Evaluation of metabolic equivalents of task (METs) in the preoperative assessment in aortic repair

Alicja Zientara, Igor Schwegler, Omer Dzemali, Hans Bruijnen, Alain Bernheim, Florian Dick, Nicolas Attigah, Alicja Zientara, Igor Schwegler, Omer Dzemali, Hans Bruijnen, Alain Bernheim, Florian Dick, Nicolas Attigah

Abstract

Background: Reliable prediction of the preoperative risk is of crucial importance for patients undergoing aortic repair. In this retrospective cohort study, we evaluated the metabolic equivalent of task (MET) in the preoperative risk assessment with clinical outcome in a cohort of consecutive patients.

Methods: Retrospective analysis of prospectively collected data in a single center unit of 296 patients undergoing open or endovascular aortic repair from 2009 to 2016. The patients were divided into four anatomic main groups (infrarenal (endo: n = 94; open: n = 88), juxta- and para-renal (open n = 84), thoraco-abdominal (open n = 13) and thoracic (endo: n = 11; open: n = 6). Out of these, 276 patients had a preoperative statement of their functional capacity in metabolic units and were evaluated concerning their postoperative outcome including survival, in-hospital mortality, postoperative complications, myocardial infarction and stroke, and the need of later cardiovascular interventions.

Results: The median follow-up of the cohort was 10.8 months. Patients with < 4MET had a higher incidence of diabetes mellitus (p = 0.0002), peripheral arterial disease (p < 0.0001), history of smoking (p = 0.003), obesity (p = 0.03) and chronic obstructive pulmonary disease (p = 0.05). Overall in-hospital mortality was 4.4% (13 patients). There was no significant difference in the survival between patients with a functional capacity of more than 4 MET (220 patients, mean survival: 74.5 months) and patients with less than 4 MET (56 patients, mean survival: 65.4 months) (p = 0.64). The mean survival of the infrarenal cohort (n = 169) was 74.3 months with no significant differences between both MET groups (> 4 MET: 131 patients, mean survival 75.5 months; < 4 MET: 38 patients, mean survival 63.6 months. p = 0.35). The subgroup after open surgical technique with less than 4 MET had the lowest mean survival of 38.8 months. In 46 patients with > 4MET (20.9%) perioperative complications occurred compared to the group with < 4MET with 18 patients (32.1%) (p = 0.075). There were no significant differences in both groups in the late cardiovascular interventions (p = 0.91) and major events including stroke and myocardial infarction (p = 0.4) monitored during the follow up period. The risk to miss a potential need for cardiac optimization in patients > 4MET was 7%.

Conclusion: The functional preoperative evaluation by MET in patients undergoing aortic surgery is a useful surrogate marker of perioperative performance but cannot be seen as a substitute for preoperative cardiopulmonary testing in selected individuals. Trial registration clinicaltrials.gov, registration number NCT03617601 (retrospectively registered).

Keywords: Aortic repair; Functional capacity; Metabolic equivalent of task (MET); Preoperative assessment.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
The Kaplan Meier survival curve of the whole cohort subdivided in patients with preoperative status of > 4 MET and 

Fig. 2

The Kaplan Meier survival curve…

Fig. 2

The Kaplan Meier survival curve after infrarenal aortic procedure; all four subgroups (open…

Fig. 2
The Kaplan Meier survival curve after infrarenal aortic procedure; all four subgroups (open vs endovascular, > 4MET vs 

Fig. 3

Sensitivity of MET status for…

Fig. 3

Sensitivity of MET status for perioperative cardiovascular risk assessment: All 148 patients received…

