Emergency use of sugammadex after failure of standard reversal drugs and postoperative pulmonary complications: A retrospective cohort study.

Background and Aims: The use of sugammadex instead of neostigmine for the reversal of neuromuscular blockade may decrease postoperative pulmonary complications. It is unclear if this finding is applicable to situations where sugammadex is administered after the administration of neostigmine. The objective of this study was to compare the incidence of a composite outcome measure of major postoperative pulmonary complications in patients who received sugammadex as a rescue agent after neostigmine versus those who received sugammadex alone for reversal of neuromuscular blockade. Material and Methods: This retrospective cohort study analyzed the medical records of adult patients who underwent elective inpatient noncardiac surgery under general anesthesia and received sugammadex for reversal of neuromuscular blockade, at a tertiary care academic hospital between August 2016 and November 2018. Results: A total of 1,672 patients were included, of whom 1,452 underwent reversal with sugammadex alone and 220 received sugammadex following reversal with neostigmine/glycopyrrolate. The composite primary outcome was diagnosed in 60 (3.6%) patients. Comparing these two groups, and after adjusting for confounding factors, patients who received sugammadex after reversal with neostigmine had more postoperative pulmonary complications than those reversed with sugammadex alone (6.8% vs. 3.1%, odds ratio, 2.29; 95% confidence interval [CI], 1.25 to 4.18; P = 0.006). Conclusion: The use of sugammadex following reversal with neostigmine was associated with a higher incidence of postoperative pulmonary complications as compared to the use of sugammadex alone. The implications of using sugammadex after the failure of standard reversal drugs should be investigated in prospective studies.

Oral versus intravenous acetaminophen for perioperative pain management in adult patients undergoing non-cardiac surgery: A quantile segmented regression analysis.

STUDY OBJECTIVE: Determine whether preferential use of perioperative enteral acetaminophen is associated with changes in perioperative pain, narcotic administration, or time to meeting criteria for post anesthesia care unit (PACU) discharge, compared to preferential parenteral administration. DESIGN: Retrospective Cohort with quantile segmented regression analysis. Groups determined by date of surgery, one year pre-initiative and one year post-initiative. SETTING: Operating room and PACU of a tertiary academic medical center. PATIENTS: Adult (age > 18 years), ASA status 1-5, non-pregnant patients undergoing non-cardiac surgery of less than six hours duration admitted to the PACU postoperatively. INTERVENTIONS: A multidisciplinary initiative to preferentially utilize enteral over parenteral acetaminophen. MEASUREMENTS: The primary outcome was narcotic consumption in the PACU. Secondary outcomes were intraoperative narcotic administration, pain score on PACU admission and discharge, and time to meeting criteria for PACU discharge. RESULTS: 24,701 patients were included in the analysis; 12,379 had surgery prior to the initiative and 12,322 after. Enteral acetaminophen administration increased preoperatively from 13.49% to 26.84%, and postoperatively from 43.16% to 51.45%, while intraoperative parenteral APAP use dropped from 43.23% to 6.81%. Quantile Segmented regression analysis after adjusting for period (pre versus postintervention), day, age, gender, inpatient status, and ASA class demonstrated a decrease in adjusted median perioperative acetaminophen dose (-175 mg P < 0.001), with no significant difference in level change of intraoperative or PACU narcotic administration. There was no significant difference in median time to meet criteria for PACU discharge, though there was a significant change in the slope, (-0.36, p = 0.007.) Median pain scores measured on a standard 0-10 numeric rating scale at PACU admission did not change, while median pain scores at PACU discharge decreased slightly (-0.24 p < 0.001). There was no change in the probability of PONV. CONCLUSION: In adult patients undergoing non-cardiac surgery of <6 h duration, preferential use of enteral rather than parenteral acetaminophen is associated with non-inferior outcomes in narcotic requirements, pain scores, time to PACU discharge, and probability of PONV when compared with routine parenteral administration. Further studies are needed to validate these findings.

Failure to Rescue After Severe Acute Kidney Injury in Patients Undergoing Non-Cardiac Surgery.

