Subclinical Peri-operative Myocardial Injury following Complex Endovascular Aortic Repair is Associated with Increased Midterm Mortality: A Retrospective Study

OBJECTIVE: Peri-operative myocardial injury (PMI), defined by an asymptomatic increase in troponin levels, has been recognised as a prognostic marker for impaired survival following non-cardiac surgery, with therapy for improvement potentially available. Patients undergoing complex endovascular aneurysm repair (cEVAR) may be at particular risk of PMI owing to their cardiovascular burden. However, due to lack of routine peri-operative troponin monitoring, the incidence proportion and association between PMI and long term mortality following cEVAR remains unclear, with no possibility of applying improvement strategies. METHODS: Pre-operative and consecutive post-operative high sensitivity troponin T (hsTnT) levels were retrospectively analysed from all patients who underwent elective cEVAR in a Dutch tertiary hospital between 2012 and 2022. PMI was defined as the difference between pre- and post-operative troponin concentrations (ΔhsTnT) of ≥ 14 ng/L in the absence of clinical features of myocardial infarction. Primary objectives were the incidence proportion of PMI following cEVAR and its association with 4 year mortality. The study adhered to the STROBE guidelines. RESULTS: A total of 187 patients were included. The median follow up was 56 months. Forty-one patients (21.9%) developed PMI. Coronary artery disease was more prevalent (65.9% vs. 41.8%; p = .018) and American Society of Anesthesiologists (ASA) scores were higher (ASA 4, 13.1% vs. 7.8%; p = .023) in patients with PMI. PMI was independently associated with an increased 4 year mortality rate (adjusted hazard ratio [HR] 2.37, 95% confidence interval [CI] 1.21 - 4.67; p = .013). Pre-operative elevated troponin levels (adjusted HR 2.91, 95% CI 1.41 - 6.33; p = .005) and longer operation time (adjusted HR 1.01, 95% CI 1.00 - 1.01; p = .002) were independently associated with an increased risk of PMI. CONCLUSION: Asymptomatic PMI is relatively common following cEVAR and is associated with impaired midterm survival. Given the high prevalence of cardiovascular comorbidities in patients with PMI, prospective follow up studies should focus on the potential of routine peri-operative hsTnT monitoring for identifying high risk patients who could potentially benefit from enhanced cardiac care.