Download surgical risk factors or procedures

NY Heart Association
Classification
Class I: Patients with cardiac disease but without resulting
limitation of physical activity. Ordinary physical activity does not
cause undue fatigue, palpitation, dyspnea, or angina pain.
 Class II: Patients with cardiac disease resulting in slight
limitation of physical activity. They are comfortable at rest.
Ordinary physical activity results in fatigue, palpitation, dyspnea,
or angina pain.
 Class III: Patients with cardiac disease resulting in marked
limitation of physical activity. They are comfortable at rest. Less
than ordinary physical activity causes fatigue, palpitation,
dyspnea, or anginal pain.
 Class IV: Patients with cardiac disease resulting in an inability
to carry on any physical activity without discomfort. Symptoms
of cardiac insufficiency or of the anginal syndrome may be
present even at rest. If any physical activity is undertaken,
discomfort is increased.
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Preop Risk Assessment
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Major predictors:
 unstable coronary syndrome (recent MI)
 decompensated heart failure (NYHA class IV),
 significant arrhythmias and severe valvular disease.
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Intermediate predictors:
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mild angina (old MI)
compensated heart failure (NYHA class II and III),
Diabetes
renal insufficiency.
Mild predictors:
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advanced age
uncontrolled systemic hypertension,
irregular rhythm
prior stroke
abnormal EKG
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Specific surgical risk factors or procedures expose the
patient to greater or lesser risk of a cardiovascular event.
High-risk procedures :
 emergent, major procedures in the elderly
 major vascular procedures
 long general surgical procedures with anticipated large fluid
shifts and/or blood loss (e.g., pancreatectomy, hepatic resection,
or abdominoperineal resection).
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Intermediate-risk procedures:
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any intraperitoneal or intrathoracic operation
carotid endarterectomy
Orthopedic
head and neck procedures
Low-risk procedures:
 Endoscopic
 breast
 superficial operations.
Assign a class
High, Intermediate, Low risk
 Do noninvasive testing based on risk
 If positive, pursue coronary angiography
if possible
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 Remember, CAD has same risk factors as
PVD (major vascular surgery)
Studies
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EKG
CXR
ECHO -- see flow pattern and valvular
insufficiency
 Dobutamine stress echocardiograph
○ PPV for cardiac event is 20-40%
○ A negative test is 93 to 100% predictive that no cardiac
event will occur.
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Radionuclide Studies – thallium scan – uptake
dependent on myocardial perfusion
PET good for looking at viability of
underperfused areas  determine if capable
to responding to reperfusion
Cardiac Catheterization
Measures pressures and cardiac output
 Shunts
 Determines anatomy
 Coronary Angiography – measures the
degree of disease
 Can determine area of a cardiac valve
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CAD
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1946 IMA to myocardial tunnel  flow low and abandoned
1950’s coronary endarterectomy attempted
1960’s first CABG with SVG at Cleveland Clinic
Primarily ATH being multifactorial with segmental plaque
Sx: angina, MI, CHF, arrhythmias, sudden death
MI is the most common serious complication of CAD
 Modern therapy: early reperfusion with either thrombolytic
therapy or emergent angioplasty
○ lowered the mortality to <5
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CHF may develop after MI
 If late scarring, bypass grafting may not be beneficial
CABG
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CABG may be indicated in patients with chronic angina, unstable angina, or
postinfarction angina, and in asymptomatic patients with severe proximal lesions or
patients with atypical symptoms who have easily provoked ischemia during stress
testing.
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The Veterans Administration Cooperative Study.
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improved survival with surgery in patients with triple-vessel disease and depressed cardiac function.
Unstable Angina
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Surgery was found to be associated with improved survival in patients with triple-vessel disease and in
patients with double-vessel disease with proximal left anterior descending and circumflex artery lesions.
Coronary Artery Surgery Study.
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demonstrated improved long-term survival in patients with left main disease treated with surgical
The European Coronary Surgery Study Group.
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In general, patients with more severe angina (CCS class III or IV symptoms) are most likely to benefit from
bypass
Most patients require urgent revascularization with either percutaneous coronary intervention (PCI) or
CABG.
Acute Myocardial Infarction
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CABG generally does not have a primary role in the treatment of uncompoccurlicated acute MI
PCI or thrombolysis is the preferred method of emergent revascularization
The primary indication for surgery after acute transmural MI is in patients who develop mechanical
complications
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Usually occurs 4 to 5 days after MI,
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Need intra-aortic balloon pump (IABP) placed and undergo emergent repair
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High mortality rates
The left IMA has a 10-year patency rate
of approximately 95% when used as an
in situ graft to the LAD.
