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Albert MA, Antman EM. Preoperative Evaluation for Cardiac Surgery.
In: Cohn LH, Edmunds LH Jr, eds. Cardiac Surgery in the Adult. New York: McGraw-Hill, 2003:235248.

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Chapter 8

Preoperative Evaluation for Cardiac Surgery

Michelle A. Albert/ Elliott M. Antman

THE PHYSICAL EXAMINATION
PREOPERATIVE LABORATORY EVALUATION
????Heparin-induced Thrombocytopenia
????Hypercoaguable Disorders
????Multiple Anticoagulants in the Setting of Failed Percutaneous Intervention
PREOPERATIVE ESTIMATION OF MORBIDITY AND MORTALITY RISK
RISK FACTORS FOR MORBIDITY AND MORTALITY
????Atrial Fibrillation
????Renal Disease
????Age
????Ventricular Dysfunction
????Pulmonary Disease
????Reoperation
????Nutrition and BMI
????Diabetes
????Carotid Artery Disease
????Bradyarrhythmias and Atrioventricular and Intraventricular Block
REFERENCES

?? INTRODUCTION
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Cardiac surgery, including coronary artery bypass grafting and surgery for valvular disease, represents one of the most common classes of surgical procedures performed worldwide. Advances in the percutaneous management of coronary artery disease as well as in cardiac surgical techniques have led to improved outcomes with consequent longer life expectancy for patients. Developments relating to antiplatelet drug therapy, rapamycin-coated stents to minimize restenosis risk, and advanced catheter-guided techniques allow more patients to be treated via percutaneous means, thereby channeling older and sicker patients to coronary bypass grafting surgery.16 Greater numbers of patients with depressed left ventricular function, multiple comorbidities, failed interventional procedures, and prior revascularization operations are now referred for cardiac surgery.79 As a result, preoperative risk assessment is even more critical to ensure the safe performance of cardiac surgical procedures and the achievement of low mortality rates. Furthermore, advances in cardiac surgery utilizing novel approaches such as robotically assisted surgery, off-pump coronary artery bypass graft (CABG) procedures, and minimally invasive valve surgery with robotics extend the operative options for patients.812 Along with the implementation of proper quality surveillance mechanisms, these improvements translate into an improved risk-adjusted mortality for CABG of less than 2% for the general population and 3% to 4% for the Medicare population.1315 This chapter reviews the information essential to the cardiologist and surgeon in the evaluation and management of patients prior to cardiac surgery.


?? THE PHYSICAL EXAMINATION
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The preoperative physical examination is a critical aspect of a patient's evaluation for CABG since the findings can greatly influence perioperative management. During the physical examination, particular attention should be paid to the patient's risk for endocarditis, the presence of aortic insufficiency, the presence of vascular disease, and the neurologic status. Examination of the head, eyes, ears, throat, and teeth for infection is helpful in the assessment of an individual's risk of endocarditis in valvular surgery. Inspection of the patient's skin is helpful in detecting and preventing infection (e.g., the presence of tinea pedis on the lower extremities increases the risk of lower extremity cellulitis). Identifying the presence of an aortic regurgitation murmur is important because regurgitation can worsen during cardiopulmonary bypass and acute left ventricular distention may develop.

The physical examination also helps to identify potential contraindications to the use of an intra-aortic balloon pump, which include aortic insufficiency, severe peripheral vascular insufficiency, abdominal aortic aneurysm, or significant atherosclerosis. Attention should also be paid to the patency of the venous system in the lower extremities since extensive varicosities may necessitate the use of arm veins as conduits; if the latter are needed, then avoidance of intravenous line placement in the arm from which veins will be harvested is necessary. In the event of reoperation, noninvasive imaging of the lower extremities as well as imaging of the left internal mammary artery during cardiac catheterization may be desirable to assess patency of potential conduits.

Since neurologic status may be compromised perioperatively and/or postoperatively, carotid ultrasound should be performed on all patients, and combined endarterectomy/ CABG should be considered in those individuals with a history of prior stroke, severe bilateral stenoses, or contralateral occlusion and in patients with a history of neurologic symptoms that could represent cerebral ischemia.16,17 In addition, perioperative identification of any baseline neurologic deficits provides an important reference in the event of neurofunctional deterioration postoperatively.

