Prevalence, phenotypes, and long-term outcomes of cardiac complications after arterial vascular surgery.

Abstract

The aim of this study prospective diagnostic study with central adjudication was to (1) determine the incidence and phenotypes of cardiac complications after arterial vascular surgery, (2) investigate possible heterogeneity, and (3) assess short- and long-term mortality and major adverse cardiac events (MACEs) according to different phenotypes of these cardiac complications. Consecutive high-risk patients (age >65 years or with known cardiovascular disease) undergoing arterial vascular surgery were included between 2014 and 2019. Cardiac complications including perioperative myocardial infarction/injury (PMI) were centrally adjudicated by two independent physicians. PMI etiologies were hierarchically classified into extracardiac if caused by a primarily extracardiac disease such as severe sepsis or pulmonary embolism, or cardiac, and further subtyped into type 1 MI, tachyarrhythmia, postoperative acute heart failure (pAHF), or likely type 2 MI. All-cause death and MACE, including acute MI, pAHF, life-threatening arrhythmia, and cardiovascular death, were assessed during 1-year follow-up. Among 2'265 patients (median age 71 years, 27% female), PMI occurred in 423 (18.7%) with substantial heterogeneity. The highest incidence was seen after open thoracic, thoracoabdominal and abdominal aortic aneurysm repair (42%) and the lowest after carotid endarterectomy (11%). Open and endovascular peripheral revascularization procedures were associated with PMI rates of 17% and 14%, respectively. Within 1 year, 267/2'265 patients (11.8%) died and at least one MACE occurred in 325/2'265 patients (14.3%). Long-term outcomes differed substantially according to etiology: in patients with extracardiac PMI, type 1 MI, tachyarrhythmia, pAHF, and likely type 2 MI, 67%, 24%, 45%, 47%, and 18% died and 63%, 50%, 73%, 73%, and 20% had MACE within 1 year, respectively, in comparison with 8% and 10% (all P < .001) in patients without a PMI. The incidence of cardiac complications after arterial vascular surgery procedures is high and is associated with high rates of mortality and MACE, with extracardiac PMI, pAHF, and tachyarrhythmias being associated with a particularly poor prognosis, underscoring the urgent need for appropriate diagnosis and treatment.