INTRODUCTION: Many deaths after surgery can be attributed to "failure to rescue," which may be a better surgical quality indicator than the occurrence of a postoperative complication. Acute kidney injury (AKI) is one such postoperative complication associated with high mortality. The purpose of this study is to identify perioperative risk factors associated with failure to rescue among patients who develop postoperative AKI. METHODS: We identified adult patients who underwent non-cardiac surgery between 2012 and 2018 and experienced postoperative severe AKI (an increase in blood creatinine concentration of >2 mg/dL above baseline or requiring hemodialysis) from the American College of Surgeons National Surgical Quality Improvement Program database. Multivariable logistic regression was used to identify risk factors for failure to rescue among patients who developed severe AKI. RESULTS: Among 5,765,904 patients who met inclusion criteria, 26,705 (0.46%) patients developed postoperative severe AKI, of which 6834 (25.6%) experienced failure to rescue. Risk factors with the strongest association (adjusted odds ratio >1.5) with failure to rescue in patients with AKI included advanced age, higher American Society of Anesthesiologists class, presence of preoperative ascites, disseminated cancer, septic shock, and blood transfusion within 72 h of surgery start time. CONCLUSIONS: About one-fourth of patients who develop severe AKI after non-cardiac surgery die within 30 d of surgery. Both patient- and surgery-related risk factors are associated with this failure to rescue. Further studies are needed to identify early and effective interventions in high-risk patients who develop postoperative severe AKI to prevent the antecedent mortality.

Discharge prescribing of enteral opioids in opioid naïve patients following non-surgical intensive care: A retrospective cohort study.

PURPOSE: To estimate the incidence of new prescription of enteral opioids on hospital discharge in opioid naïve, non-surgical, critically ill patients and evaluate the risk factors associated with such occurrence. METHODS: Using hospital-wide and ICU databases, we retrospectively identified all patients (≥ 18 years old) who were admitted to the 20-bed adult ICU of Memorial Sloan Kettering Cancer Center (MSKCC) between July 1, 2015 and April 20, 2020. Patients' electronic medical records (EMR) were retrieved and patient demographics, peri-ICU admission data were captured and analyzed. RESULTS: During the study period, a total of 3755 opioid naïve patients were admitted to the ICU and 848 patients met the inclusion criteria. Among these, 346 (40.8%) patients were discharged with a new opioid prescription. Age at ICU admission, preadmission use of benzodiazepine, and antidepressants, a diagnosis of sepsis, and use of mechanical ventilation, antidepressants or, opioid infusion for greater than 4 h during the ICU stay, hospital length of stay (LOS), and days between ICU discharge and hospital discharge were independently associated with increased odds of a new opioid prescription. CONCLUSIONS: A significant proportion of opioid naïve non-surgical ICU survivors receive a new opioid prescription on hospital discharge.

Postoperative atrial fibrillation in paraesophageal hernia repair: can it be prevented?

Acute ischemic thromboembolic stroke is one of the most feared complications of atrial fibrillation (AF), and the risk increases with higher CHA2DS2-VASc scores. Postoperative atrial fibrillation (POAF) is common after noncardiac surgery, particularly after thoracic surgery, and can result in significant morbidity and mortality. We report the case of an 85-year-old female with a history of untreated hypertension (HTN) and no prior history of AF, who presented 5 days after an elective repair of a paraesophageal hernia with recurrence of a large type III paraesophageal hiatal hernia, AF, and subsequent acute thromboembolic ischemic stroke. Patient's AF resolved shortly after treatment with calcium channel blocker. The risk of stroke is high in patients who develop AF and a period of 48 h after onset of AF is usually considered safe as the risk of stroke is low in this time period. However, this may not be the case during the perioperative period and preventive measures such as preoperative calcium channel blocker could be considered. Our case highlights that acute ischemic thromboembolic stroke might develop earlier tha 48 h after onset of POAF in patients undergoing paraesophageal hernia repair. Initiation of a calcium channel blocker should be considered during preoperative evaluation for patients undergoing paraesophageal hernia repairs, especially in those with untreated HTN.

Cardiac Arrhythmias in Critically Ill Patients With COVID-19: A Brief Review.

Coronavirus disease 2019, caused by severe acute respiratory syndrome coronavirus 2, is now a global pandemic affecting more than 12 million patients across 188 countries. A significant proportion of these patients require admission to intensive care units for acute hypoxic respiratory failure and are at an increased risk of developing cardiac arrhythmias. The presence of underlying comorbidities, pathophysiologic changes imposed by the disease, and concomitant polypharmacy, increase the likelihood of life-threatening arrhythmias in these patients. Supraventricular, as well as ventricular arrhythmias, are common and are associated with significant morbidity and mortality. It is important to understand the interplay of various causal factors while instituting strategies to mitigate the impact of modifiable risk factors. Furthermore, avoidance and early recognition of drug interactions, along with prompt treatment, might help improve outcomes in this vulnerable patient population.

