Perioperative bleeding remains a major complication in cardiac surgery and is associated with increased morbidity, mortality, and transfusion requirements. While patient blood management strategies and goal-directed hemostatic therapies have improved outcomes, the role of fundamental physiological conditions such as acid-base balance, temperature, calcium homeostasis, and hematocrit remains underexplored in clinical research. These factors may critically modulate coagulation and influence the efficacy of hemostatic interventions. This comprehensive narrative review assesses the in vitro and in vivo impact of acidosis, hypothermia, hypocalcemia, and anemia on hemostasis and proposes the concept of a coagulation-friendly environment as a prerequisite for effective bleeding management in cardiac surgery. Optimization of these variables represents an essential foundation for effective hemostatic therapy and may improve bleeding outcomes when integrated into patient blood management strategies.

BACKGROUND:The prognostic relevance of perioperative myocardial injury/infarction (PMI) in older patients undergoing major noncardiac surgery remains unclear, as high comorbidity burden may lessen its impact. METHODS:Older patients (defined as age ≥70 years with ≥3 comorbidities, or ≥80 years) enrolled in a multicentre, prospective study of patients at increased cardiovascular risk undergoing major noncardiac surgery were analysed. The primary endpoint, all-cause mortality at 1 year, was analysed using Cox proportional hazards regression. Secondary endpoints included major adverse cardiac events (MACE) (cardiovascular death, acute myocardial infarction, life-threatening arrhythmia and acute heart failure), analysed using Fine-Grey hazard regression. All models were adjusted for prespecified confounders with PMI as a time-varying exposure. RESULTS:Amongst 4634 older patients (median age 80 years; 42.9% women), PMI occurred in 892 patients (19.2%), which was higher than in younger patients (P < .0001). The distribution of PMI aetiologies was comparable between groups. At 1 year, all-cause mortality was 26.2% in patients with PMI and 13.2% in patients without PMI, and MACE occurred in 30% versus 13%, respectively. After multivariable adjustment, the hazard ratio of PMI was highest on postoperative day 1 (all-cause mortality: 10.5 [95% CI 4.5-24.5]; MACE: 4.4 [95% CI 3.2-5.9]), declined by day 90 (1.4 [95% CI 1.0-1.9] and 2.2 [95% CI 1.7-2.7], respectively), and persisted through 1 year. CONCLUSIONS:PMI was very common amongst older patients and associated with substantially higher 1-year risks of all-cause mortality and MACE, with greatest vulnerability observed during the initial 90 postoperative days.

The Society of Cardiovascular Anesthesiologists (SCA) along with the Society of Thoracic Surgeons (STS) sought to improve the care of adult patients undergoing cardiac surgery who are taking direct oral anticoagulants (DOACs), such as factor Xa and direct thrombin inhibitors. To fulfill this, a systematic review of the literature on cessation of DOACs before cardiac surgery, options for monitoring DOACs, the need for bridging, reversal agents, and resuming the medications after surgery was performed. Additionally, an expert consensus around the management of these patients was completed. Summary statements were created using evidence and expert consensus to guide care of patients in each of these domains, with the ultimate goal to enhance patient safety and outcomes.

