Emergenze-Urgenze
in
Cardiochirurgia
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Modality of the Surgical Procedure
• Exigen or Emergent salvage immediately!!!
(Tamponade, RCA, Massive haemorragy….)
• Emergent: just possible (operation performed immediately on
referral to surgeon or before the beginning of the next working day)
• Urgent: between 12-24 h (operation performed at or after the
beginning of the next working day but the patient must absolutely be kept in hospital
before surgery)
• Elective
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
U-E is a Risk Factor in CS
Non-elective Surgery modality is an independent
Risk Factor in all scoring systems:
– Parsonnet
– Higgins (Cleveland Clinic)
– STS
– NNE
OR
– VA (Veteran Affairs)
– EuroSCORE
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
= 1.5 to 7.1
Preoperative
estimation of risk of
mortality,
cerebrovascular
accident, and
mediastinitis,
developed by the
Northern New
England
Cardiovascular
Disease Study Group.
(Eagle KA, et al: ACC/AHA guidelines for
CABG. J Am Coll Cardiol 1999; 34:1262.)
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
European
System for
Cardiac
Operative
Risk
Evaluation
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UNIVERSITA’ DEGLI STUDI DI FIRENZE
Operative mortality for elective, urgent, emergency, and salvage
procedures for primary operations and reoperations for mitral vavlular
replacements. (Data used with permission from Society of Thoracic Surgeons.)
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Risk Factors for Hospital
Mortality in Aortic Surgery
Risk factor
p-value (range)
Emergent operation
000–.0017
NYHA
Age
.0001–.015
.01–.045
CPB time
<.001–.018
Dissection
<.001–.04
Concomitant CABG
.001–.0014
Previous cardiac operation
<.001–.0068
Arch replacement
<.001
Reoperation for bleed
.0009–.032
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Kaplan-Meier
survival analysis
for 675 patients
with Marfan
syndrome from
ten different
surgical centers
according to the
urgency of the
procedure. (Gott VL,
et al: Replacement of the
aortic root in patients with
Marfan's syndrome. N Engl J
Med 1999; 340:1307.)
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Re-operation CABG: Mortality Risk
•
•
•
•
elective reoperations
urgent reoperations
emergency reoperations
"salvage" reoperations
5.2%
7.4%
13.5%
40.7%
There is clearly a major increment in risk associated with emergency
reoperations, a larger increment than has existed for patients
undergoing primary surgery. (Data from the Society of Thoracic Surgeons for the year
1997)
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
Determinant Factors for Risk in E-U
• Patient related
• Patology related
• Surgical-Anesthetical procedures
related
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UNIVERSITA’ DEGLI STUDI DI FIRENZE
Postoperative Mortality
Preoperative Hemoglobin
% Mortality
40
30
20
n=1958
10
0
6
7
8
9
10
11
Hemaglobin g/dl
Carson et al. Lancet 1996;348:1055.
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE
12
>12
Critical preoperative conditions
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UNIVERSITA’ DEGLI STUDI DI FIRENZE
Pathology needing non-elective
Cardiac Surgery
• Traumatology/Iatrogenic
• Non elective Ischaemic or
valvular/prostheses surgery
• Acute Aortic Diseases
• RCA
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UNIVERSITA’ DEGLI STUDI DI FIRENZE
Surgical/Anesthetical Procedures
in non elective conditions
“Life saving”
• Sub-optimal
• Incomplete
• Inadeguate
Cattedra di Cardiochirurgia
UNIVERSITA’ DEGLI STUDI DI FIRENZE