 Right IMA may be used to provide a
second arterial conduit as either an in
situ or a free --patency rates are
approximately 70 to 80% at 10 years.
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Saphenous vein grafts
 Targets on the lateral and posterior walls of
the heart.
 The 10-year patency of saphenous vein
grafts is only approximately 65%
○ patency is limited by the development of
progressive intimal hyperplasia and late vein
graft atherosclerosis.
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Radial Artery Graft
 Allen test
 Excellent results
CABG Results
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Mortality 1-3%
Variables that have been identified as influencing operative risk
according to STS risk modeling include:
 female gender, age, race, body surface area, NYHA class IV status, low
ejection fraction, hypertension, PVD, prior stroke, diabetes, renal failure,
chronic obstructive pulmonary disease, immunosuppressive therapy,
prior cardiac surgery, recent MI, urgent or emergent presentation,
cardiogenic shock, left main coronary disease, and concomitant valvular
disease. Perioperative complications include MI, bleeding, stroke,
arrhythmias, tamponade, wound infection, aortic dissection, pneumonia,
respiratory failure, renal failure, GI complications, and multiorgan failure.
Angina completely relieved or markedly decreased in >98% of
patients,.
 Exercise capacity with most patients demonstrating a markedly
improved functional response to exercise secondary to
improved blood flow.
 Late survival is similarly excellent after CABG, with a 5-year
survival of >90% and a 10-year survival of 75 to 90
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 Again depends on risk factors present
CABG versus Stent
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The Bypass Angioplasty Revascularization Investigation Trial.
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Arterial Revascularization Therapies Study Group.
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At 1 year, death, stroke, and MI rates were similar
PCI patients had more recurrent symptoms, 16.8 vs. 3.5% in CABG patients.
The 1-year event-free survival rate was 73.8% with PCI compared with 87.8% with CABG.
New York State Study Group.
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There was no significant difference in 5-year survival
PCI group required more repeat interventions, with 54% within 5 years vs. only 8% for CABG.
In diabetic patients with triple-vessel disease, CABG offered a clear survival advantage at 5
years, 80.6 vs. 65.5% with PCI (P = .003).
Long-term patient survival was superior with CABG rather than stenting in patients with two or
more diseased coronary arteries.17
Summary
When comparing CABG to PCI for the treatment of patients with CAD, results
demonstrate that with appropriate patient selection both procedures are safe and
effective, with little difference in mortality. PCI is associated with less short-term
morbidity, decreased cost, and shorter hospital stay, but requires more late
reinterventions. CABG provides more complete relief of angina, requires fewer
reinterventions, and is more durable. Additionally, CABG appears to offer a survival
advantage in diabetic patients with multivessel disease.
Valvular Heart Disease
Surgical rate increased as CABG rate
declines
 Surgical therapy is now recommended
at a much earlier stage of the disease
process in an attempt to maintain
normal cardiac function long after valve
surgery.
 Surgical Options
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 Replacement
 Repair
Valves
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Mechanical Valves
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excellent flow characteristics
an acceptably low risk of late valve-related complications
extremely low risk of mechanical valve failure
Must anticoagulate
Tissue Valves
 Porcine or bovine
 Low thromboembolism rate
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Homografts
 Uncertain durablity
 Difficulty with preservation
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Autografts
 Pulmonary Valve as Aortic Valve and homograft for PV
(Ross procedure)
Mitral Disease
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Mitral Valve Disease
 Mitral Stenosis
○ almost always caused by rheumatic heart disease
○ Mitral stenosis usually has a prolonged course after the initial rheumatic
infection, and symptoms may not appear for 10 to 20 years.
○ Pulmonary congestion
○ Can develop mural thrombi
○ ECHO diagnostic
○ Balloon valvuloplasty if uncomplicated stenosis
○ Commissurotomy has advantage of addressing nonpliable or calcified
valves
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Valve Repair
 procedure of choice for most patients with MV insufficiency,
 the primary advance in MV repair resulted from work by Carpentier in the
1970s.