Fig. 3
Sensitivity of MET status for perioperative cardiovascular risk assessment: All 148 patients received a preoperative cardiac assessment. The graph underlines the risk of missing a potential need for cardiac optimization in both MET groups.
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References
    1. Bertges DJ, Goodney PP, Zhao Y, Schanzer A, Nolan BW, Likosky DS, et al. The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the Revised Cardiac Risk Index in vascular surgery patients. J Vasc Surg. 2010;52(3):674–83, 83 e1–83 e3. - PubMed
    1. Karkos CD, Thomson GJ, Hughes R, Hollis S, Hill JC, Mukhopadhyay US. Prediction of cardiac risk before abdominal aortic reconstruction: comparison of a revised Goldman Cardiac Risk Index and radioisotope ejection fraction. J Vasc Surg. 2002;35(5):943–949. doi: 10.1067/mva.2002.121982. - DOI - PubMed
    1. Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study I. Devereaux PJ, Chan MT, Alonso-Coello P, Walsh M, Berwanger O, et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA. 2012;307(21):2295–304. doi: 10.1001/jama.2012.5502. - DOI - PubMed
    1. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–499. doi: 10.1056/NEJMsa0810119. - DOI - PubMed
    1. McFalls EO, Ward HB, Moritz TE, Littooy F, Santilli S, Rapp J, et al. Clinical factors associated with long-term mortality following vascular surgery: outcomes from the Coronary Artery Revascularization Prophylaxis (CARP) Trial. J Vasc Surg. 2007;46(4):694–700. doi: 10.1016/j.jvs.2007.05.060. - DOI - PubMed
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Fig. 2
Fig. 2
The Kaplan Meier survival curve after infrarenal aortic procedure; all four subgroups (open vs endovascular, > 4MET vs 

Fig. 3

Sensitivity of MET status for…

Fig. 3

Sensitivity of MET status for perioperative cardiovascular risk assessment: All 148 patients received…

Fig. 3
Sensitivity of MET status for perioperative cardiovascular risk assessment: All 148 patients received a preoperative cardiac assessment. The graph underlines the risk of missing a potential need for cardiac optimization in both MET groups.
Fig. 3
Fig. 3
Sensitivity of MET status for perioperative cardiovascular risk assessment: All 148 patients received a preoperative cardiac assessment. The graph underlines the risk of missing a potential need for cardiac optimization in both MET groups.

