Myocardial Dysfunction in the Perioperative Period

  • O. F. Boyd
Conference paper


Perioperative myocardial dysfunction is an important cause of post-operative mortality and morbidity, due to myocardial infarction and sudden death and also due to changes in vital organ perfusion caused by myocardial failure. This contribution will describe methods of pre-operative risk stratification that can be used to identify patients at risk of post-operative myocardial dysfunction and will describe what goes wrong with myocardial function during the perioperative period. Furthermore it will discuss techniques and treatment that can be employed to prevent post-operative myocardial dysfunction, and the consequences of this.


Abdominal Aortic Aneurysm Myocardial Dysfunction Stress Echocardiography Dobutamine Stress Echocardiography Noncardiac Surgery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Goldman L, Caldera DL, Nussbaum SR et al (1977) Multifactorial index of risk in noncardiac surgical procedures. N Eng J Med 297: 845–850.CrossRefGoogle Scholar
  2. 2.
    Detsky AS, Abrams HB, Forbath N et al (1986) Cardiac assessment for patients undergoing noncardiac surgery. A multifactorial clinical risk index. Arch Intern Med 146(11): 2131–4.PubMedCrossRefGoogle Scholar
  3. 3.
    Brady AR, Fowkes FG, Greenhalgh RM et al (2000) Risk factors for postoperative death following elective surgical repair of abdominal aortic aneurysm: results from the UK Small Aneurysm Trial. On behalf of the UK Small Aneurysm Trial participants. Br J Surg 87(6): 742–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Becquemin JP, Chemla E, Chatellier G et al (2000) Peroperative factors influencing the outcome of elective abdominal aorta aneurysm repair. Eur J Vasc Endovasc Surg 20(1): 84–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Gilbert K, Larocque BJ, Patrick LT (2000) Prospective evaluation of cardiac risk indices for patients undergoing noncardiac surgery. Ann Intern Med 133(5): 356–9.PubMedGoogle Scholar
  6. 6.
    Copeland GP, Jones D, Walters M (1991) POSSUM: a scoring system for surgical audit. Br J Surg 78(3): 355–360.PubMedCrossRefGoogle Scholar
  7. 7.
    Jones HJ, de Cossart L (1999) Risk scoring in surgical patients. Br J Surg 86(2): 149–57.PubMedCrossRefGoogle Scholar
  8. 8.
    Jones DR, Copeland GP, de Cossart L (1992) Comparison of POSSUM with APACHE II for prediction of outcome from a surgical high-dependency unit. Br J Surg 79: 1293–1296.PubMedCrossRefGoogle Scholar
  9. 9.
    Lazarides MK, Arvanitis DP, Drista H et al (1997) POSSUM and APACHE II scores do not predict the outcome of ruptured infrarenal aortic aneurysms. Ann Vasc Surg 11(2): 155–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Tekkis PP, Kocher HM, Bentley AJ et al (2000) Operative mortality rates among surgeons: comparison of POSSUM and p-POSSUM scoring systems in gastrointestinal surgery. Dis Colon Rectum 43(11): 1528–32, discusssion 1532-4.PubMedCrossRefGoogle Scholar
  11. 11.
    Midwinter MJ, Tytherleigh M, Ashley S, (1999) Estimation of mortality and morbidity risk in vascular surgery using POSSUM and the Portsmouth predictor equation. Br J Surg 86(4): 471–4.PubMedCrossRefGoogle Scholar
  12. 12.
    Curran JE, Grounds RM (1998) Ward versus intensive care management of high-risk surgical patients. Br J Surg 85(7): 956–61.PubMedCrossRefGoogle Scholar
  13. 13.
    Older P, Smith R, Courtney P et al (1993) Preoperative evaluation of cardiac failure and ischemia in elderly patients by cardiopulmonary exercise testing. Chest 104(3): 701–4.PubMedCrossRefGoogle Scholar
  14. 14.
    Older P, Hall A, Hader R (1999) Cardiopulmonary Exercise Testing as a Screening Test for Perioperative Management of Major Surgery in the Elderly. Chest 116: 355–362.PubMedCrossRefGoogle Scholar
  15. 15.
    Gauss A, Rohm HJ, Schauffeien A et al (2001) Electrocardiographic exercise stress testing for cardiac risk assessment in patients undergoing noncardiac surgery. Anesthesiology 94(1): 38–46.PubMedCrossRefGoogle Scholar
  16. 16.