 15-year freedom from valve repair failure is >90% in patients with
degenerative mitral insufficiency.
 lower risks of thromboembolic- and anticoagulant-related complications
Mitral Disease
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Mitral Insufficiency
 Degenerative disease is the most common cause of mitral insufficiency
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in the United States,
The basic physiologic abnormality in patients with mitral insufficiency is
regurgitation of a portion of the LV stroke volume into the left atrium.
This results in decreased forward blood flow and an elevated left atrial
pressure, producing pulmonary congestion and volume overload of the
left ventricle.
findings of mitral insufficiency are an apical holosystolic murmur and a
forceful apical impulse
Surgery for any NYHA II (SOB on exertion).
Options
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Repair
Replacement
Annuloplasty device
Commissurotomy
Aortic Disease
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Aortic Stenosis
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Primary causes of aortic stenosis include acquired calcific disease, bicuspid aortic valve, and
rheumatic disease.
Must be reduced to one third its normal cross-sectional area before significant hemodynamic
changes occur.
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Aortic stenosis results in increased myocardial work and progressive concentric LV hypertrophy
with little ventricular dilatation.
The classic symptoms of aortic stenosis include exertional dyspnea, decreased exercise capacity,
heart failure, angina, and syncope.
Once the patient becomes symptomatic, prompt operation is indicated.
Operative Indications
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Moderate aortic stenosis is defined as an aortic valve area between 1.0 and 1.5 cm2
Severe stenosis is defined as a valve area <1.0 cm2
Aortic valve replacement is indicated for virtually all symptomatic patients with aortic stenosis.
Surgery also may be recommended for asymptomatic patients with aortic stenosis who have a
progressive increase in the transvalvular gradient on serial echocardiographic studies, a rapid rise in
diastolic dimensions, a valve area <0.80 cm2, progressive pulmonary hypertension, or right ventricular
dysfunction during exercise testing.
Aortic Insufficiency
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Multiple causes: degenerative, inflammatory, infectious etiology, etc
Produces volume loading strain on the LV
Repair for any NYHA II or above  may be irreversible once symptoms occur
IHSS
Idiopathic Hypertrophic Subaortic
Stenosis
 Varying degrees of subaortic LV outflow
tract obstruction
 Dynamic component usually be
provoked with volume depletion,
vasodilators, or inotropes.
 Operative Techniques
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 Surgical septal myotomy and myectomy
(Morrow technique)
Heart Failure
Transplant the gold standard for endstage heart disease
 CABG for ischemic cardiomyopathy
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 Myocardial viability is the pivotal
Assist Devices
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Balloon Pump
 balloon is inflated during diastole and deflated
during systole.
 Coronary blood flow is increased by improved
diastolic perfusion, and afterload is reduced.
 Generally, the IABP is used for a few days with
minimal morbidity.
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Ventricular Assist Devices
 anytime the heart can no longer support the
oxygen delivery demands of the body
 Bridge to recovery or transplant
 May be “destination” for non transplant
candidates
Atrial Fibrillation
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Cox Maze procedures
 Series of surgical incisions and
reconstruction of the atria such that the
sinus mechanism is preserved
 98% success rate, an extremely low followup neurologic event rate
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Interventional EP Lab
 Ablation
Pacemakers
Pacemakers were first developed in the
1950s, patients attached with power cord
 Now done with transvenous leads that
require only a subcutaneous access
procedure and fluoroscopic control.
 Defibrillators
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 1990s: ICDs created
 Detect and treat ventricular tachyarrhythmias.
 Battery charges a capacitor and delivers jolt of
energy to myocardiuma
Myxoma
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Myxomas
 Sixty to 75% of cardiac myxomas develop in the left atrium
 There is no tendency to invade other areas of the heart, and
distant metastases are rarely reported
 May be completely asymptomatic until it grows large enough to
obstruct the MV or TV or fragments to produce embolispecimen.
The neck of the mass that was obstructing the mitral orifice is
clearly delineated.
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Clinical Manifestations
 Symptoms may include those of MV obstruction; peripheral
embolization; or generalized autoimmune symptoms.
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Treatment
 Surgery should be performed as soon as possible after the
diagnosis has been established due to the inherent risk of a
disabling or fatal cerebral embolus
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Endocarditis
 AV MC site of prosthetic valve complications
 MV MC site of native valve
 TV MC site of IV drug users
 S. aureus for 50%
Anticoagulation?
 ABX Prophylaxis?
 Best conduit for CABG?
 CABG versus Stent?
 A-fib management?
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