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Mitral regurgitation (MR) is one of the most frequently encountered types of valvular heart disease in the United States. Patients with significant MR (moderate-to-severe or severe) undergoing noncardiac surgery have an increased risk of perioperative cardiovascular complications. MR can arise from a diverse array of causes that fall into 2 broad categories: primary (diseases intrinsic to the valvular apparatus) and secondary (diseases that disrupt normal valve function via effects on the left ventricle or mitral annulus). This article highlights key guideline updates from the American College of Cardiologists (ACC) and the American Heart Association (AHA) that inform decision-making for the anesthesiologist caring for a patient with MR undergoing noncardiac surgery. The pathophysiology and natural history of acute and chronic MR, staging of chronic primary and secondary MR, and considerations for timing of valvular corrective surgery are reviewed. These topics are then applied to a discussion of anesthetic management, including preoperative risk evaluation, anesthetic selection, hemodynamic goals, and intraoperative monitoring of the noncardiac surgical patient with MR.

Background The left ventricle assist device (LVAD) patient population is rapidly expanding. Unique characteristics of these patients complicate the management of noncardiac surgical problems. Emergent general surgery (EGS) intervention is often warranted but remains poorly described. We reviewed EGS consultations in LVAD patients to better understand these patients. Methods During a 12-year period, 301 LVAD patients were reviewed. Demographics, comorbidities, reason for EGS consultation, operative intervention, transplantation, and mortality were analyzed. Wilcoxon, Fisher’s exact, and chi-square tests were used for analysis. Statistical significance was P < .05. Results A total of 139 (46.2%) patients required EGS consultation. EGS consultations were older (63 vs 57 years; P = .002), primarily Caucasian (86%), and male (83%) with average preimplant cardiac index of 1.84. Comorbidities were similar between those with and without EGS consultation. Gastrointestinal (GI) bleeding was the most common reason for consultation (53%), followed by abdominal pain (22%) and bowel ischemia/obstruction (19%). Of EGS consultations, 77% were on warfarin and 60% on aspirin. Procedures were not withheld: 46% required esophagogastroduodenoscopy (EGD) and 30% required colonoscopy. Surgical intervention was performed in 28% of EGS consults—49% emergent (within 24 hours) and 44% urgent (during hospitalization). Mean time to surgery was 48 days after LVAD placement. EGS intervention precluded 7 (18%) patients from heart transplantation and 10 (26%) patients suffered perioperative mortality. Elevated lactic acid was associated with increased mortality. Conclusion EGS consultation is necessary in almost half of all LVAD patients, most commonly for GI bleed. EGD/colonoscopy can be safely used to manage the majority of these consultations; one-third will require surgery. High lactic acid is associated with higher mortality. Additional analysis of this population is required for improving surgical management.

Objective. The total relative value unit (TRVU) of surgery reflects surgical complexity. However, its impact on mortality after noncardiac surgery has not been identified. This study aimed to investigate the association of TRVUs for surgery with postoperative 90-day mortality in adult patients who received planned, elective noncardiac surgery. We hypothesized that higher TRVU was associated with an increase in 90-day mortality after noncardiac surgery. Method. This retrospective cohort study analyzed medical records of adult patients admitted to a single tertiary academic hospital between January 2012 and December 2018 for planned elective noncardiac surgery. The primary end point was 90-day mortality. Results. A total of 112 606 patients were included. Among them, 561 patients (.5%) exhibited mortality within 90-days. In the multivariable model, an increase of 10 000 points of TRVUs was not significantly associated with 90-day mortality (odds ratio: .98, 95% confidence interval: .93 to 1.04; P = .536). Additionally, when it was divided into 4 quartile groups (Q1, Q2, Q3, and Q4), Q2, Q3, and Q4 group of TRVUs were not associated with 90-day mortality compared to the Q1 group of TRVUs ( P = .058, .984, and .237, respectively). In receiver-operating characteristic analysis, the area under the curve of TRVUs for a 90-day mortality rate was .61. Conclusions. In conclusion , TRVUs were not associated significantly with a 90-day mortality rate after noncardiac surgery and have a low predictive ability for 90-day mortality after noncardiac surgery alone.