BACKGROUND:Thromboelastometry is often used to guide coagulation management, but validation outside cardiac surgery is limited. We evaluated correlations between thromboelastometry parameters and conventional laboratory tests in noncardiac patients and assessed a cardiac surgery-derived predictive app. METHODS:A retrospective single-center cohort of 257 patients with simultaneous thromboelastometry and laboratory measurements formed the study population. Correlations were assessed with the Pearson r and agreement with Bland-Altman analysis. Diagnostic performance for hypofibrinogenemia (≤1.5 g/L) and thrombocytopenia (≤100 × 10⁹/L) was evaluated using receiver operating characteristic (ROC) analyses with area under the ROC (AUROC) and 95% confidence intervals. RESULTS:Fibrinogen correlated strongly with FIBTEM (the extrinsic activation pathway, whereby platelets are blocked in FIBTEM and the resulting clot consists only of fibrin formation and polymerization) A10 (specific point of time of 10 minutes) and FIBTEM MCF (maximal clot firmness) (r = 0.82). Platelet count correlated with EXTEM (the extrinsic activation pathway) A10 (r = 0.58), INTEM (the intrinsic pathway is activated) A10 (r = 0.61), and EXTEM-FIBTEM A10 (r = 0.57). AUROC for hypofibrinogenemia was 0.92 (FIBTEM A10), 0.89 (FIBTEM MCF), and 0.89 (EXTEM alpha). AUROC for thrombocytopenia was 0.95 (EXTEM A10), 0.96 (INTEM A10), and 0.97 (EXTEM-FIBTEM A10). Predicted versus observed values correlated at r = 0.82 for fibrinogen and r = 0.58 to 0.61 for platelets. Bland-Altman analyses showed systematic underestimation by the app with wide limits of agreement (bias +0.8 g/L for fibrinogen; +62, +50, and +50 × 10⁹/L for platelets). CONCLUSIONS:FIBTEM A10 (fibrinogen) and EXTEM/INTEM A10 (platelets) correlate well with conventional laboratory measures in a heterogenous noncardiac cohort, supporting thromboelastometry as a point-of-care tool. However, the cardiac-derived predictive model shows substantial bias and variability, precluding reliable patient-level estimates. The use cannot be recommended in noncardiac patients.

BACKGROUND:International clinical practice guidelines recommend discontinuing sodium-glucose cotransporter-2 inhibitors (SGLT2i) 3-4 days before surgery to prevent euglycemic diabetic ketoacidosis, chiefly on the basis of case reports/series. Whether SGLT2i discontinuation may increase the risk of postoperative cardiovascular complications is unclear. METHODS:In a secondary analysis of the Basel-PMI (NCT02573532) and PMI-Vital (NCT05866874) prospective cohort studies in major noncardiac surgery, the exposure of interest was continuing, or stopping, SGLT2i in participants receiving chronic SGLT2i therapy. The primary outcome was an ordinal composite of acute heart failure hospitalisation and cardiovascular death within 90 days of surgery, adjusting for prespecified covariates. Secondary outcomes included the incidence of euglycemic diabetic ketoacidosis within 7 days. RESULTS:Among 451 study participants receiving SGLT2i (mean age 72 (range: 47-86) yr; 22% women), 404/451 (89.6%) had diabetes mellitus, and 166/451 (36.9%) had chronic heart failure. SGLT2i were discontinued before surgery in 393/451 (87.1%) participants (39.2% for 1 day, 34.4% for 2 days, 13.5% for ≥3 days). Cardiovascular complications occurred in 1/58 (1.7%) participants who continued SGLT2i, compared with 10/177 (5.7%) stopping for 1 day, 13/155 (8.4%) stopping for 2 days and 7/61 (11.5%) stopping for ≥3 days (P=0.011; adjusted odds ratio: 1.58 [95% confidence interval: 1.08-2.30] per discontinued day). Euglycemic diabetic ketoacidosis occurred in 1/451 participants after SGLT2i discontinuation. CONCLUSIONS:Perioperative SGLT2i discontinuation was associated with a substantially increased risk of 90-day cardiac complications. This suggests potential harm in current guideline recommendations; randomised controlled trials are needed to confirm these findings. STUDY REGISTRATION:NCT02573532, NCT05866874.

