesnike je, preoperativno, izračunat VSG-CRI skor pomoću 9 definisanih varijabli: starost ispitanika, koronarna arterijska bolest, kongestivna srčana insuficijencija, hronična opstruktivna bolest pluća, prisustvo insulin zavisnog dijabetesa, nivo kreatinina u krvi, navike pušenja, dugoročna terapija β-blokatorima i istorija perkutane koronarne intervencije (PCI) ili hirurške revaskularizacije miokarda (CABG). Transtorakalnim ehokardiografskim pregledom (TTE) je svim bolesnicima preoperativno procenjena vrednost LVEF kao i prisustvo LVWMAs. Praćena je incidenca intraoperativnih MACEs, postoperativnih MACEs, MACEs ukupno, kao i incidenca pojave MACEs kod bolesnika u oba posmatrana perioda (i intraoperativno i postoperativno). Metodom multivarijabilne regresione analize VSG-CRI je validiran na kohorti bolesnika, a zatim modifikovan uključivanjem LVWMA u analizu. Komparirana je diskriminatorna sposobnost VSG-CRI i M VSG-CRI u predikciji kompozitnog MACE pomoću ROC kriva. Rezultati. Postoperativni MACEs registrovani su kod ukupno 61 bolesnika (22.5%), od čega je poremećaj ritma registrovan kod 53 bolesnika (19.6%), infarkt miokarda kod 5 bolesnika (1.8%) i kongestivna srčana insuficijencija kod 9 bolesnika (3.3%). Bolesnici sa LVWMAs bili su zastupljeni u grupi bolesnika sa postoperativnim MACEs (62.3% vs. 32.9%, p<0.001). Multivarijabilna regresiona analiza identifikovala je VSG-CRI (OR 1.46; 95% CI 1.21–1.77; p< 0.001) i LVMWA (OR 2.76; 95% CI 1.46–5.23; p=0.002) kao prediktore rizika za postoperativne MACEs. Modifikovani VSG-CRI pokazao je veću senzitivnost u predikciji postoperativnih MACEs u odnosu na originalni skor AUC 0.74; 95% CI 0.68–0.81 vs. AUC 0.70; 95% CI 0.63–0.77, respektivno. Intraoperativni MACEs registrovani su kod 60 bolesnika (22.1%). Bolesnici sa LVWMAs bili su učestaliji u grupi bolesnika sa intraoperativnim MACEs u odnosu na grupu bolesnika bez intraoperativnih MACEs (58.3% vs. 34.1%, p=0.001). Takođe, bolesnici sa LVWMAs lateralnog, posteriornog, septalnog i inferiornog zida bili su učestaliji u grupi bolesnika sa intraoperativnim MACEs...

Introduction. Abdominal aortic surgery carries a high surgical risk for the development of cardiac complications. Major adverse cardiac events (MACEs) in patients include rhythm disturbances, myocardial infarction and heart failure and are associated with significant morbidity and mortality. The Vascular Study Group Cardiac Risk Index (VSG-CRI) has emerged as a standard index for predicting cardiac risk in vascular surgery. Although previous studies have indicated the potential predictive value of echocardiographic parameters, preoperative LV ejection fraction (LVEF) and left ventricular wall motion abnormalities (LVWMAs), VSG-CRI did not include them as predictor variables. Aim. The aim of this study was to examine the impact of preoperative LVEF and LVWMAs on improving the discriminatory ability of the VSG-CRI in the prediction of MACEs in abdominal aortic surgery. Methods. The observational prospective study included 271 patients undergoing reconstructive surgery of the abdominal aorta, of these 200 patients underwent open abdominal aortic aneurysm repair (OAAA) and 71 patients underwent aortofemoral or aortoiliac bypass. Preoperatively, VSGCRI was calculated for all patients using nine defined variables: age, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, presence of insulin-dependent diabetes, creatinine levels, smoking habits, long-term β-blockade therapy and history of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). All patients underwent transthoracic echocardiographic examination preoperatively (TTE) to evaluate the value of LVEF and LVWMAs. The incidence of intraoperative MACEs, postoperative MACEs, total MACEs, as well as the occurrence of MACEs in patients in both period (intraoperatively and postoperatively) were monitored. The VSG-CRI was validated on a cohort of patients by using multivariable regression analysis, and then modificated by including LVWMA in the analysis. The discriminatory ability of the VSG-CRI and the M VSG-CRI for predicting of composite MACE was compared by using ROC curves. Results. Postoperative MACEs were registered in a total of 61 patients (22.5%), of these rhythm disorder was registered in 53 patients (19.6%), myocardial infarction in 5 patients (1.8%) and congestive heart failure in 9 patients (3.3%). Patients with LVWMAs were more often represented in the group of patients with postoperative MACEs (62.3% vs. 32.9%, p<0.001). Multivariable regression analysis identified VSG-CRI (OR 1.46; 95% CI 1.21–1.77; p<0.001) and LVMWA (OR 2.76; 95% CI 1.46–5.23; p=0.002) as predictors for postoperative MACEs. The modified VSG-CRI showed a higher sensitivity for predicting postoperative MACEs compared to the original score AUC 0.74; 95% CI 0.68–0.81 vs. AUC 0.70; 95% CI 0.63–0.77, respectively. Intraoperative MACEs were registered in 60 patients (22.1%). Patients with LVWMAs were more frequent in the group of patients with intraoperative MACE compared to the group of patients without intraoperative MACEs (58.3% vs. 34.1%, p=0.001). Also, patients with LVWMAs of the lateral, posterior, septal and inferior walls were more frequent in the group of patients with intraoperative MACEs...

kardijalni rizik, otvorena hirurgija abdominalne aorte, promene u kinetici zidova leve komore, Indeks kardijalnog rizika vaskularne studijske grupe, VSG-CRI

cardiac risk, open abdominal aortic surgery, left ventricular wall motion abnormalities, the Vascular Study Group Cardiac Risk Index, VSG-CRI

616.136-089(043.3)

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