Objective Perioperative cardiovascular events constitute the majority of complications in noncardiac surgery. Older and female patients have been less investigated. We aimed to evaluate differences in perioperative cardiovascular outcomes by age and sex. Methods We enrolled 1079 patients (57.5 ± 17.0 years, 42.6% women) undergoing intra-abdominal surgery from July 2007 to June 2008 and compared occurrence of perioperative cardiac events by age (≥65 vs. Results Age ≥65 years was associated with perioperative myocardial infarction (MI) (odds ratio [OR] 2.9, 95% confidence interval [CI]: 1.3–6.6) and total cardiovascular events (OR 2.4, 95% CI: 1.3–4.2). Age ≥65 years was associated with higher perioperative MI risks in men (OR 4.7, 95% CI: 1.3–17.6) than in women (OR 3.1, 95% CI: 1.2–8.3). Advanced age was associated with heart failure in women (OR 13.9, 95% CI: 1.7–110.5). Female sex was a risk factor for heart failure in elderly patients (OR 4.2, 95% CI: 1.1–15.7). Conclusions Advanced age appeared to be associated with increased perioperative cardiac risk but differed by sex. Tailored strategies should be considered with respect to the patient’s sex.

Objective Prevention of postoperative cognitive dysfunction (POCD) in patients of advanced age remains unclear. Studies have shown that the cholinergic anti-inflammatory pathway contributes to a decreased risk of POCD and that nicotine stimulates the cholinergic anti-inflammatory pathway. We investigated whether patients of advanced age with a preoperative smoking history have a decreased risk of POCD. Methods In total, 382 patients (190 smokers, 192 nonsmokers) aged ≥60 years who underwent major noncardiac surgery were enrolled. Cognitive function was assessed, and multivariate logistic regression analyses were performed to identify risk factors. Results On postoperative days 5 and 7, 111 (29.05%) and 90 (23.56%) patients exhibited POCD, respectively. A preoperative smoking history was significantly correlated with a decreased risk of POCD. A high serum tumor necrosis factor-α (TNF-α) level on the operative day was significantly associated with an increased risk of POCD. Early POCD was significantly associated with the sufentanil dosage, age, and education level. The hospital stay in patients with and without POCD was 10.54 ± 2.03 and 8.33 ± 1.58 days, respectively. Conclusion A preoperative smoking history was associated with a decreased risk of early POCD, and a high serum TNF-α level was significantly associated with an increased risk of POCD.

Intraoperative use of transesophageal echocardiography (TEE) has become commonplace in high-risk noncardiac surgeries but the balance of benefits and harms remains unclear. This systematic review investigated the comparative effectiveness and harms of intraoperative TEE in noncardiac surgery. We searched Ovid MEDLINE, PubMed, EMBASE, and the Cochrane Library from 1946 to March 2017. Two reviewers independently screened the literature for eligibility. Studies were assessed for the risk of selection bias, confounding, measurement bias, and reporting bias. Three comparative and 13 noncomparative studies were included. Intraoperative TEE was employed in a total of 1912 of 3837 patients. Studies had important design limitations. Data were not amenable to quantitative synthesis due to clinical and methodological diversity. Reported incidence of TEE complications ranged from 0% to 1.7% in patients undergoing various procedures (5 studies, 540 patients). No serious adverse events were observed for mixed surgeries (2 studies, 197 patients). Changes in surgical or medical management attributable to the use of TEE were noted in 17% to 81% of patients (7 studies, 558 patients). The only randomized trial of intraoperative TEE was grossly underpowered to detect meaningful differences in 30-day postoperative outcomes. There is lack of high-quality evidence of effectiveness and harms of intraoperative TEE in the management of non-cardiac surgeries. Evidence, however, indicates timely evaluation of cardiac function and structure, and hemodynamics. Future studies should be comparative evaluating confounder-adjusted impact on both intraoperative and 30-day postoperative clinical outcomes.

