Abstract
Background
Limited data exists on cardiac complications following head and neck free flaps.
Design
A retrospective review was performed on patients that underwent free flap reconstruction from 2012 to 2015.
Results
368 flaps were performed. 12.5% of patients experienced a cardiac event. Hypertension, coronary artery disease, heart failure, venous thromboembolism, and anticoagulation were associated with cardiac complications. ASA class was not predictive of cardiac events. 7.6% of patients required anticoagulation, which exhibited a strong association with surgical site hematoma. Cardiac complications led to a significantly increased length of stay.
Conclusions
There is a significant rate of cardiac events in this cohort. When estimating risk, a patient’s total burden of comorbidities is more important than any one factor. ASA Class fails to demonstrate utility in this setting. Cardiac events have implications for quality-related metrics including length of stay and hematoma rate.
1
Introduction
Healthcare reform has become a national priority, with focus on strategies to contain costs while delivering quality care. Providers at both academic and private settings will be increasingly scrutinized on outcomes and quality-related metrics including length of stay (LOS), readmissions, complications, and efficient resource utilization. In addition, these quality-related metrics will likely be tied to reimbursements; therefore benchmark standards for what is considered quality, cost effective care must be defined . The National Surgical Quality Improvement Project (NSQIP) sponsored by the American College of Surgeons (ACS) is a currently available tool for surgeons and hospitals to track and compare their outcomes to national benchmarks for many general surgery and some subspecialty procedures; the tools, however, are not particularly effective for patients undergoing head and neck free flap reconstruction .
Presently, outcomes pertaining to head and neck free flap reconstruction typically focus on flap viability and functional results. There is a paucity of data on perioperative complications and in particular, postoperative cardiac events. Due to the lengthy operative times, perioperative fluid shifts, and manipulation of the upper aerodigestive tract, patients undergoing head and neck free flap reconstruction are at risk for cardiac complications . In addition, head and neck cancer patients are likely to have multiple comorbidities including advanced age, history of tobacco abuse, and cardiopulmonary disease further predisposing them to postoperative complications.
Identifying which patients are most likely to experience a perioperative cardiac event allows for the potential to mitigate risk through preoperative medical optimization. Furthermore, it provides the opportunity to counsel patients regarding expected rates of postoperative complications based on existing comorbidities.
The primary objective of this study was to define rates of major postoperative cardiovascular events (defined as: cardiac arrest, acute coronary syndrome, heart failure, or cardiac dysrhythmia) in a cohort of patients that underwent head and neck free flap reconstruction, identify risk factors for these complications, and to measure the effect of cardiac events on the quality-related measures including length of stay, mortality, and surgical site hematomas.
2
Materials and methods
We performed a retrospective chart review of consecutive patients that underwent head and neck free flap reconstruction performed by two senior surgeons (E.L. and M.F.) at the Cleveland Clinic (Cleveland, OH, USA) from January 1, 2012 to December 31, 2015. Clinical data including demographics, preoperative risk factors, operative data, and postoperative course was obtained from a review of electronic medical records. The clinical index known as the American Society of Anesthesiologists Classification of Physical Status System (ASA Class) as determined prospectively by the anesthesia team was used as a predictor of overall health prior to surgery ( Table 1 ). Patients were referred for preoperative medical optimization at our institution’s Internal Medicine Preoperative Assessment, Consultation and Treatment Center (IMPACT), as determined necessary by the senior surgeons.
| Class | Definition |
|---|---|
| ASA I | A normal healthy person |
| ASA II | A patient with mild systemic disease |
| ASA III | A patient with severe systemic disease |
| ASA IV | A patient with severe systemic disease that is a constant threat to life |
| ASA V | A moribund person that is not expected to survive without operation |
The postoperative hospital course of each patient was reviewed. Only the events that occurred in the immediate postoperative hospitalization were included in the data. The primary outcome of interest was a cardiac complication defined as: cardiac arrest, acute coronary syndrome, heart failure, or cardiac dysrhythmia. Secondary outcomes of interest included length of stay, need for therapeutic anticoagulation, mortality, and surgical site hematoma.
