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Validation of Selective Cardiac Evaluation Prior to Aortic Aneurysm Repair
Alvina Won, MD;
Jose A. Acosta, MD;
Deidre Browner, MPH;
Robert J. Hye, MD
Arch Surg. 1998;133:833-838.
Objective To evaluate perioperative and long-term morbidity in patients undergoing selective evaluation of coronary artery disease prior to abdominal aortic aneurysm (AAA) repair.
Design Case series.
Setting University and Veterans' Administration medical centers.
Patients One hundred eighty-nine consecutive patients undergoing AAA repair between January 1989 and September 1996 were selectively evaluated for coronary artery disease and assigned to 1 of 3 groups: group 1, no abnormal cardiac history, normal electrocardiogram; group 2, minimal symptoms, history of myocardial infarction (MI), older than 70 years, diabetes mellitus, or congestive heart failure; or group 3, severe or unstable angina, ventricular dysfunction.
Interventions Group 1 patients proceeded to AAA repair without further workup. Group 2 patients underwent pharmacologic or exercise stress testing followed by coronary angiography and intervention as required. Group 3 patients went directly to coronary angiography and intervention as needed.
Main Outcome Measures Perioperative MI, arrhythmias, or death. Long-term follow-up measures included MI and death.
Results Adequate documentation was available on 171 patients. Twenty-four patients (14%) were in group 1. Of 136 patients (79.5%) in group 2, coronary angiography was performed in 36 (26%), followed by percutaneous transluminal coronary angioplasty (PTCA) in 9 (7%) and coronary artery bypass (CAB) in 5 (4%). Of 11 patients in group 3, 3 (27%) each received PTCA and CAB. Remote CAB or PTCA had been performed in 32 (19%) and 12 (7%) patients, respectively. Two perioperative deaths (1.1%) occurred in the 189 patients, one due to MI in a group 2 patient. There were 2 (1%) nonfatal MIs, both in group 2 patients who had no preoperative intervention. Arrhythmias and/or congestive heart failure occurred in 17 (9%) cases, 7 (39%) having had recent coronary revascularization (P=.001). By univariate analysis, only preoperative renal dysfunction predicted perioperative complications (P=.03) Overall survival by life-table analysis was 87.9% and 69.7% at 3 and 5 years, respectively.
Conclusion Coronary artery disease is common in patients undergoing AAA repair, with 35.7% having preoperative coronary revascularization at some point. Selective preoperative coronary artery disease screening achieves excellent perioperative and late results in this population.
From the Departments of Surgery, University of California Medical Center, VA Medical Center, and Kaiser Permanente Medical Center, San Diego, Calif. Dr Won is now with the Department of Surgery, University of Iowa, Iowa City. Dr Acosta is now with the National Naval Medical Center, Bethesda, Md. Dr Hye is now with the Southern California Permanente Medical Group, San Diego.
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Ghansah and Murphy
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