The Australian and New Zealand College of Anaesthetists (ANZCA) has more than 200 accredited training sites in Australia, New Zealand, Hong Kong, Malaysia and Singapore, many of which participate in ANZCA Clinical Trials Network (CTN)–endorsed clinical trials. We undertook a survey of accredited sites to determine research capability, activity and potential. With ethics committee approval an electronic survey was distributed to accredited sites in July 2015. Of 207 accredited sites, 167 were sent the questionnaire (after eliminating ineligible sites) and 128 responded. Response rates for Australia, New Zealand, Hong Kong, Malaysia and Singapore were 100%, 100%, 35%, 25% and 75% respectively. Forty-four (34%) of 128 responding sites had a head of research; 101 (80%) of 126 responding sites were active in research; 42 (33%) of 126 responding sites had no publications since January 2011 and 15 (12%) had >50 publications; 95 (76%) of 125 responding sites had at least one specialist anaesthetist engaged in research (median = 4 [range 1–25]); and 45 (36%) of 125 responding sites had at least one research coordinator (median = 2 [range 1–15]). Fifty-eight (28%) of the 207 accredited sites were identified as participating in recent ANZCA CTN–endorsed clinical trials. Research capability and activity were higher in these sites. This survey has identified a strong base upon which to expand clinical trial activity, and regions, sectors, investigators and research coordinators who may benefit from additional support.

Cardiac events are an important cause of postsurgical morbidity and mortality. Statin drugs have been studied as potentially risk-modifying agents in perioperative medicine. They have been shown to confer a protective benefit in cardiac surgery, but the evidence available in noncardiac surgery patient populations remains less conclusive. We hypothesized that perioperative statin treatment would be associated with lower incidence of postsurgical cardiac events (PSCEs) after major noncardiac surgery. A retrospective cohort study included 21,637 major noncardiac surgeries. Statin treatment was the exposure of interest and PSCE was the primary outcome measure. Data collection included patient age, body mass index, smoking status, diabetic status, cardiac event history, statin treatment history, and PSCE diagnoses. Perioperative statin treatment occurred in 4176 cases (19.3%). PSCEs occurred in 50 cases (0.23%), 29 in the untreated control group (0.17%) and 21 in the statin treatment group (0.50%). Relative risk in the untreated group was 0.3303 (95% confidence interval = 0.1886, 0.5786). This implied that statin-treated patients had higher risk than the untreated group. However, a logistic regression model that accounted for observed cardiac disease risk factors showed statin treatment not to be a significant predictor of PSCE in this sample. Analysis repeated in high-risk subsets of the cohort yielded similar results. A propensity score matching method that minimized differences between study groups also failed to demonstrate a significant association between statin treatment and PSCE risk. Our study did not demonstrate a significant association between perioperative statin treatment and PSCEs after major noncardiac surgery.

Echocardiography plays a major role in the diagnosis and management of hemodynamic compromise during the perioperative period. Both transthoracic and transesophageal echocardiography have been shown to improve outcomes after cardiac and noncardiac surgery. Teaching basic echocardiographic skills to perioperative physicians remains a challenging task. Thus far, simulation-based medical education has been proven useful in teaching specific procedural skills and management of infrequent catastrophic events. Simulation-based echocardiography education has the potential to facilitate clinical training in echocardiography. Several small studies have shown the benefits of echocardiographic simulation on developing psychomotor and cognitive echocardiography skills. Future research should focus on the impact of simulation on actual clinical echocardiographic performance in the operating room and ultimately, patient outcomes.

In our institution, the vast majority of patients presenting for noncardiac surgery (NCS) while supported by a left ventricular assist device (LVAD) are now cared for by noncardiac-trained anesthesiologists as the result of a decade of educational intervention to effect this transition. This represents a significant departure from the published experiences of other institutions. With institutional review board approval, we queried the database of our anesthesia record keeping system (CompuRecord) to determine various aspects of the perioperative management of these patients from July 1, 2003, through June 30, 2013, during which time 271 NCS procedures were performed on adult patients supported by LVADs. Over the entire study period (2003-2013), anesthetic care was provided by a cardiac anesthesiologist 47% of the time and by a noncardiac anesthesiologist 53% of the time. However, by the time period 2012-2013, 88% of the NCS procedures were staffed by a noncardiac anesthesiologist. Despite the prevalence of continuous flow devices in this series, the use of invasive blood pressure monitoring decreased dramatically by the later years of the study. Vasoactive and inotropic medications were rarely required intraoperatively. No intraoperative cardiac arrests, thromboembolic complications, or device malfunctions occurred. Our conclusion is that NCS procedures on LVAD-supported patients can be safely managed by educated noncardiac anesthesiologists.