    Rohde LE, Polanczyk CA, Goldman L et al (2001) Usefulness of transthoracic echocardiography as a tool for risk stratification of patients undergoing major noncardiac surgery. Am J Cardiol 87(5): 505–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Halm EA, Browner WS, Tubau JF et al (1996) Echocardiography for assessing cardiac risk in patients having noncardiac surgery. Study of Perioperative Ischemia Research Group. Ann Intern Med 125(6): 433–41.PubMedGoogle Scholar
  18. 18.
    Day SM, Younger JG, Karavite D et al (2000) Usefulness of hypotension during dobutamine echocardiography in predicting perioperative cardiac events. Am J Cardiol 85(4): 478–83.PubMedCrossRefGoogle Scholar
  19. 19.
    Das MK, Pellikka PA, Mahoney DW et al (2000) Assessment of cardiac risk before nonvascular surgery: dobutamine stress echocardiography in 530 patients. J Am Coll Cardiol 35(6): 1647–53.PubMedCrossRefGoogle Scholar
  20. 20.
    Krivokapich J, Child JS, Walter DO et al (1999) Prognostic value of dobutamine stress echocardiography in predicting cardiac events in patients with known or suspected coronary artery disease. J Am Coll Cardiol 33(3): 708–16.PubMedCrossRefGoogle Scholar
  21. 21.
    Boersma E, Poldermans D, Bax JJ et al (2001) Predictors of cardiac events after major vascular surgery: Role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy. Jama 285(14): 1865–73.PubMedCrossRefGoogle Scholar
  22. 22.
    Tischler MD, Lee TH, Hirsch AT et al (1991) Prediction of major cardiac events after peripheral vascular surgery using dipyridamole echocardiography. Am J Cardiol 68(6): 593–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Beleslin BD, Ostojic M, Stepanovic J et al (1994) Stress echocardiography in the detection of myocardial ischemia. Head-to-head comparison of exercise, dobutamine, and dipyridamole tests. Circulation 90(3): 1168–76.PubMedCrossRefGoogle Scholar
  24. 24.
    Roghi A, Palmieri B, Crivellaro W et al (1999) Preoperative assessment of cardiac risk in noncardiac major vascular surgery. Am J Cardiol 83(2): 169–74.PubMedCrossRefGoogle Scholar
  25. 25.
    Takase B, Younis LT, Byers SL et al (1993) Comparative prognostic value of clinical risk indexes, resting two-dimensional echocardiography, and dipyridamole stress thallium-201 myocardial imaging for perioperative cardiac events in major nonvascular surgery patients. Am Heart J 126(5): 1099–106.PubMedCrossRefGoogle Scholar
  26. 26.
    Slogoff S, Keats AS (1985) Does perioperative myocardial ischemia lead to postoperative myocardial infarction? Anesthesiology 62(2): 107–14.PubMedCrossRefGoogle Scholar
  27. 27.
    Mangano DT, Hollenberg M, Fegert G et al ( 1991) Perioperative myocardial ischemia in patients undergoing noncardiac surgery—I: Incidence and severity during the 4 day perioperative period. The Study of Perioperative Ischemia (SPI) Research Group. J Am Coll Cardiol 17(4): 843–50.PubMedCrossRefGoogle Scholar
  28. 28.
    Mangano DT, Wong MG, London MJ et al (1991) Perioperative myocardial ischemia in patients undergoing noncardiac surgery—II: Incidence and severity during the 1st week after surgery. The Study of Perioperative Ischemia (SPI) Research Group. J Am Coll Cardiol 17(4): 851–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Glantz L, Drenger B, Gozal Y (2000) Perioperative myocardial ischemia in cataract surgery patients: general versus local anesthesia. Anesth Analg 91(6): 1415–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Sbarigia E, DarioVizza C, Antonini M et al (1999) Locoregional versus general anesthesia in carotid surgery: is there an impact on perioperative myocardial ischemia? Results of a prospective monocentric randomized trial. J Vasc Surg 30(1): 131–8.PubMedCrossRefGoogle Scholar
  31. 31.
    Wong DH, Hagar JM, Mootz J et al (1996) Incidence of perioperative myocardial ischemia in TURP patients. J Clin Anesth 8(8): 627–30.PubMedCrossRefGoogle Scholar
  32. 32.