BACKGROUND AND AIMS:Peri-operative myocardial infarction/injury (PMI) is a common cardiac complication following non-cardiac surgery. It remains unclear whether involvement of cardiologists in the management of patients developing PMI improves outcomes. METHODS:This multicentre, prospective study included high-risk patients undergoing non-cardiac surgery, eligible for the institutional PMI active surveillance and response programme. Due to staffing constraints, cardiologist evaluation of patients with PMI was inconsistently available on weekends, on public holidays, or when care for more urgent patients had to be prioritized, allowing a comparison between patients receiving cardiologist evaluation and those who did not. The primary endpoint was major adverse cardiac events, defined as a composite of cardiovascular death, myocardial infarction, acute heart failure, and life-threatening arrhythmia at 365 days. The secondary endpoint was all-cause death at 365 days. Cox proportional hazards models were used to evaluate the association between cardiologist evaluation and outcomes. RESULTS:Among 14 294 patients, 1048 developed PMI and were eligible for this analysis, of whom 614 patients (58.6%) received post-operative cardiologist evaluation. Baseline characteristics were similar between groups. After adjustment, cardiologist evaluation was independently associated with lower risk of major adverse cardiac events (adjusted hazard ratio .54, P = .001) and all-cause death (adjusted hazard ratio .65, P = .037) at 365 days. Sensitivity analyses confirmed these findings. Patients receiving cardiology evaluation were more likely to undergo non-invasive cardiac imaging and to receive dual antiplatelet and statin therapy. CONCLUSIONS:Cardiologist evaluation of patients with PMI following major non-cardiac surgery was associated with a reduced risk of major adverse cardiac events and all-cause mortality at 365 days after surgery, suggesting that interdisciplinary management may improve post-operative outcomes.

INTRODUCTION:Of the 3 published trials, only 1 showed possible efficacy of endovascular treatment (EVT) compared to best medical treatment (BMT) alone for medium or distal vessel occlusions (MDVO), whereas the others were neutral. Procedural conditions may affect the outcome. PATIENTS AND METHODS:This is a post-hoc analysis of the randomised, controlled DISTAL trial, conducted in 55 centers between 12/2021 and 7/2024. Patients with isolated MDVO within 24 hours of last seen well randomised to EVT plus BMT were treated under general anaesthesia (GA), conscious sedation (CS) or local anaesthesia (LA) at investigators' discretion. Endovascular treatment under different anaesthesia modalities was compared head-to-head, and to BMT alone. RESULTS:Among 491 patients included in the analysis, 224 received EVT plus BMT (108 GA, 64 LA, 52 CS) and 267 received BMT alone. Compared to BMT alone, EVT under CS was associated with worse 90-day modified Rankin Scale (median 2.5 vs 2.0; adjusted odds ratio [aOR] 0.51 [95% CI 0.29-0.90]), whereas no difference was observed between EVT under other anaesthesia modalities and BMT alone. Symptomatic intracranial haemorrhage occurred more frequently after EVT under GA compared to BMT alone (8.3% vs 2.6%; aOR 3.37 [95% CI, 1.22-9.66]). LA was associated with higher odds of better functional outcome (aOR 2.11 [95% CI, 1.09-4.12]) and lower mortality (aOR 0.28 [95% CI, 0.08-0.95]) compared to CS, whereas there was no difference to GA. DISCUSSION AND CONCLUSION:The lack of superiority of EVT plus BMT over BMT alone in DISTAL may not have been driven by anaesthesia modality.

PreOpNet is a novel deep-learning algorithm using 12-lead digital electrocardiogram (ECG) for preoperative risk assessment of all-cause death and major adverse cardiac events (MACE) within 30 days. Its performance in European high-risk patients undergoing major non-cardiac surgery—the target population for guideline-recommended risk assessment—and comparison to high-sensitivity cardiac troponin T (hs-cTnT), is unknown. In a prospective European study (2014–2019), 6098 high-risk patients with available ECGs were enrolled. PreOpNet showed moderate discrimination for death (AUC 0.707) and MACE (0.675), but overestimated risk. It outperformed the revised cardiac risk index (RCRI) for death (AUC 0.644), but not for MACE (0.662). Hs-cTnT remained superior for both outcomes (AUC 0.762 and 0.743). Importantly, PreOpNet provided incremental prognostic value when combined with RCRI and/or hs-cTnT. PreOpNet has limited benefit for preoperative risk stratification in high-risk surgical patients as a stand-alone test. However, it holds promise when used in conjunction with RCRI and hs-cTnT. Clinical Trial Registration: ClinicalTrials.gov number: NCT02573532; https://www.clinicaltrials.gov/study/NCT02573532 .