Objectives: Atrial fibrillation after surgery is associated with increased rates of heart failure and ischemic stroke, and extension of hospitalization. Bisoprolol is a β-blocker used to reduce heart rate and manage arrhythmias during atrial fibrillation. However, the safety and efficacy of bisoprolol transdermal patch treatment in patients with postoperative atrial fibrillation remain unclear. Methods: We retrospectively assessed the electronic health records of our hospital between September 2013 and July 2018 and identified patients with postoperative atrial fibrillation who had been treated with a bisoprolol transdermal patch. We excluded patients with sinus rhythm using bisoprolol transdermal patch to prevent atrial fibrillation recurrence and those with sustained atrial fibrillation before surgery. Data on heart rhythm, heart rate, and blood pressure at the baseline and after 24 h of treatment were obtained from the electronic health records. Results: Of the 603 patients treated with the bisoprolol transdermal patch, 61 patients with postoperative atrial fibrillation after noncardiac surgery were included. The bisoprolol transdermal patch was discontinued due to bradycardia in two patients (3.3%). In both cases, the heart rate increased after the removal of the bisoprolol transdermal patch and no additional treatment was necessary. Among the 61 patients, sinus rhythm was restored within 24 h of bisoprolol treatment in 47 patients (77.0%). The heart rate significantly decreased from 124.8 ± 26.3 bpm at the baseline to 78.9 ± 16.6 bpm at 24 h after treatment ( p Conclusion: The results of this study indicate that the bisoprolol transdermal patch is well tolerated and effective in patients with atrial fibrillation after noncardiac surgery.

Objective: Although safety concerns still remain among patients undergoing unanticipated noncardiac surgery after prior percutaneous coronary intervention (PCI), it has not been directly compared with coronary artery bypass grafting (CABG). The objective of this study was to compare clinical outcomes after noncardiac surgery in patients with prior (>6 months) coronary revascularization by PCI or CABG. Methods: From February 2010 to December 2015, 413 patients with a history of coronary revascularization, scheduled for noncardiac surgery were identified. Patients were divided into PCI group and CABG group and postoperative clinical outcome was compared between 2 groups. The primary outcome was composite of all-cause death, myocardial infarction, and stroke in 1-year follow-up. Results: The 413 patients were divided according to prior coronary revascularization types: 236 (57.1%) into PCI and 177 (42.9%) into CABG group. In multivariate analysis within 1-year follow-up, there was no significant difference in clinical outcome which was composite of all-cause death, myocardial infarction, and stroke (hazard ratio [HR]: 1.50; 95% confidence interval [CI]: 0.76-2.93; P = .24). The same result was present in propensity-matched population analysis (HR: 1.43; 95% CI: 0.68-3.0; P = .34). Conclusions: In patients undergoing noncardiac surgery with prior coronary revascularization by PCI or CABG performed on an average of 42 months after PCI and 50 months after CABG, postoperative clinical outcome at 1-year follow-up is comparable.

Surgical management of disease has a tremendous impact on our health system. Millions of people worldwide undergo surgeries every year. Cardiovascular complications in the perioperative period are one of the most common events leading to increased morbidity and mortality. Although such events are very small in number, they are associated with a high mortality rate making it essential for physicians to understand the importance of perioperative cardiovascular risk assessment and evaluation. Its involves a detailed process of history taking, patient's medical profile, medications being used, functional status of the patient, and knowledge about the surgical procedure and its inherent risks. Different risk assessment tools and calculators have also been developed to aid in this process, each with their own advantages and limitations. After such a comprehensive evaluation, a physician will be able to provide a risk assessment or it may all lead to further testing if it is believed that a change in management after such testing will help to reduce perioperative morbidity and mortality. There is extensive literature on the significance of multiple perioperative testing modalities and how they can change management. The purpose of our review is to provide a concise but comprehensive analysis on all such aspects of perioperative cardiovascular risk assessment for noncardiac surgeries and provide a basic methodology toward such assessment and decision making.