    Christopherson R, Glavan NJ, Norris EJ et al (1996) Control of blood pressure and heart rate in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Perioperative Ischemia Randomized Anesthesia Trial (PIRAT) Study Group. J Clin Anesth 8(7): 578–84.PubMedCrossRefGoogle Scholar
  33. 33.
    Rapp HJ, Rabethge S, Luiz T et al (1999) Perioperative ST-segment depression and troponin T release. Identification of patients with highest risk for myocardial damage. Acta Anaesthesiol Scand 43(2): 124–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Fleisher LA, Zielski MM, Schulman SP (1997) Perioperative ST-segment depression is rare and may not indicate myocardial ischemia in moderate-risk patients undergoing noncardiac surgery. J Cardiothorac Vasc Anesth 11(2): 155–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Rao TLK, Jacobs KH, El-Etr AA (1983) Reinfarction following anesthesia in patients with myocardial infarction. Anesth 59: 499–505.CrossRefGoogle Scholar
  36. 36.
    Rosenberg J, Dirkes WE, Kehlet H (1989) Episodic arterial oxygen desaturation and heart rate variations following major abdominal surgery. Br J Anaesth 63(6): 651–4.PubMedCrossRefGoogle Scholar
  37. 37.
    Rosenberg-Adamsen S, Lie C, Bernhard A et al (1999) Effect of oxygen treatment on heart rate after abdominal surgery. Anesthesiology 90(2): 380–4.PubMedCrossRefGoogle Scholar
  38. 38.
    Haque R, Kan H, Finkel MS (1998) Effects of cytokines and nitric oxide on myocardial E-C coupling. Basic Res Cardiol 93(Suppl 1): 86–94.PubMedCrossRefGoogle Scholar
  39. 39.
    Kan H, Finkel MS (2001) Interactions between cytokines and neurohormonal systems in the failing heart. Heart Fail Rev 6(2): 119–27.PubMedCrossRefGoogle Scholar
  40. 40.
    Hill GE, Whitten CW (1998) Proinflammatory mediator release after total hip arthroplasty. Anesthesiology 88(5): 1407–8.PubMedCrossRefGoogle Scholar
  41. 41.
    Hill GE (1998) Cardiopulmonary bypass-induced inflammation: is it important? J Cardiothorac Vasc Anesth 12(2 Suppl 1): 21–5.PubMedGoogle Scholar
  42. 42.
    Mangano DT, Layug EL, Wallace A et al (1996) Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Iscemia Research Group. N Eng J Med 335: 1713–1720.CrossRefGoogle Scholar
  43. 43.
    Poldermans D, Boersma E, Bax JJ et al (1999) The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med 341(24): 1789–94.PubMedCrossRefGoogle Scholar
  44. 44.
    ACC/AHA task force report (1996) Special report: guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Cardiothorac Vasc Anesth 10(4): 540–52.CrossRefGoogle Scholar
  45. 45.
    Howell SJ, Sear JW, Foex P (2001) Peri-operative beta-blockade: a useful treatment that should be greeted with cautious enthusiasm. Br J Anaesth 86: 161–164.PubMedCrossRefGoogle Scholar
  46. 46.
    Fleisher LA (1999) Con: beta-blockers should not be used in all patients undergoing vascular surgery. J Cardiothorac Vasc Anesth 13(4): 496–7.PubMedCrossRefGoogle Scholar
  47. 47.
    Dawood MM, Gutpa DK, Southern J et al (1996) Pathology of fatal perioperative myocardial infarction: implications regarding pathophysiology and prevention. Int J Cardiol 57(1): 37–44.PubMedCrossRefGoogle Scholar
  48. 48.
    UK Prospective Diabetes Study Group, (1998) Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. Br Med J 317:713–20.CrossRefGoogle Scholar
  49. 49.
    Winther K, Willich SN (1991) Beta 1-blockade and acute coronary ischemia. Possible role of platelets. Circulation 84(6 Suppl): VI68-71.Google Scholar
  50. 50.
    Katafuchi T, Take S, Hori T (1993) Roles of sympathetic nervous system in the suppression of cytotoxicity of splenic natural killer cells in the rat. J Physiol 465: 343–57.PubMedGoogle Scholar
  51. 51.
