Diagnostik und Management der perioperativen Myokardischämie im Rahmen elektiver Eingriffe bei Aortenaneurysmen

Zusammenfassung

Einleitung Die perioperative Myokardischämie (PMI) stellt eine schwerwiegende postoperative Komplikation dar. Insbesondere die Aortenchirurgie gehört zu den Hochrisikoeingriffen in Bezug auf das kardiale Operationsrisiko. Ziel dieser Arbeit ist es, die Krankheitsverläufe von Patienten mit PMI nach elektiven Aortenaneurysmen-Operationen zu untersuchen.

Patienten und Methoden Es handelt sich um eine retrospektive Datenanalyse von elektiv im Zeitraum Januar 2005 bis Januar 2012 in der Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie des Universitätsklinikums Heidelberg an der Aorta wegen Aneurysma operierten Patienten. Die Diagnose PMI wurde anhand einer Erhöhung des Serumtroponins gestellt. Es erfolgte eine Charakterisierung der PMI bezüglich des Zeitpunkt ihres perioperativen Auftretens, der klinischen Symptomatik sowie Besonderheiten der durchgeführten Diagnostik. Des Weiteren wurden Therapie-, Entlass- und Verlegungsmanagement analysiert.

Ergebnisse Insgesamt wurden im angegebenen Zeitraum 863 Patienten einem elektiven Aorteneingriff unterzogen. Eine PMI wurde bei 31 (3,6%) Patienten beobachtet, wobei in 21 von 31 (67,7%) Fällen eine konventionelle Operation erfolgt war. Bei 24 Patienten (77,4%) trat eine PMI während der ersten 3 postoperativen Tage auf. Mehr als die Hälfte der Patienten (16/31) waren klinisch asymptomatisch, in 77,4% der Fälle (24/31) war das Elektrokardiogramm unauffällig. In 25,8% der Patienten (8/31) lag der primäre Serumtroponinwert im Normbereich. Eine rein medikamentöse Therapie erfolgte in 17 Fällen (54,8%). Eine interventionelle Behandlung im Sinne einer Herzkatheteruntersuchung wurde in 12 Fällen (38,7%) durchgeführt, bei 2 (6,5%) Patienten wurde eine notfallmäßige aortokoronare Bypassanlage durchgeführt. Insgesamt 14 (45,1%) Patienten konnten direkt nach Hause entlassen werden, weitere 14 (45,1%) Patienten wurden zur Weiterbehandlung der PMI in ein Akutkrankenhaus (einschließlich hausinterne Verlegung) verlegt. Zwei Patienten verstarben während des Krankenhausaufenthalts an Multiorganversagen.

Schlussfolgerung Die PMI ist eine häufige Komplikation im Rahmen elektiver Aorteneingriffe. Die Diagnostik der PMI kann bei gering ausgeprägter/okkulter Klinik im Rahmen der Intensivtherapie erschwert sein. Aufgrund der potenziell schwerwiegenden Folgen sollte eine Herzenzymdiagnostik frühzeitig eingeleitet werden, um eine zeitnahe kardiologische Therapie zu ermöglichen.

Abstract

Introduction Perioperative myocardial ischemia (PMI) is a serious postoperative complication. Aortic operations represent an especially high-risk surgery concerning cardiac complications. This aim of this study was to analyse the clinical features of PMI after elective aortic aneurysm surgery.

Patients and Methods This study is a retrospective analysis of 863 patients who underwent elective aortic aneurysm surgery between 2005 and 2012 in the Department of Vascular and Endovascular Surgery of Heidelberg University Hospital with regard to PMI. The PMI diagnosis was based on a positive serum troponin diagnostic test. We evaluated the clinical course, time point of the diagnosis and features of diagnostics to characterise PMI. Moreover, we analysed the treatment options and management of the patients’ discharge.

Results Thirty-one patients (3.6% of 863) with PMI after elective aortic aneurysm surgery were identified. Of these, 21 patients (67.7%) underwent open surgery and 10 patients (32.3%) received endovascular treatment. PMI was diagnosed in 24 patients (77%) during the first 3 days. More than half of these patients (16/31) were clinically asymptomatic. Electrocardiogram did not show pathological findings in 24 cases (77.4%). The first troponin measurement was not elevated in eight patients (25.8%). Drug therapy alone was used in 17 cases (54.8%) of PMI, coronary catheterisation was performed in 12 patients (38.7%) and two patients (6.5%) received aortocoronary bypass. Fourteen patients (45.1%) were discharged home and another 14 patients (44.1%) were transferred to another hospital or to a rehabilitation institution. Two patients died because of multi-organ failure.

Conclusion PMI is not a rare complication after elective aortic surgery. The diagnosis of PMI can be challenging because of occult symptoms especially in a perioperative setting. Due to the potentially serious consequences, cardiac enzyme diagnostics should be initiated immediately if there is suspicion of PMI or routinely in defined at-risk patients after aortic surgery.

Schlüsselwörter

endovaskulär - Gefäßchirurgie - infrarenales Aortenaneurysma - Intensivmedizin - perioperative Myokardischämie

Keywords

abdominal aorta - aortic surgery - infrarenal aortic aneurysm - intensive medicine - perioperative myocardial ischemia

Publication History

Received: 31 January 2022

Accepted after revision: 12 June 2022

Article published online:
01 August 2022

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