Perioperative risk factors in patients with idiopathic pulmonary fibrosis: a historical cohort study.

PURPOSE: Perioperative complications of patients with idiopathic pulmonary fibrosis (IPF) are not well described. The aim of this study was to identify risk factors associated with adverse postoperative outcomes in IPF patients. METHODS: We performed a single-centre historical cohort study of adult patients with IPF who underwent surgery between 2008 and 2018. We analyzed the prognostic utility of select perioperative factors for postoperative acute exacerbation of IPF (AE-IPF), acute respiratory worsening (ARW), pneumonia, and 30-day and one-year mortality using univariable and multivariable regression analyses. To adjust for multiple interactions, the false discovery rate (Q value) was utilized to appropriately adjust P values and a Q value < 0.05 was considered to be significant. RESULTS: Two hundred and eighty-two patients were identified. After excluding emergency cases and bronchoscopies performed for active pneumonia, 14.2% of the cohort developed ARW that persisted > 24 hr after surgery, 5.0% had AE-IPF, and 9.2% were diagnosed with postoperative pneumonia within 30 days of surgery. The 30-day mortality was 6.0% and the one-year mortality was 14.9%. Preoperative home oxygen use (relative risk [RR], 2.70; 95% confidence interval [CI], 1.50 to 4.86; P < 0.001) and increasing surgical time (per 60 min) (RR, 1.03; 95% CI, 1.02 to 1.05; P < 0.001) were identified as independent risk factors for postoperative ARW. CONCLUSIONS: In IPF patients, preoperative home oxygen requirement and increasing surgical time showed a strong relationship with postoperative ARW and may be useful markers for perioperative risk stratification. Facteurs de risque périopératoires des patients atteints de fibrose pulmonaire idiopathique : une étude de cohorte historique.

RéSUMé: OBJECTIF: Les complications périopératoires chez les patients atteints de fibrose pulmonaire idiopathique (FPI) ne sont pas bien décrites. L'objectif de cette étude était d'identifier les facteurs de risque associés aux devenirs postopératoires défavorables chez les patients atteints de FPI. MéTHODE: Nous avons réalisé une étude de cohorte historique monocentrique portant sur des patients adultes atteints de FPI et ayant subi une chirurgie entre 2008 et 2018. Nous avons analysé l'utilité pronostique de facteurs périopératoires choisis pour l'exacerbation postopératoire aiguë de la FPI, la détérioration respiratoire aiguë, la pneumonie, et la mortalité à 30 jours et à un an à l'aide d'analyses de régression univariées et multivariées. Afin de tenir compte d'interactions multiples, le taux de fausses découvertes (valeur Q) a été utilisé pour ajuster adéquatement les valeurs P, et une valeur Q < 0,05 a été considérée significative. RéSULTATS: Deux cent quatre-vingt-deux patients ont été identifiés. Après avoir exclu les cas en urgence et les bronchoscopies réalisées lors de pneumonie active, 14,2 % des patients de la cohorte ont souffert d'une détérioration respiratoire aiguë qui a persisté > 24 h après la chirurgie, 5,0 % ont subi une exacerbation aiguë de la FPI, et 9,2 % ont reçu un diagnostic de pneumonie postopératoire dans les 30 jours suivant leur chirurgie. La mortalité à 30 jours était de 6,0 %, et la mortalité à un an de 14,9 %. L'utilisation préopératoire d'oxygène à domicile (risque relatif [RR], 2,70; intervalle de confiance [IC] 95 %, 1,50 à 4,86; P < 0,001) et l'augmentation du temps chirurgical (par tranche de 60 min) (RR, 1,03; IC 95 %, 1,02 à 1,05; P < 0,001) ont été identifiées comme des facteurs de risque indépendants de détérioration respiratoire aiguë en période postopératoire. CONCLUSION: Chez les patients atteints de FPI, une forte association a été observée entre les besoins préopératoires en oxygène au domicile ainsi que l'augmentation du temps chirurgical et la détérioration respiratoire aiguë en période postopératoire; ces deux facteurs pourraient constituer des marqueurs utiles pour stratifier le risque en période périopératoire.

