Case discussion: BKA after after CABG 7 days ago

[manygas]

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I'm on my regional month and was asked to do block for BKA in a patient 7 days post op from a cabg after an MI. I'm not sure how long you should wait after a cabg for surgery? The AHA guidelines only really go over timing of surgery after PCI/DES. Couldn't really find substantial evidence about cabg one way or the other. She did have a gangrenous foot and so I assumed it was emergent/urgent. I'm sure if it was something elective like cholelithiasis there would be more of a reluctance to do the case. Any thoughts?

 

[Arch Guillotti]

It’s better than having to do it before the patient is revascularized

 

[sevoflurane]

Hi the nail on the head. Sounds emergent. Last thing you want is to end up with endocarditis on a fresh valve.

 

[vector2]

I'm on my regional month and was asked to do block for BKA in a patient 7 days post op from a cabg after an MI. I'm not sure how long you should wait after a cabg for surgery? The AHA guidelines only really go over timing of surgery after PCI/DES. Couldn't really find substantial evidence about cabg one way or the other. She did have a gangrenous foot and so I assumed it was emergent/urgent. I'm sure if it was something elective like cholelithiasis there would be more of a reluctance to do the case. Any thoughts?

Medscape: Medscape Access

Abstract
Aims: Coronary artery bypass grafts (CABGs) are increasingly performed in elderly patients. Risk factors and outcomes are poorly described for those undergoing noncardiac surgery within 1 year after CABG. Our objectives were to assess the risk and predictors of major adverse events associated with noncardiac surgery within 1 year after CABG.

Methods: In a retrospective review of medical records at Mayo Clinic (Rochester, MN, USA), over a period of 5 years, we identified patients who underwent noncardiac procedures within 1 year post-CABG. All events that occurred within 30 days after noncardiac surgery and deaths within 1 year after noncardiac surgery were considered to be related to CABG.

Results: We identified 211 patients; of these, 21 patients had 24 adverse events. Within 1 year, 11 died, and within the first 30 days, three myocardial infarctions, six acute congestive heart failure episodes, three cerebrovascular accidents and one deep vein thrombosis episode had occurred. Predictors of an adverse event included emergency operation (odds ratio: 6.8), ejection fraction less than 45% (p < 0.001) and elevated right ventricular systolic pressure by 40 mmHg or more (p = 0.03). After the noncardiac procedure, patients requiring dialysis (p = 0.02), ventilatory support (p = 0.03) and longer hospital stay (p = 0.03) had greater rates of adverse outcomes.

Conclusion: Post-CABG, preoperative ejection fraction less than 45%, right ventricular systolic pressure of 40 mmHg or more, as well as emergent noncardiac surgery, were predictors of adverse outcomes after the noncardiac procedure. Longer postoperative hospital stay, dialysis, as well as ventilatory support, were predictors of adverse outcomes after CABG.


From the discussion:
"
Our study has limitations, which should be considered. Our study is a retrospective review, the information bias and inability to control all confounding variables are inherent in the study design. The incidence of adverse events in our study are higher compared with prior reports,[30]since, in our study, noncardiac operations were completed within 1 year post-CABG, which is considered a high-risk period.

In summary, among the patients who underwent a noncardiac operation within 1 year after CABG, compromised cardiac function after CABG and emergent noncardiac surgery were significant predictors of adverse outcomes. If a patient presents for an elective noncardiac operation, has either low EF or high RVSP and has undergone a recent CABG, a 3-month delay of the noncardiac surgery would be preferable, if possible. In addition, if the patient requires perioperative dialysis or ventilatory support, or if a longer stay in the hospital is needed after CABG, clinicians should be aware of the potential for adverse outcomes"

 

[manygas]

Thank you vector2, I also came across that article, I need to look at the full article to see how exactly far out the patients were from their CABG. Within 1 year is such a big time frame.

Also I wonder what one would expect after a 3-month delay for elective non-cardiac surgery? Do the authors expect the parameters (low EF or high RVSP) to improve that far out from a CABG? I wouldn't think it would, it seems arbitrary.

To sevoflurane: I didn't think about that, that's definitely something I would not want happening! In retrospect I'm sure the cardiac surgeon was thinking about this.

 

[Noyac]

Gangrene is emergent. Move forward. I understand that it is not ideal to operate on someone like this but you have zero options essentially. That foot will kill her.

 

[Twiggidy]

I'm on my regional month and was asked to do block for BKA in a patient 7 days post op from a cabg after an MI. I'm not sure how long you should wait after a cabg for surgery? The AHA guidelines only really go over timing of surgery after PCI/DES. Couldn't really find substantial evidence about cabg one way or the other. She did have a gangrenous foot and so I assumed it was emergent/urgent. I'm sure if it was something elective like cholelithiasis there would be more of a reluctance to do the case. Any thoughts?

the cardiac surgeons took care of the comorbidity for you. do the case