An increasing number of patients with congenital heart disease survive to adulthood. Expert opinion suggests that noncardiac surgery is a high-risk event, but few data describe perioperative outcomes in this population. Using the National Surgical Quality Improvement Program database, we identified a cohort of patients aged 18 to 39 years with prior heart surgery who underwent noncardiac surgery between 2005 and 2010. A comparison cohort with no prior cardiovascular surgery was matched on age, sex, race/ethnicity, operation year, American Society of Anesthesiologists physical status, and Current Procedural Terminology code. A study cohort consisting of 1191 patients was compared with a cohort of 5127 patients. Baseline dyspnea, inpatient status at the time of surgery, and a prior operation within 30 days were more common in the study cohort. Postoperative outcomes were less favorable in the study cohort. Observed rates of death, peri-operative cardiac arrest, myocardial infarction, stroke, respiratory complications, renal failure, sepsis, venous thromboembolism, perioperative transfusion, and reoperation were significantly higher in the study cohort ( P < 0.01 for all). Mean postoperative length of stay was greater in the study cohort (5.8 vs 3.6 days, P < 0.01). Compared with a matched control cohort, young adult patients with a history of prior cardiac surgery experienced significantly greater perioperative morbidity and mortality after noncardiac surgery. A history of prior cardiac surgery represents a marker of substantial perioperative risk in this young population that is not accounted for by the matched variables. These results suggest that adult patients with congenital heart disease are at risk for adverse outcomes and support the need for further registry-based investigations.

As the population ages, the incidence of patients presenting for surgical procedures with diastolic dysfunction and heart failure with preserved ejection fraction will rise. This review will discuss the most current and relevant information on the pathophysiology, treatment, and perioperative management of these patients.

While originally primarily used as bridge to cardiac transplantation and bridge to recovery, more commonly ventricular assist devices (VADs) are being inserted as destination therapy. These patients are being discharged from transplant and mechanical assist centers, living as outpatients, and thus the pool of community-dwelling patients with VADs continues to expand. Not infrequently they present for surgical procedures either directly related to the device itself or more often incidental to the fact that they have a VAD. This scenario may be more common in patients with VADs placed for destination therapy because these patients tend to be older and have more comorbidities and are living longer with their device. Thus, it is important for all anesthesiologists to be aware of the special anesthesia needs of patients with VADs requiring noncardiac surgery.

The airway is a crucial dynamic structure that spans different anatomical zones, including the intrathoracic, extrathoracic, tracheal, bronchial, and alveolar zones. Because of its vital role as the sole oxygen-conducting pathway to the alveoli, and hence to the human body, surgery involving any portion requires careful and specific planning by both the surgeon and the anesthesiologist. The review covers essential management points for proximal and distal tracheal procedures, including a discussion of tracheal stenting and tracheoplasty.

Since its introduction in the early part of the last century, fresh whole blood (FWB) has been used by the US military as a battlefield expedient resuscitation method, even after the development of component therapy in the 1960s. In the recent conflicts in Iraq and Afghanistan, FWB was used once more, often collected in the setting of a walking blood bank (WBB). Considerable research and opinion from military circles has cited these experiences and sparked renewed interest in FWB as an effective resuscitation tool in the setting of trauma. Despite efforts by the US military to improve the effectiveness and safety of FWB through a series of widely published guidelines, transfusion transmitted infections (TTI) remain a vexing challenge. These experiences in Iraq and Afghanistan will help inform a larger discussion regarding the reintroduction of FWB in civilian trauma resuscitation.