Timing of Transversus Abdominis Plane Block and Postoperative Pain Management.

BACKGROUND: Transversus abdominis plane (TAP) blocks using liposomal bupivacaine can reduce postoperative pain and opioid consumption after surgery. The impact of timing of administration of such blocks has not been determined. MATERIALS AND METHODS: A retrospective cohort study of all adult patients that underwent colorectal procedures between January 2013 and October 2015 and received TAP blocks with liposomal bupivacaine at our institution was conducted. The primary outcomes were postoperative pain scores and opioid consumption. Secondary outcomes included postoperative use of non-opioid analgesics as well as total hospital cost of admission and postoperative hospital length of stay. RESULTS: A total of 287 patients were identified and included in the analysis. A total of 71 patients received blocks prior to induction of general anesthesia (pre-ind), 85 patients received blocks after induction of general anesthesia but prior to surgical incision (post-ind) and 131 patients received blocks after completion of surgery (post-op). No significant differences were observed in the postoperative pain scores (either in the first 4 hours or for the entire duration of hospital stay) or opioid consumption between the pre-ind and the post-ind groups. More ketorolac was used in the post-op group compared to the pre-ind group (or= 3.36, 95% CI (1.08, 10.43); p=0.03). CONCLUSION: Our findings suggest that there seems to be no difference if tap blocks with liposomal bupivacaine are performed before or after induction of anesthesia. Patient preference as well as operating room efficiency should be considered when deciding on the timing of these blocks.

Acute heart failure after liver transplantation: A narrative review.

Acute heart failure (AHF) is an under recognized yet potentially lethal complication after liver transplantation (LT) surgery. The increase in incidence of liver transplantation amongst high-risk patients and the leniency in the criteria for transplantation, predisposes these patients to postoperative AHF and the antecedent morbidity and mortality. The inability of conventional preoperative cardiovascular testing to accurately identify patients at risk for post-LT AHF poses a considerable challenge to clinicians caring for these patients. Even if high-risk patients are identified, there is considerable ambiguity in the candidacy for transplantation as well as optimization strategies that could potentially prevent the development of AHF in the postoperative period. The intraoperative and postoperative management of patients who develop AHF is also challenging and requires a well-coordinated multidisciplinary approach. The use of mechanical circulatory support in patients with refractory heart failure has the potential to improve outcomes but its use in this complex patient population can be associated with significant complications and requires a stringent risk-benefit analysis on a case-by-case basis.

Atrial Fibrillation: Current Evidence and Management Strategies During the Perioperative Period.

Atrial fibrillation (AF) is the most common arrhythmia in the perioperative period. Previously considered a benign and self-limited entity, recent data suggest that perioperative AF is associated with considerable morbidity and mortality and may predict long-term AF and stroke risk in some patients. Despite known risk factors, AF remains largely unpredictable, especially after noncardiac surgery. As a consequence, strategies to minimize perioperative risk are mostly supportive and include avoiding potential arrhythmogenic triggers and proactively treating patient- and surgery-related factors that might precipitate AF. In addition to managing AF itself, clinicians must also address the hemodynamic perturbations that result from AF to prevent end-organ dysfunction. This review will discuss current evidence with respect to causes, risk factors, and outcomes of patients with AF, and address current controversies in the perioperative setting.

Post-operative intensive care unit admission after elective non-cardiac surgery: A single-center analysis of the NSQIP database.

BACKGROUND: Admission to the intensive care unit (ICU) after surgery can be associated with significant morbidity and mortality. This observational cohort study aims to identify perioperative factors associated with post-operative ICU admission in patients undergoing elective non-cardiac surgery. METHODS: Data from the ACS NSQIP® database at a tertiary care academic medical center were analyzed from January 2011 to September 2016. Univariable and multivariable logistic regression of patient and surgery-specific characteristics was performed to assess association with post-operative ICU admission. The Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-9) billing codes, as well as associated outcomes, were reviewed. RESULTS: Of 5254 database patient records, 1150 met our inclusion criteria. Elevated body mass index (BMI), longer procedure duration and a diagnosis of disseminated cancer were associated with post-operative ICU admission. Prostatectomy and morbid obesity were the most common CPT and ICD-9 codes identified. Patients who were admitted to the ICU after surgery had a longer hospital length of stay (LOS), had a higher frequency of readmission, re-operation, and in-hospital mortality. CONCLUSION: Admission to the ICU after elective non-cardiac surgery is common. Our analysis of the ACS NSQIP® database identified elevated BMI, longer duration of surgery and disseminated cancer as predictors of post-operative ICU admissions in patients undergoing elective non-cardiac surgery.