References

    1. Bertges DJ, Goodney PP, Zhao Y, Schanzer A, Nolan BW, Likosky DS, et al. The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the Revised Cardiac Risk Index in vascular surgery patients. J Vasc Surg. 2010;52(3):674–83, 83 e1–83 e3.
    1. Karkos CD, Thomson GJ, Hughes R, Hollis S, Hill JC, Mukhopadhyay US. Prediction of cardiac risk before abdominal aortic reconstruction: comparison of a revised Goldman Cardiac Risk Index and radioisotope ejection fraction. J Vasc Surg. 2002;35(5):943–949. doi: 10.1067/mva.2002.121982.
    1. Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study I. Devereaux PJ, Chan MT, Alonso-Coello P, Walsh M, Berwanger O, et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA. 2012;307(21):2295–304. doi: 10.1001/jama.2012.5502.
    1. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–499. doi: 10.1056/NEJMsa0810119.
    1. McFalls EO, Ward HB, Moritz TE, Littooy F, Santilli S, Rapp J, et al. Clinical factors associated with long-term mortality following vascular surgery: outcomes from the Coronary Artery Revascularization Prophylaxis (CARP) Trial. J Vasc Surg. 2007;46(4):694–700. doi: 10.1016/j.jvs.2007.05.060.
    1. Wong EY, Lawrence HP, Wong DT. The effects of prophylactic coronary revascularization or medical management on patient outcomes after noncardiac surgery–a meta-analysis. Can J Anaesth. 2007;54(9):705–717. doi: 10.1007/BF03026867.
    1. Jette M, Sidney K, Blumchen G. Metabolic equivalents (METS) in exercise testing, exercise prescription, and evaluation of functional capacity. Clin Cardiol. 1990;13(8):555–565. doi: 10.1002/clc.4960130809.
    1. Guarracino F, Baldassarri R, Priebe HJ. Revised ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Implications for preoperative clinical evaluation. Minerva Anestesiol. 2015;81(2):226–33.
    1. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):e278–333.
    1. Ballal RS, Kapadia S, Secknus MA, Rubin D, Arheart K, Marwick TH. Prognosis of patients with vascular disease after clinical evaluation and dobutamine stress echocardiography. Am Heart J. 1999;137(3):469–475. doi: 10.1016/S0002-8703(99)70494-1.
    1. Coselli JS. The use of left heart bypass in the repair of thoracoabdominal aortic aneurysms: current techniques and results. Semin Thorac Cardiovasc Surg. 2003;15(4):326–332. doi: 10.1053/S1043-0679(03)00090-X.
    1. Bischoff MS, Di Luozzo G, Griepp EB, Griepp RB. Spinal cord preservation in thoracoabdominal aneurysm repair. Perspect Vasc Surg Endovasc Ther. 2011;23(3):214–222. doi: 10.1177/1531003511400622.
    1. Mitchell RS, Ishimaru S, Ehrlich MP, Iwase T, Lauterjung L, Shimono T, et al. First International Summit on Thoracic Aortic Endografting: roundtable on thoracic aortic dissection as an indication for endografting. J Endovasc. 2002;9(Suppl 2):IL98–105. doi: 10.1177/15266028020090S216.
    1. Buth J, Harris PL, Hobo R, van Eps R, Cuypers P, Duijm L, et al. Neurologic complications associated with endovascular repair of thoracic aortic pathology: Incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vasc Surg. 2007;46(6):1103–10. doi: 10.1016/j.jvs.2007.08.020.
    1. Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004;351(16):1607–1618. doi: 10.1056/NEJMoa042002.
    1. Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG, Participants Et Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet. 2004;364(9437):843–8. doi: 10.1016/S0140-6736(04)16979-1.
    1. United Kingdom ETI. Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D. Endovascular repair of aortic aneurysm in patients physically ineligible for open repair. N Engl J Med. 2010;362(20):1872–1880. doi: 10.1056/NEJMoa0911056.
    1. Reilly DF, McNeely MJ, Doerner D, Greenberg DL, Staiger TO, Geist MJ, et al. Self-reported exercise tolerance and the risk of serious perioperative complications. Arch Intern Med. 1999;159(18):2185–2192. doi: 10.1001/archinte.159.18.2185.
    1. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):2215–2245. doi: 10.1161/CIR.0000000000000105.
    1. New classification of physical status Anesthesiology. 1963;24:111.
    1. Wolters U, Wolf T, Stutzer H, Schroder T. ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth. 1996;77(2):217–222. doi: 10.1093/bja/77.2.217.
    1. Starczewska MH, Mon W, Shirley P. Anaesthesia in patients with liver disease. Curr Opin Anaesthesiol. 2017;30:392. doi: 10.1097/ACO.0000000000000470.
    1. Fields AC, Divino CM. Surgical outcomes in patients with chronic obstructive pulmonary disease undergoing abdominal operations: an analysis of 331,425 patients. Surgery. 2016;159(4):1210–1216. doi: 10.1016/j.surg.2015.11.007.
    1. Woodfield JC, Pettigrew RA, Plank LD, Landmann M, van Rij AM. Accuracy of the surgeons' clinical prediction of perioperative complications using a visual analog scale. World J Surg. 2007;31(10):1912–1920. doi: 10.1007/s00268-007-9178-0.
    1. Biccard BM. Relationship between the inability to climb two flights of stairs and outcome after major non-cardiac surgery: implications for the pre-operative assessment of functional capacity. Anaesthesia. 2005;60(6):588–593. doi: 10.1111/j.1365-2044.2005.04181.x.
    1. Girish M, Trayner E, Jr, Dammann O, Pinto-Plata V, Celli B. Symptom-limited stair climbing as a predictor of postoperative cardiopulmonary complications after high-risk surgery. Chest. 2001;120(4):1147–1151. doi: 10.1378/chest.120.4.1147.

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