Summary statistics and frequencies for demographic and clinical outcomes were calculated. Univariate and multivariate analyses was performed to determine associations between preoperative factors and postoperative outcomes. Associations of outcomes with categorical variables were determined using the chi-squared or Fischer’s exact test. Associations of outcomes with continuous variables were assessed using logistic regression. Association plots were created to demonstrate the relationship between preoperative variables and LOS, using either the Spearman’s or Kruskal-Wallis test. P value of < 0.05 was considered statistically significant. Statistical analysis was performed using R version 2.15.1 ( www.R-project.org ).
2
Materials and methods
We performed a retrospective chart review of consecutive patients that underwent head and neck free flap reconstruction performed by two senior surgeons (E.L. and M.F.) at the Cleveland Clinic (Cleveland, OH, USA) from January 1, 2012 to December 31, 2015. Clinical data including demographics, preoperative risk factors, operative data, and postoperative course was obtained from a review of electronic medical records. The clinical index known as the American Society of Anesthesiologists Classification of Physical Status System (ASA Class) as determined prospectively by the anesthesia team was used as a predictor of overall health prior to surgery ( Table 1 ). Patients were referred for preoperative medical optimization at our institution’s Internal Medicine Preoperative Assessment, Consultation and Treatment Center (IMPACT), as determined necessary by the senior surgeons.
| Class | Definition |
|---|---|
| ASA I | A normal healthy person |
| ASA II | A patient with mild systemic disease |
| ASA III | A patient with severe systemic disease |
| ASA IV | A patient with severe systemic disease that is a constant threat to life |
| ASA V | A moribund person that is not expected to survive without operation |
The postoperative hospital course of each patient was reviewed. Only the events that occurred in the immediate postoperative hospitalization were included in the data. The primary outcome of interest was a cardiac complication defined as: cardiac arrest, acute coronary syndrome, heart failure, or cardiac dysrhythmia. Secondary outcomes of interest included length of stay, need for therapeutic anticoagulation, mortality, and surgical site hematoma.
Summary statistics and frequencies for demographic and clinical outcomes were calculated. Univariate and multivariate analyses was performed to determine associations between preoperative factors and postoperative outcomes. Associations of outcomes with categorical variables were determined using the chi-squared or Fischer’s exact test. Associations of outcomes with continuous variables were assessed using logistic regression. Association plots were created to demonstrate the relationship between preoperative variables and LOS, using either the Spearman’s or Kruskal-Wallis test. P value of < 0.05 was considered statistically significant. Statistical analysis was performed using R version 2.15.1 ( www.R-project.org ).
3
Results
A total of 368 free flap reconstructions for defects of the head and neck were performed on 347 patients. Seventeen patients underwent 2 free flaps. Two patients underwent 3 free flaps. Preoperative demographics are displayed in Table 2 .
| Characteristic | No. (%) of patients |
|---|---|
| Age, mean (SD), years | 61.64 (13.57) |
| Sex | |
| Male | 236 (64.1) |
| Female | 132 (35.9) |
| IMPACT referral | 235 (63.9) |
| ASA Class | |
| 1 | 1 (0.27) |
| 2 | 39 (10.6) |
| 3 | 245 (66.8) |
| 4 | 82 (22.3) |
| Medical history | |
| Hypertension | 168 (45.7) |
| Coronary artery disease | 60 (16.3) |
| Heart failure | 19 (5.2) |
| Dysrhythmia | 30 (8.2) |
| Diabetes Mellitus | 45 (12.2) |
| COPD | 62 (16.8) |
| VTE | 13 (3.5) |
| Stroke | 24 (6.5) |
| Anticoagulation | 19 (5.2) |
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