Whereas the development of coronary stents has been a major breakthrough in the treatment of coronary artery disease, stent thrombosis, associated with myocardial infarction and death, has introduced a new challenge in the care of patients with coronary stents undergoing noncardiac surgery. This review presents the authors’ recommendations regarding the optimal management of such patients. Elective surgery should be postponed for at least 6 weeks and optimally 3 months for a bare-metal stent and at least 1 year for a drug-eluting stent. On the other hand, managing a patient undergoing non-elective surgery is more difficult and necessitates a case-by-case assessment of bleeding risk versus thrombotic risk based on patient comorbidities, type of stents present, details of the coronary intervention, and type of surgical procedure. Patients with a risk of bleeding that outweighs the risk of stent thrombosis should discontinue at least clopidogrel, whereas all other patients should continue dual antiplatelet therapy throughout the perioperative period.

The leading cause of perioperative morbidity and mortality after major noncardiac surgery is cardiovascular complications. Clinical trials of lipid-lowering 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) have shown improved cardiovascular outcomes; therefore, statins have become a mainstay in the prevention of cardiovascular disease. Retrospective trials and a small number of prospective randomized trials indicate that statin use may be beneficial during the perioperative period. In addition to the effects on serum lipid levels, statins influence inflammatory, thrombotic, and vasodilatory cellular pathways; and thus, their beneficial effects are not limited to patients with hypercholesterolemia. This review will (1) examine the evidence for using perioperative statin therapy in the noncardiac surgical patient (2) explore the possible consequences of statin withdrawal, and (3) revisit the evidence for the safety of statin use. Further studies are still needed to establish the optimal dosage as well as timing and length of statin therapy perioperatively.

Previous studies regarding preoperative coronary stents and antithrombotic agents have excluded patients with cancer as a result of hypercoagulability. The objective of this study is to determine whether preoperative heparin-coated coronary stents are as safe in patients with cancer undergoing surgery as patients without cancer. Between February 2003 and February 2005, 29 patients had heparin-coated coronary stents placed before noncardiac surgery. The incidence of postoperative myocardial infarction (MI) and/or death was compared in patients with and without cancer, and outcomes were further evaluated based on preoperative antithrombotic status. Postoperative MI occurred in three of 13 (23%) patients with cancer compared with zero of 16 non-cancer patients. Patients with cancer were 9.6 times more likely to have a postoperative MI resulting in death compared with noncancer patients. There was a positive correlation between patients having cancer and having a postoperative MI ( r = 0.38, P = 0.044) and between patients with cancer being on antithrombotic medications during surgery and having a postoperative MI ( r = 0.567, P = 0.044). After stent placement, patients with cancer undergoing surgery experienced a higher incidence of postoperative MI resulting in death compared with noncancer patients despite continued antithrombotic use. In these patients, alternatives to stenting should be considered to avoid perioperative cardiac complications.

Advances in the treatment of patients with chronic pulmonary hypertension have greatly improved their functional status and longevity, and increasing numbers of these complex patients are presenting for elective noncardiac surgery. In this communication we will briefly review the classification and pathophysiology of pulmonary hypertension, summarize outpatient pharmacotherapy approaches, and discuss the perioperative preparation and management of these complex patients. With an understanding of the underlying pathophysiology of the disease and pharmacology of these new therapies, combined with careful perioperative planning and care, these patients can safely undergo elective surgical procedures.

This review covers the classification of congenital heart diseases, and the preoperative assessment, monitoring, anesthetic considerations, and management in the pediatric population with congenital heart disease. It does not present “recipes” for individual cardiac defects. The pathophysiology is presented as it relates to principles of management, patient assessment, selection, and application of an anesthetic regimen to specific cardiac lesions and procedures. Familiarity with the child's pathophysiology, preoperative preparation, choice of monitors, induction, maintenance, emergence from anesthesia, and plans for the postoperative period should avoid major problems in anesthetic management.

This is an investigation of the association of intraoperative hypotension and perioperative myocardial infarction (MI) in low-risk patients undergoing noncardiac surgery. The case-control study compared all patients who experienced perioperative MI during the years 1996 through 1999 to a similar group of patients matched for multiple variables. Perioperative MI occurred in 22 patients. Two patients, who underwent unusual surgical procedures, were excluded from the study. The remaining 20 MI patients were compared with 40 patients who had the same types of surgery and similar mean ages, co-morbidities and preoperative evaluations. Of the patients suffering a perioperative MI, 14 (70%) experienced intraoperative hypotension, as opposed to 11 (28%) of those who did not have an MI ( P = .002). Six (30%) MI patients died as opposed to only one (2.5%) of the non-MI group ( P = .004). When subjected to logistic regression analysis, intraoperative hypotension remained the only significant variable associated with perioperative MI ( P = .0056). Intraoperative hypotension is associated with an increased risk of perioperative myocardial infarction and death.