Preoperative anemia and non-anemic iron deficiency are common in cardiac surgery patients. Both are frequently caused by absolute iron deficiency or are associated with chronic diseases and inflammation. Multiple studies have shown an association between preoperative anemia and increased RBC transfusion, prolonged intensive care unit and hospital length of stay, and higher postoperative morbidity and mortality. The impact of preoperative non-anemic iron deficiency on postoperative adverse outcome is less clear, but worsened postoperative outcomes have been suggested. Accordingly, treatment for anemia and iron deficiency is a primary goal in preoperative optimization in cardiac surgery patients. Several guidelines recommend timely supplementation with modern oral iron formulation as first-line intervention, followed by intravenous iron administration in case of patient intolerance or time restriction. In patients with non-pure iron deficiency or in ultra-short treatment strategies, the combined therapy of intravenous iron and erythropoiesis-stimulating agents seems safe and most efficacious to increase red blood mass before surgery. However, the positive effects of preoperative interventions in anemic or iron-deficient patients were mostly limited to reduced transfusion of red blood cells, whereas lower morbidity and mortality were shown in limited studies only. It is also important to note that allogeneic blood products are a limited resource, and preoperative oral iron supplementation showed the best cost-effectiveness.

OBJECTIVE: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. METHODS: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. RESULTS: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. CONCLUSIONS: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.

INTRODUCTION:Heart failure is a frequent comorbidity in patients undergoing non-cardiac surgery and an acknowledged risk factor for postoperative mortality. The associations between stable chronic heart failure and postoperative outcomes have not been explored extensively. The aim of this study was to determine associations between stable chronic heart failure and its peri-operative management and postoperative outcomes after major non-cardiac surgery. METHODS:This is a secondary analysis of MET-REPAIR, an international prospective cohort study including patients undergoing non-cardiac surgery aged ≥ 45 y with increased cardiovascular risk. Main exposures were stable chronic heart failure and availability of a pre-operative transthoracic echocardiogram. The primary endpoint was the incidence of postoperative major adverse cardiovascular events at 30 days. Secondary endpoints included 30-day mortality and severe in-hospital complications. Multivariable logistic regression models were calculated. RESULTS:Of 15,158 included patients, 3880 (25.6%) fulfilled the diagnostic criteria for stable chronic heart failure, of whom 1397 (36%) were female. Chronic heart failure was associated with increased risk of postoperative 30-day major adverse cardiovascular events (OR 2.04, 95%CI 1.59-2.60), 30-day mortality (OR 1.50, 95%CI 1.17-1.92) and in-hospital complications (OR 1.47, 95%CI 1.30-1.66). Transthoracic echocardiography was performed in 1267 (32.7%) patients with heart failure; 146 (11.5%) patients with heart failure presented with a left ventricular ejection fraction < 40%. Reduced ejection fraction was associated with major adverse cardiovascular events (OR 2.0, 95%CI 1.01-3.81). DISCUSSION:Stable chronic heart failure is independently associated with major adverse cardiovascular events, mortality and severe postoperative complications when measured 30 days after non-cardiac surgery.