    Boyd AR, Tremblay RE, Spencer FC et al (1959) Estimation of cardiac output soon after cardiac surgery with cardiopulmonary bypass. Ann Surg 150: 613–625.PubMedCrossRefGoogle Scholar
  52. 52.
    Clowes GHA, Jr., Del Guercio LRM (1960) Circulatory response to trauma of surgical operations. Metabolism 9(1): 67–81.PubMedGoogle Scholar
  53. 53.
    Shoemaker WC (1972) Cardiorespiratory patterns of surviving and non-surviving postoperative surgical patients. Surg Gynecol Obstet 134(5): 810–814.PubMedGoogle Scholar
  54. 54.
    Shoemaker WC, Montgomery ES, Kaplan E et al (1973) Physiologic patterns in surviving and non-surviving shock patients. Use of sequential cardiorespiratory parameters in defining criteria for therapeutic goals and early warning of death. Arch Surg 106(5): 630–636.PubMedCrossRefGoogle Scholar
  55. 55.
    Shoemaker WC, Czer LSC ( 1979) Evaluation of the biologic importance of various haemodynamic and oxygen transport variables. Crit Care Med 7(9): 424–429.PubMedCrossRefGoogle Scholar
  56. 56.
    Shoemaker WC, Appel PL, Kram HB (1993) Hemodynamic and oxygen transport responses in survivors and non-survivors of high-risk surgery. Crit Care Med 21: 977–990.PubMedCrossRefGoogle Scholar
  57. 57.
    Kusano C, Baba M, Takao S et al (1997) Oxygen delivery as a factor in the development of fatal postoperative complications after oesophagectomy. Br J Surg 84(2): 252–7.PubMedCrossRefGoogle Scholar
  58. 58.
    Peerless JR, Alexander JJ, Pinchak AC et al (1998) Oxygen delivery is an important predictor of outcome in patients with ruptured abdominal aortic aneurysms [In Process Citation]. Ann Surg 227(5): 726–34.PubMedCrossRefGoogle Scholar
  59. 59.
    Polonen P, Hippelainen M, Takala R et al (1997) Relationship between intra-and postoperative oxygen transport and prolonged intensive care after cardiac surgery: a prospective study. Acta Anaesthesiol Scand 41(7): 810–7.PubMedCrossRefGoogle Scholar
  60. 60.
    Ganz W (1971) A new technique for measurement of cardiac output by thermodilution in man. Am J Cardiol 27(4): 392–396.PubMedCrossRefGoogle Scholar
  61. 61.
    Bland RD, Shoemaker WC, Shabot MM (1978) Physiologic monitoring goals for the critically ill patient. Surg Gynecol Obstet 147(6): 833–841.PubMedGoogle Scholar
  62. 62.
    Schultz RJ, Whitfield GF, LaMura JJ et al (1985) The role of physiologic monitoring in patients with fractures of the hip. J Trauma 25: 309–316.PubMedCrossRefGoogle Scholar
  63. 63.
    Shoemaker WC, Appel PL, Kram HB et al (1988) Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 94(6): 1176–86.PubMedCrossRefGoogle Scholar
  64. 64.
    Berlauk JF, Abrams JH, Gilmour IJ et al (1991) Preoperative optimization of cardiovascular hemodynamics improves outcome in peripheral vascular surgery. Ann Surg 214(3): 289–297.PubMedCrossRefGoogle Scholar
  65. 65.
    Fleming A, Bishop M, Shoemaker W et al (1992) Prospective trial of supranormal values as goals of resuscitation in severe trauma. Arch Surg 127(10): 1175–9; discussion 1179-81.PubMedCrossRefGoogle Scholar
  66. 66.
    Boyd O, Grounds RM, Bennett ED (1993) A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA 270: 2699–2707.PubMedCrossRefGoogle Scholar
  67. 67.
    Bishop MH, Shoemaker WC, Appel PL et al (1995) Prospective, randomized trial of survivor values of cardiac index, oxygen delivery, and oxygen consumption as resuscitation endpoints in severe trauma [see comments]. J Trauma 38(5): 780–7.PubMedCrossRefGoogle Scholar
  68. 68.
    Mythen MG, Webb AR (1994) Intra-operative gut mucosal hypoperfusion is associated with increased post-operative complications and cost. Int Care Med 20: 99–104.CrossRefGoogle Scholar
  69. 69.
