Impaired Long Term Survival with Asymptomatic Peri-operative Myocardial Injury following Endovascular Infrarenal Abdominal Aortic Aneurysm Repair: A Retrospective Study

Objective: Peri-operative myocardial injury (PMI) is characterised by an acute but clinically asymptomatic increase in troponin levels. Its incidence in vascular surgery is under-reported. Moreover, the impact of PMI on survival in patients undergoing endovascular aneurysm repair (EVAR), who are particularly at risk owing to their cardiovascular burden, remains unclear. This study aimed to assess the incidence of PMI following infrarenal EVAR and its association with long term mortality. Methods: Pre- and consecutive post-operative high sensitivity troponin T (hsTnT) levels were retrospectively analysed from patients who underwent standard infrarenal EVAR in a tertiary Dutch hospital between 2012 and 2022. PMI was defined as a difference of ≥ 14 ng/L (ΔhsTnT) between pre- and post-operative troponin concentrations without clinical features of myocardial ischaemia. Patients with clinically evident myocardial infarction were excluded. The primary outcomes were the incidence of PMI and the long term mortality rate. A secondary outcome was the association between the magnitude of ΔhsTnT and long term mortality rate, irrespective of PMI criteria. Results: Three hundred and eighteen patients were included, with a median follow up of 43 months. PMI occurred in 38 patients (11.9%). The 6 year risk of death was statistically significantly higher in patients with PMI (42.1% vs. 23.6%, adjusted hazard ratio [HR] 2.11, 95% confidence interval [CI] 1.13 – 3.92; p = .019). Age (adjusted HR 1.06, 95% CI 1.02 – 1.09; p ≤ .001) and American Society of Anesthesiologists score (adjusted HR 1.82, 95% CI 1.16 – 2.87; p = .009) were independent predictors of death. Statin therapy demonstrated protective advantages against death (adjusted HR 0.40, 95% CI 0.25 – 0.65; p < .001). Lastly, there was a statistically significant association between the magnitude of ΔhsTnT and long term death (adjusted HR = 1.016/Δ1 ng/L, 95% CI 1.004 – 1.029; p = .012). Conclusion: Asymptomatic PMI is relatively common following EVAR and is associated with impaired long term survival. HsTnT is a sensitive marker for identifying cardiac damage in patients undergoing EVAR. Prospective studies may strengthen the evidence of the potential association between PMI and post-EVAR death and clarify any benefit from intensified post-operative cardiac care.