BACKGROUND:False cardiac troponin (cTn) elevations from non-cardiac causes are a major concern. We aimed to assess terminal renal failure as a possible non-cardiac cause of elevated high-sensitivity cTnT (hs-cTnT) concentrations using renal transplantation as an in vivo model of rapid restoration of renal function. METHODS:We analysed consecutive patients with end-stage renal disease (ESRD) undergoing renal transplantation at a single centre. Patients with perioperative myocardial infarction or injury were excluded. Changes in hs-cTnT and creatinine were measured pretransplant and at four post-transplant intervals (day 1, days 2-5 and days 14-180). A decrease of ≥25% in hs-cTnT within 24 hours post-transplant was deemed evidence of renal clearance recovery. RESULTS:Among 45 patients (median age 67 years, 31% women), the median pretransplant plasma creatinine concentration was 608 μmol/L (IQR 482-830), and fell to 425 μmol/L (IQR 337-619) on day 1, 289 μmol/L (IQR 201-492) on days 2-5 and 126 μmol/L (IQR 103-191) on days 14-180 (p<0.001, p<0.001 and p=0.003, respectively). The median pretransplant hs-cTnT concentration was 48 ng/L (IQR 34-70). It fell to 26 ng/L (IQR 15-38; geometric mean of relative change 36%) on day 1 (p<0.001) and then remained constant on days 2-5 (26 ng/L (IQR 18-35)) and days 14-180 (25 ng/L (IQR 20-30), p=ns). CONCLUSION:Terminal renal failure is a non-cardiac cause of elevated circulating hs-cTnT concentrations, contributing more than one-third in this cohort, while the remaining two-thirds seem related to chronic cardiomyocyte injury.

PURPOSE OF REVIEW:To provide evidence-based management of patients on direct oral anticoagulants (DOAC) needing acute procedures, including those facing hemorrhage. RECENT FINDINGS:Standard coagulation parameters are insufficient for precise DOAC plasma level measurement; calibrated anti factor X activated assays are reliable, and point-of-care assays may be useful in urgent situations. For intracerebral hemorrhage (ICH) in patients on DOACs, direct reversal strategies seem to be more effective than nonspecific hemostatic agents, but evidence still remains unclear in terms of efficacy and safety compared to nonspecific hemostatic agents. Before invasive procedures like neuraxial anesthesia or cerebral thrombectomy, idarucizumab is recommended for dabigatran-treated patients, despite recent observational data not fully supporting this. No recommendations can be made for FXa inhibitors because of the lack of data. SUMMARY:Clinicians should assess the overall risk of bleeding for an acute procedure or the severity of any ongoing hemorrhage in DOAC-treated patients before initiating any reversal treatment, regardless of current evidence levels.

Introduction: Postoperative atrial fibrillation (POAF) after cardiac surgery is associated with higher morbidity and mortality. This paper presents several studies that conclude the presence of an aberrant p-terminal force vector in lead V1 (PTFV1) has been identified as a significant predictor of atrial fibrillation in the non-surgical population. It is uncertain whether or not there is an association of PTFV1 and new-onset POAF in patients after cardiac surgery. Methods: In this secondary analysis, adult patients undergoing on-pump cardiac surgery for aortocoronary bypasses, valve surgery, combined bypass, and valve surgery were analyzed from 12/2018 to 08/2020. Patients who had a previous occurrence of atrial fibrillation or atrial flutter, patients with pacemakers and/or Implantable Cardioverter-Defibrillators (ICDs), and those who did not have an electrocardiogram (ECG) performed within the 3 months before surgery were excluded. In addition, ECGs that were considered to be of low quality were also removed. Preoperative 12-lead ECGs were examined and the PTFV1 was measured. Secondarily, we examined the P-wave length in lead II, the area under the P-wave in lead II, PR interval, and QRS duration in lead V1 and II. The occurrence of POAF was extracted from the hospital record. Results: Out of a total of 252 patients, 62 patients (24.6%) developed new onset POAF during their hospital stay. POAF occurred primarily in older patients, with poor renal function, and exhibited larger left atria. Analysis of ORs (odds ratios) revealed that age, creatinine clearance, valve surgery, and left atrial volume index (LAVI) were associated with POAF. In the context of the multivariable analysis, it was demonstrated that only age presented a significant correlation with postoperative atrial fibrillation (POAF). There was no observed relationship between any of the parameters based on ECG and the occurrence of POAF. Conclusion: No association was found between PTFV1 or other ECG-based measurements and new onset POAF in cardiac surgery patients. Age was the only independent predictor of POAF.