Patients undergoing cardiac and high-risk noncardiac surgery have a high incidence of perioperative myocardial infarction. The early diagnosis of perioperative myocardial injury in these patients is complicated. In the perioperative period, there is a high incidence of nonspecific electrocardiographic changes and cardiac biomarker release. It is becoming increasingly imortant to differentiate myocardial necrosis from nonspecific changes because of the need for early intervention and the poential long term implications of a perioperative myocardial event. Although sensitive and specific assays to assess myoardial damage have been developed, specific thresholds to establish the occurrence a significant perioperative event have not been firmly defined. This review will attempt to outline the current evidence supporting the use of clinical symptoms, electrocardiographic changes, and cardiac biomarkers in the diagnosis of perioperative myocardial infarction and the longerm implication of these findings.

In this article, the reader will get some insights into managing patient with implantable cardiac devices while undergoing noncardiac surgery. We will review basic concepts regarding normal function of pacemakers and implantable cardioverter defibrillators, understanding how their function will be influenced during noncardiac surgeries. You will be guided through management steps from preoperative, intraoperative, and postoperative aspects. In an ever-changing world of medicine, it is important to keep up with progress as more and more patients get implantable cardiac devices.

Cardiac risk stratification tests should be pursued only in the subgroup of patients who have a moderate to high incidence of significant coronary artery disease and only in those who will gain long-term benefit from coronary revascularization if they are found to have significant coronary artery disease. Furthermore, car diac risk stratification tests should be pursued only if the perioperative mortality and morbidity from com bined coronary revascularization followed by noncar diac surgery is not significantly higher than proceeding straight to noncardiac surgery alone. Indentification of the subgroup of patients who will need cardiac strati fication tests should be based on integration of the patient's cardiac risk factors and functional capacity with the risk and stress of the particular surgery.

Pediatric cardiac transplantation has been performed with increasing frequency to treat hypoplastic left heart syn drome and other types of congenital heart disease. A large number of these patients will require anesthesia posttrans plantation for noncardiac surgery. A review of our series of 92 anesthetics in 46 patients has better defined periopera tive risk factors, anesthetic management, common surgical procedures, and complications associated with noncardiac surgery in posttransplantation patients. Anesthetic manage ment concerns include allograft coronary artery disease, graft rejection, denervation, cardiac dysrhythmias, immuno suppression, cyclosporine-induced hypertension, drug inter actions, renal dysfunction, and intravenous access prob lems. Preoperative evaluation must include the possibility and definition of these problems. Medically stable patients undergoing noncardiac/nonthoracic surgery after cardiac transplantation undergo the same surgical procedures as similarly aged nontransplantation patients. Similar induc tion techniques can be used as in nontransplantation pa tients. These patients may also be scheduled for same-day surgery if other significant medical problems are not present and the difficulty of the surgery is compatible with an out patient setting. Patients with more complex medical prob lems, including chronic rejection, significant coronary artery disease, or a history of congestive failure may need over night monitoring in a hospital setting despite that only a minor surgical procedure is being performed.