Angiotensin axis blockade, acute kidney injury, and perioperative morbidity in patients undergoing colorectal surgery: A retrospective cohort study.

Patients undergoing surgery and taking angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) are susceptible to complications related to intraoperative hypotension. Perioperative continuation of such medications in patients undergoing colorectal surgery may be associated with more harm than benefit, as these patients are often exposed to other risk factors which may contribute to intraoperative hypotension. Our objectives were to assess the incidence and severity of postinduction hypotension as well as the rates of acute kidney injury (AKI), 30-day all-cause mortality, 30-day readmission, and hospital length of stay in adult patients undergoing colorectal surgery who take ACEi/ARB.We performed a retrospective chart review of patients undergoing colorectal surgery of ≥4 hour duration at a tertiary care academic medical center between January 2011 and November 2016. The preoperative and intraoperative characteristics as well as postoperative outcomes were compared between patients taking ACEi/ARB and patients not taking these medications.Of the 1020 patients meeting inclusion criteria, 174 (17%) were taking either ACEi or ARB before surgery. Patients taking these medications were more likely to receive both postinduction and intraoperative phenylephrine and ephedrine. The incidences of postoperative AKI (P = .35), 30-day all-cause mortality (P = .36), 30-day hospital readmission (P = .45), and hospital length of stay (P = .25), were not significantly different between the 2 groups.Our results support the current recommendation that ACEi/ARB use is probably safe within the colorectal surgery population during the perioperative period. Intraoperative hypotension should be expected and treated with vasopressors.

Cardiovascular Collapse in a Patient With Parotid Abscess: Dangerous Cross Talk Between the Brain and Heart: A Case Report.

Postsurgical trigeminal neuralgia (TN), although rare, can lead to significant hemodynamic perturbations by triggering the trigeminocardiac reflex (TCR). The combination can lead to diagnostic as well as management challenges for clinicians. We present the case of a patient with a parotid abscess, which developed as a complication of his otolaryngologic surgery, and which led to repeated episodes of symptomatic bradycardia associated with cardiovascular collapse. This case highlights the importance of heightened awareness, early diagnosis, and timely treatment of postsurgical neuropathic pain syndromes to avoid life-threatening complications.

The Serotonin Syndrome: From Molecular Mechanisms to Clinical Practice.

The serotonin syndrome is a medication-induced condition resulting from serotonergic hyperactivity, usually involving antidepressant medications. As the number of patients experiencing medically-treated major depressive disorder increases, so does the population at risk for experiencing serotonin syndrome. Excessive synaptic stimulation of 5-HT2A receptors results in autonomic and neuromuscular aberrations with potentially life-threatening consequences. In this review, we will outline the molecular basis of the disease and describe how pharmacologic agents that are in common clinical use can interfere with normal serotonergic pathways to result in a potentially fatal outcome. Given that serotonin syndrome can imitate other clinical conditions, an understanding of the molecular context of this condition is essential for its detection and in order to prevent rapid clinical deterioration.

In a Model of Neuroinflammation Designed to Mimic Delirium, Quetiapine Reduces Cortisol Secretion and Preserves Reversal Learning in the Attentional Set Shifting Task.

