European Association of Cardio-Thoracic Surgery (EACTS) expert consensus statement on perioperative myocardial infarction after cardiac surgery

Cardiac surgery may lead to myocardial damage and release of cardiac biomarkers through various mechanisms such as cardiac manipulation, systemic inflammation, myocardial hypoxia, cardioplegic arrest and ischaemia caused by coronary or graft occlusion. Defining perioperative myocardial infarction (PMI) after cardiac surgery presents challenges, and the association between the current PMI definitions and postoperative outcomes remains uncertain. To address these challenges, the European Association of Cardio-Thoracic Surgery (EACTS) facilitated collaboration among a multidisciplinary group to evaluate the existing evidence on the mechanisms, diagnosis and prognostic implications of PMI after cardiac surgery. The review found that the postoperative troponin value thresholds associated with an increased risk of mortality are markedly higher than those proposed by all the current definitions of PMI. Additionally, it was found that large postoperative increases in cardiac biomarkers are prognostically relevant even in absence of additional supportive signs of ischaemia. A new algorithm for PMI detection after cardiac surgery was also proposed, and a consensus was reached within the group that establishing a prognostically relevant definition of PMI is critically needed in the cardiovascular field and that PMI should be included in the primary composite outcome of coronary intervention trials. Cardiac surgery involves the performance of life-enhancing procedures in patients with severe cardiac conditions, including congenital, coronary, valvular and structural heart disease. Graphical Abstract Proposed algorithm for detecting myocardial injury and myocardial infarction by using troponin levels as a key metric determinant. This algorithm requires additional testing and verification before further application in clinical and research settings. From the VISION study, 90% of patients showed a troponin I elevation >= 35 times the upper reference limit after cardiac surgery; hence the threshold on the left of the image. The same study associated levels of troponin 500 times the upper reference limit with an increased risk of death (not specifically related to myocardial infarction) after cardiac surgery; hence the use of this threshold in the algorithm.