Congestive heart failure represents a severe health condition with unfavourable long-term prognosis despite all the progress in pharmacological therapy of heart failure. Another therapeutic option is represented by mechanical cardiac support devices. Ventricular assist devices (VAD) constitute largest subgroup of these devices. Patients supported with VAD carry many considerations which are important for successful perioperative management of these patients for noncardiac surgery. The general perioperative considerations include consultation with VAD management personnel, detailed assessment of end-organ dysfunction before surgery, appropriate antibiotic prophylaxis, deactivation of implantable cardioverter-defibrillator for the time of surgical procedure, and the choice between general and regional anesthesia. Intraoperative monitoring depends primarily on the type of blood flow generated by VAD. For devices generating pulsatile blood flow, standard monitoring arrangements are needed. In the patients supported by devices which provide nonpulsatile blood flow, pulse oximetry and noninvasive blood pressure measurement are not reliable monitoring methods, and placement of intra-arterial catheter is warranted. In all the patients supported with VAD, transesophageal echocardiography is extremely useful method for monitoring the function of VAD itself, and in the case of univentricular VAD for monitoring the function of nonsupported cardiac ventricle. The most important issue in hemodynamic management of the patients with VAD is avoiding hypovolemia because it can cause inadequate VAD output with resulting low cardiac output and hypotension. All the patients with VAD need some degree of anticoagulation, and for noncardiac surgery the question of interrupting or decreasing the level of anticoagulation should be discussed among members of the caring team.

Adverse cardiac events during noncardiac surgery are a major cause of morbidity and mortality. As the population ages, greater numbers of patients (including the elderly) are undergoing noncardiac surgical procedures; additional emphasis must therefore be placed on effective preoperative risk assessment. On a national level, the estimated annual expenditure for this process is already $3.7 billion. There is a need for both the specialist and primary care provider to execute a safe, methodical, and cost efficient screening plan. This process should identify both the patients at highest risk and also those at lowest risk. Subsequently, the emphasis should attempt to minimize the overall risk of perioperative complications. The cornerstone of risk assessment requires meticulous history taking, a thorough physical examination, and usually a chest radiograph and an ECG. Five subsequent (basic) steps for the evaluation of patients for noncardiac surgery are outlined here in assessment of clinical markers and the patient's functional capacity, risk of the surgical procedure, the need for noninvasive testing, and when appropriate, the indications for invasive testing. The AHA/ACC Practice Guidelines Committee has outlined a clinical algorithm which provides a stepwise approach to guide the clinician during the decision making process. The purpose of preoperative evaluation is not to “give medical clearance” per se, but rather to evaluate the patient's current medical status, detect stress-induced ischemia in a cost effective manner, and to make recommendations about patient management throughout the entire perioperative period.

Adverse cardiac events during noncardiac surgery are a major cause of morbidity and mortality. As the population ages, greater numbers of patients (including the elderly) are undergoing noncardiac surgical procedures; additional emphasis must therefore be placed on effective preoperative risk assessment. On a national level, the estimated annual expenditure for this process is already $3.7 billion. There is a need for both the specialist and primary care provider to execute a safe, methodical, and cost efficient screening plan. This process should identify both the patients at highest risk and also those at lowest risk. Subsequently, the emphasis should attempt to minimize the overall risk of perioperative complications. The cornerstone of risk assessment requires meticulous history taking, a thorough physical examination, and usually a chest radiograph and an ECG. Five subsequent (basic) steps for the evaluation of patients for noncardiac surgery are outlined here in assessment of clinical markers and the pa- tient's functional capacity, risk of the surgical procedure, the need for noninvasive testing, and when appropriate, the indications for invasive testing. The AHA/ACC Practice Guidelines Committee has outlined a clinical algorithm which provides a stepwise approach to guide the clinician during the decision making process. The purpose of preoperative evaluation is not to "give medical clearance" per se, but rather to evaluate the patient's current medical status, detect stress-induced ischemia in a cost effective manner, and to make recommendations about patient management throughout the entire perioperative period.

In this article, the incidence of nervous system injuries associated with noncardiac surgery is reviewed briefly. In general, these can be divided into injuries that are clinically apparent (eg, stroke or peripheral nerve damage), which may generally be detectable on clinical examination, and more subtle forms of brain injury (eg, personality changes and postoperative cognitive dysfunction), injuries that are primarily detected by neuropsychological testing.

A delayed bilateral pneumothorax complicated unilateral left subclavian vein catheterization and required treatment with tube thoracostomy. This case is unique in the demonstration that bilateral pneumothorax can present in a delayed fashion, and that, as a result of a previously formed pleuropleural fistula, it can occur in patients with a history of noncardiac surgery involving median sternotomy. Historical data on delayed pneumothoraces and bilateral pneumothoraces are presented.