Peripheral Vascular Surgery Society

David A. Bigatel, MD, David P. Franklin, MD, James R. Elmore, MD, L.Andrew Nassef, MD, and Jerry R. Youkey, MD.

Geisinger Medical Center-Penn State Geisinger Health System,

Danville, PA

Introduction: Cardiac evaluation prior to aortic surgery is controversial. This study was undertaken to evaluate the efficacy of dobutamine stress echocardiography (DSE) in predicting not only perioperative but also long-term cardiac events.

Methods: 159 patients who were evaluated for elective abdominal aortic surgery were screened preoperatively with DSE from January 1, 1992 to December 31, 1993. Follow-up was obtained for all patients. 71 patients had a normal DSE (Group I). 55 patients had resting wall motion abnormalities consistent with coronary artery disease (CAD), but without dobutamine inducible ischemia (Group II). 33 patients had inducible ischemia (Group III). Patients were evaluated in follow-up for myocardial infarction (MI), congestive heart failure, coronary revascularization, and death. Mean follow-up was 45 months.

Results: DSE of the 159 patients prompted cardiac catheterization in 17.6% and subsequent coronary revascularization in 5.7% (7 coronary bypass procedures and 2 coronary angioplasties). Two of these revascularization patients died before aortic surgery. Four other patients were advised against aortic surgery. All four died during follow-up of causes other than their aortic pathology. 153 patients underwent elective abdominal aortic surgery. Perioperative MI occurred in 3.3%, including 1 fatal MI. In addition, there were 3 non-cardiac deaths (including one patient with preoperative PTCA) for an aortic perioperative mortality rate of 2.6%. Combined early mortality for all operations was 3.9%. Late follow-up identified 19 additional MIâs and 35 deaths. Seven patients required late coronary revascularization. 37% of late deaths were cardiac in origin. Late mortality could not be correlated with results of DSE, however, late cardiac death (p=0.04) and late MI (p=0.03) were predicted by an abnormal DSE.

Conclusions: DSE is useful for preoperative assessment of cardiac risk prior to elective aortic surgery to minimize the need for cardiac intervention and still maintain acceptable perioperative MI and death rates. A selective approach for coronary revascularization is justified by the higher mortality in the subgroup which require sequential procedures. DSE also allowed us to identify those high risk patients that are best excluded from aortic surgery. Patients with abnormal DSE results are at higher risk for late cardiac events, require cardiology follow-up, and may require late coronary intervention.