Quetiapine, an atypical antipsychotic medication has lacked pre-clinical validation for its purported benefits in the treatment of delirium. This laboratory investigation examined the effects of quetiapine on the attentional set shifting task (ASST), a measure of cognitive flexibility and executive functioning, in a rodent model of lipopolysaccharide (LPS) mediated neuroinflammation. 19 Sprague Dawley female rats were randomly selected to receive intraperitoneal placebo (N = 5), LPS and placebo (N = 7) or LPS and quetiapine (n = 7) and performed the ASST. We measured trials to criterion, errors, non-locomotion episodes and latency to criterion, serum cortisol and tumor necrosis factor alpha (TNF-α) levels. TNF-α levels were not different between groups at 24 h. Cortisol levels in the LPS + Quetiapine group were reduced compared to LPS + Placebo (P < 0.001) and did not differ from the placebo group (P = 0.15). Analysis between LPS + Quetiapine and LPS + Placebo treated rats demonstrated improvement in the compound discrimination reversal (CD Rev1) (P = 0.016) and the intra-dimensional reversal (ID Rev2) (P = 0.007) discriminations on trials to criterion. LPS + Quetiapine treated rats had fewer errors than LPS + Placebo treated animals in the compound discrimination (CD) (P = 0.007), CD Rev1 (P = 0.005), ID Rev2 (P < 0.001) discriminations. There was no difference in non-locomotion frequency or latency to criterion between the three groups in all discriminations (P > 0.0167). We demonstrated preserved reversal learning, no effect on attentional set shifting and normalized cortisol levels in quetiapine-treated rats in this neuroinflammatory model of delirium. This suggests that quetiapine's beneficial effects in delirium may be related to the preservation of reversal learning and potential downstream effects related to reduction in cortisol production. Graphical Abstract.

Pain management in trauma patients affected by the opioid epidemic: A narrative review.

Acute and chronic pain in trauma patients remains a challenging entity, particularly in the setting of the escalating opioid epidemic. It has been reported that chronic opioid use increases the likelihood of hospital admissions as a result of traumatic injuries. Furthermore, patients admitted with traumatic injuries have a greater than average risk of developing opioid use disorder after discharge. Practitioners providing care to these patients will encounter the issue of balancing analgesic goals and acute opioid withdrawal with the challenge of reducing postdischarge persistent opioid use. Additionally, the practitioner is faced with the worrisome prospect that inadequate treatment of acute pain may lead to the development of chronic pain and overtreatment may result in opioid dependence. It is therefore imperative to understand and execute alternative nonopioid strategies to maximize the benefits and reduce the risks of analgesic regimens in this patient population. This narrative review will analyze the current literature on pain management in trauma patients and highlight the application of the multimodal approach in potentially reducing the risks of both short- and long-term opioid use. LEVEL OF EVIDENCE: Narrative review, moderate to High.

Adherence to surgical antimicrobial prophylaxis: "checking-the-box" is not enough.

PURPOSE: The purpose of this paper is to review surgical antimicrobial prophylaxis administration practices in a small cohort and assess compliance with national guidelines. DESIGN/METHODOLOGY/APPROACH: Patients that developed surgical site infections (SSI) in a tertiary care academic medical center over a two-year period were identified. Their electronic medical records were reviewed for compliance with national guidelines with respect to surgical antibiotic prophylaxis. FINDINGS: Over a two-year period, 283 SSI patients were identified. An appropriate antibiotic was chosen in 80 percent, an appropriate dose was administered in 45 percent and timing complied in 89 percent. The antibiotics were appropriately re-dosed in only 9.2 percent in whom the requirement was met. The prescribing guidelines were adhered to in entirety in only 54 patients (23.8 percent). PRACTICAL IMPLICATIONS: Timely and appropriate antibiotic administration prior to surgery is essential to prevent SSI. Proper diligence is required to accomplish this task effectively. ORIGINALITY/VALUE: Based on the findings, it appears that merely, "checking a box" for antibiotic administration during surgery is not enough, and a multidisciplinary approach should be followed to ensure "appropriate" antibiotic administration.

Acute heart failure after Orthotopic liver transplantation: a case series from one center.

BACKGROUND: Patients undergoing liver transplantation (LT) can develop acute heart failure (HF) in the postoperative period despite having had a normal cardiac evaluation prior to surgery. End-stage liver disease is often associated with underlying cardiac dysfunction which, while not identified during preoperative testing, manifests itself during or immediately after surgery. CASE PRESENTATION: We describe three cases of non-ischemic acute HF developing shortly after LT in patients who had a normal preoperative cardiac evaluation. The challenges associated with both diagnosis and management of acute HF in the setting of a newly implanted graft will be discussed. CONCLUSIONS: Diastolic dysfunction, QTc interval prolongation, and an increase in BNP may be predictive of postoperative HF. Current recommendations for preoperative cardiovascular evaluation of transplant candidates does not include studies examining these risk factors and should be revised. Further investigations are necessary to evaluate these findings.