The role of cardiopulmonary exercise testing and echocardiography prior to elective endovascular aneurysm repair

Abstract

Introduction Cardiopulmonary exercise testing (CPET) and transthoracic echocardiography (TTE) are common preparative investigations prior to elective endovascular aneurysm repair (EVAR). Whether these investigations can predict survival following EVAR and contribute to shared decision making is unknown. Methods Patients who underwent EVAR at a tertiary centre between June 2007 and December 2014 were identified from the National Vascular Registry. Variables obtained from preoperative investigations were assessed for their association with survival at three years. Regression analysis was used to determine variables that independently predicted survival at three years. Results A total of 199 patients underwent EVAR during the study period. Of these, 120 had preoperative CPET and 123 had TTE. Lower forced expiratory ventilation (FEV1), ratio of FEV1 to forced vital capacity, work at peak oxygen consumption and higher ventilatory equivalent for carbon dioxide were associated with increased mortality. Variables obtained from TTE were not associated with survival at three years although there was a low incidence of left ventricular systolic dysfunction and significant valvular disease in this cohort. Conclusions CPET might be a useful adjunct to assist in shared decision making in patients undergoing elective EVAR and may influence anaesthetic technique. TTE does not appear to be able to discriminate between high and low risk individuals. However, a low rate of significant ventricular dysfunction and valvular disease in patients undergoing elective EVAR may account for these findings.

Prognostic value of left ventricular systolic function before vascular surgery: a systematic review

“…Comparing our findings with prior research reveals a consistent pattern of association between impaired LV systolic function (as measured by LVEF) and adverse cardiovascular outcomes following vascular surgery. Previous studies have established similar results, demonstrating that reduced LVEF is associated with an increased risk of all‐cause mortality, cardiac death and congestive heart failure following vascular surgery 21,22,27–34 . Postulated mechanisms include a surge in circulating catecholamines and perioperative fluid shifts leading to increased ventricular afterload and alterations in preload 9,10 .…”

“…Previous studies have established similar results, demonstrating that reduced LVEF is associated with an increased risk of all-cause mortality, cardiac death and congestive heart failure following vascular surgery. 21,22,[27][28][29][30][31][32][33][34] Postulated mechanisms include a surge in circulating catecholamines and perioperative fluid shifts leading to increased ventricular afterload and alterations in preload. 9,10 We attempted to stratify outcomes based on degree of LV systolic dysfunction, but were limited by the inconsistent reporting.…”

“…Other studies reveal conflicting data, owing to variable baseline demographics including history of structural heart disease, procedure type and uptake of optimal medical therapy within patient cohorts. 21,27,33,35 Contemporary studies have demonstrated varying degree of cardiac risk when comparing endovascular procedures to open aortic and lower extremity repairs. [36][37][38][39][40] The BEST-CLI highlighted that open and endovascular lower limb revascularization in appropriately selected patients with chronic limb threatening ischemia (CLTI) can be performed with similar incidence of MACE and all-cause mortality, while the BASIL-2 trial demonstrated improved survival for patients with infra-popliteal disease undergoing an endovascular-first strategy.…”

Cardiorespiratory fitness measured with cardiopulmonary exercise testing and mortality in patients with cardiovascular disease: A systematic review and meta-analysis

“…The most common CVDs were coronary artery disease 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 and heart failure, 33 , 34 , 35 , 36 , 37 and other studies included patients diagnosed with aortic stenosis, 22 hypertrophic cardiomyopathy, 38 peripheral artery disease, 39 and a combination of various pathologies. 21 , 40 , 41 , 42 General characteristics of the 21 included studies are summarized in Table 1 .…”

The physiological and clinical importance of cardiorespiratory fitness in people with abdominal aortic aneurysm

“…Specifically, Straw et al. (2020) assessed the 3‐year postoperative mortality in people undergoing EVAR and reported that patients with a $${\dot V_{{{\rm{O}}_{\rm{2}}}{\rm{peak}}}}$$ ≤ 15 ml kg −1 min −1 and a $${{{{\dot V}_{\rm{E}}}} \mathord{/ {\vphantom {{{{\dot V}_{\rm{E}}}} {{{\dot V}_{{\rm{C}}{{\rm{O}}_2}}}}}} \kern-\nulldelimiterspace} {{{\dot V}_{{\rm{C}}{{\rm{O}}_2}}}}}$$ ≥ 42 ml kg −1 min −1 have an increased risk of long‐term postoperative mortality compared with patients who have higher measures of fitness. These results reinforce the impact of cardiorespiratory fitness as a significant determinant of long‐term survival in people with AAA undergoing EVAR.…”