Cardiac complications are the most common cause of death among patients undergoing elective noncardiac surgery and are usually associated with hemodynamic changes (changes in blood circulation) during surgery. This has led in some cases to hemodynamic monitoring during and immediately after surgery via right heart catheterization (RHC) for certain patients undergoing high-risk procedures.
RHC permits measurement of the pulmonary artery pressure, right heart pressure, cardiac output, and left ventricular pressure. The goal is to detect and correct inadequate oxygen delivery due to the increased metabolic demand of surgery and early signs of cardiac ischemia or congestive heart failure. However, perioperative RHC does not reduce the rate of major postoperative cardiac complications in noncardiac surgery patients, according to a study supported by the Agency for Healthcare Research and Quality (HS06573).
Because of the risks and high costs associated with RHC, its use in perioperative care of these patients should be evaluated in randomized controlled trials, recommend Lee Goldman, M.D., M.P.H., of the University of California, San Francisco, School of Medicine, and Thomas H. Lee, M.D., of Brigham and Women's Hospital in Boston. Drs. Goldman and Lee and their colleagues evaluated the relationship between use of perioperative RHC and postoperative cardiac complication rates in 4,059 patients 50 years of age or older who underwent noncardiac surgery at one U.S. hospital between July 1989 and February 1994; 221 patients had RHC and 3,838 did not. Overall, 4.2 percent of patients suffered from major cardiac complications. Those who underwent perioperative RHC had a three-fold increase in the incidence of major postoperative cardiac complications (15.4 percent vs. 3.6 percent).
After adjusting for other factors, RHC patients were twice as likely as non-RHC patients to suffer from major postoperative cardiac and noncardiac complications. Finally, in a subset of 215 matched pairs of patients who did and did not undergo RHC, adjusted for physician propensity to use RHC and type of surgical procedure, RHC patients had three times the risk of postoperative congestive heart failure and twice the likelihood of major noncardiac complications. RHC patients also had longer hospital stays (a mean of 11 vs. 8 days). Also, any potential benefits of RHC may be offset in part by the physiological burden of indwelling instrumentation, conclude the researchers.
More details are in "Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery," by Carisi A. Polanczyk, M.D., Sc.D., Luis E. Rohde, M.D., Sc.D., Dr. Goldman, and others, in the July 18, 2001, Journal of the American Medical Association 286(3), pp. 309-314.
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