    Durham RM, Neunaber K, Mazuski JE et al (1996) The use of oxygen consumption and delivery as endpoints for resuscitation in critically ill patients. J Trauma 41(1): 32–9; discussion 39-40.PubMedCrossRefGoogle Scholar
  70. 70.
    Ziegler DW, Wright JG, Choban PS et al (1997) A prospective randomized trial of preoperative “optimization” of cardiac function in patients undergoing elective peripheral vascular surgery. Surgery 122(3): 584–92.PubMedCrossRefGoogle Scholar
  71. 71.
    Bender JS, Smith-Meek MA, Jones CE (1997) Routine pulmonary artery catheterization does not reduce morbidity and mortality of elective vascular surgery: results of a prospective, randomized trial. Ann Surg 226(3): 229–36; discussion 236-7.PubMedCrossRefGoogle Scholar
  72. 72.
    Sinclair S, James S, Singer M (1997) Intraoperative intravascular volume optimization and length of hospital stay after repair of proximal femoral fracture: randomized controlled trial. Br Med J 315:909–912.CrossRefGoogle Scholar
  73. 73.
    Ueno S, Tanabe G, Yamada H et al (1998) Response of patients with cirrhosis who have undergone partial hepatectomy to treatment aimed at achieving supranormal oxygen delivery and consumption. Surgery 123(3): 278–86.PubMedCrossRefGoogle Scholar
  74. 74.
    Valentine RJ, Duke ML, Inman MH et al (1998) Effectiveness of pulmonary artery catheters in aortic surgery: a randomized trial. J Vasc Surg 27(2): 203–11; discussion 211-2.PubMedCrossRefGoogle Scholar
  75. 75.
    Wilson J, Woods I, Fawcett J et al (1999) Reducing the risk of major elective surgery: randomized controlled trial of preoperative optimization of oxygen delivery. Br Med J 318: 1099–1103.CrossRefGoogle Scholar
  76. 76.
    Polonen P, Ruokonen E, Hippelainen M et al (2000) A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Anesth Analg 90(5): 1052–9.PubMedCrossRefGoogle Scholar
  77. 77.
    Lobo SM, Salgado PF, Castillo VG et al (2000) Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients. Crit Care Med 28(10): 3396–404.PubMedCrossRefGoogle Scholar
  78. 78.
    Boyd O, Bennett ED (1996) Enhancement of perioperative tissue perfusion as a therapeutic strategy for major surgery. New Horiz 4(4): 453–65.PubMedGoogle Scholar
  79. 79.
    Forst H (1997) Maximierung des Ch-Transports beim kritisch Kranken, Ein rationales Therapiekonzept? Anaesthetist 46: 46–52.CrossRefGoogle Scholar
  80. 80.
    Ivanov RI, Allen J, Sandham JD et al (1997) Pulmonary artery catheterization: a narrative and systematic critique of randomized controlled trials and recommendations for the future. New Horiz 5(3): 268–76.PubMedGoogle Scholar
  81. 81.
    Heyland DK, Cook DJ, King D et al (1996) Maximizing oxygen delivery in critically ill patients: a methodologic appraisal of the evidence [see comments]. Crit Care Med 24(3): 517–24.PubMedCrossRefGoogle Scholar
  82. 82.
    Leibowitz AB, Beilin Y (1997) Pulmonary artery catheters and outcome in the perioperative period. New Horiz 5(3): 214–21.PubMedGoogle Scholar
  83. 83.
    Boyd O, Hayes M (1999) The oxygen trail—the goal. Br Med Bull 55(1): 125–139.PubMedCrossRefGoogle Scholar
  84. 84.
    Bennett D, Boyd O (2000) Oxygen delivery in surgical patients—doesn’t work, or does it? Crit Care Med 28(10): 3564–5.PubMedCrossRefGoogle Scholar
  85. 85.
    Boyd O, Bennett ED (2000) The right heart catheter: leaner, fitter patient management. Crit Care Med 28(3): 881–2.PubMedCrossRefGoogle Scholar
  86. 86.
    Shoemaker WC, Appel PL, Waxman K et al (1982) Clinical trial of survivors cardiorespiratory patterns as therapeutic goals in critically ill postoperative patients. Crit Care Med 10(6): 398–403.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2002

Authors and Affiliations

  • O. F. Boyd
    • 1
  1. 1.Department of Intensive CareThe Royal Sussex County HospitalBrightonUK

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