Additionally, since women who have had left radical mastectomy can have alterations in thoracic blood flow, patency of the left internal mammary artery may be compromised; the left anterior descending artery then becomes ineffective as a conduit.18

Minimally invasive direct access (MIDA) cardiac surgical procedures are becoming more frequent as innovative surgical techniques evolve. Advantages of MIDA procedures include improvement in morbidity, shorter hospital stay, and less neurologic complications. Table 8-1 outlines the most frequently performed novel cardiac procedures and lists the preoperative considerations for each.


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TABLE 8-1 Novel cardiac surgical techniques

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?? PREOPERATIVE LABORATORY EVALUATION
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Basic laboratory testing prior to cardiac surgery should include a complete blood count, coagulation screen, chemistry profile, stool hematest, evaluation of ventricular function, and assessment of coronary anatomy via cardiac catheterization (Table 8-2). Because heparinization and hemodilution will occur on cardiopulmonary bypass, anemia should be avoided preoperatively and maintenance of a hematocrit above 35% is preferable. The causes of occult bleeding should also be sought and treated. For example, preoperative correction of occult gastrointestinal bleeding detected via hemocult stool testing limits the risk of GI bleeding during heparinization and may also influence the type of prosthetic valve inserted. Additionally, patients with conditions that potentially increase myocardial oxygen demand, such as congestive heart failure, aortic stenosis, and left main coronary artery disease, should be advised against autologous blood donation preoperatively. Evidence of increased risk for bleeding can be assessed via a coagulation screen. Prolonged bleeding time, thrombocytopenia, or increased INR or aPTT may necessitate corrective transfusions preoperatively or even lead to postponement of surgery. Also, a white blood cell count higher than 10,000/?L or white cells in the urine may generate the search for and treatment of potential occult infection.


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TABLE 8-2 Preoperative tests for cardiac surgery

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Electrolyte abnormalities increase the risk of arrhythmias, and should be corrected prior to anesthesia induction. Similarly, attention must be given to abnormal renal and liver function, which can worsen perioperatively and thereby compromise drug clearance. This is particularly true of anesthetics. Furthermore, patients with renal dysfunction may require temporary or even permanent hemodialysis.

Additionally, patients with relative malnutrition as evidenced by a low serum albumin (sepsis and respiratory failure and may need nutritional correction for at least 1 to 2 weeks prior to elective cardiac surgery.

Finally, although thyroid function tests should not be ordered routinely, they are necessary in patients with suspected or confirmed thyroid dysfunction (on replacement therapy) and in individuals who have known arrhythmias, such as atrial fibrillation, who have not undergone thyroid function evaluation. Hyperthyroidism places patients at increased risk of myocardial ischemia, heart failure, vasomotor instability, and poorly controlled ventricular rate during atrial fibrillation. In contrast, hypothyroidism produces a hypometabolic state with resultant slower clearance of anesthetic agents and consequent prolonged ventilatory requirement.

Heparin-induced Thrombocytopenia

Heparin-induced thrombocytopenia (HIT) or "white clot syndrome" is an immune-mediated, potentially life-threatening thrombotic complication of heparin therapy that occurs in 3% to 5% of individuals approximately 5 to 14 days after heparin exposure.19,20 HIT should be suspected in any patient who experiences a 50% or greater decrease in platelet count from baseline or a 30% or greater decrease in platelet count and associated thrombotic complication while on unfractionated heparin for at least 5 days. HIT can occur earlier in patients who are within 3 months of previous exposure to heparin. Thrombocytopenia usually resolves within one week of heparin discontinuation, but thrombotic tendency can persist for up to one month. Though HIT can occur with the use of low molecular weight heparin (LMWH), the incidence and development of thrombosis is much less frequent.21

Antibodies to heparin-platelet factor 4 cause platelet activation and aggregation as well as thrombin formation, resulting most commonly in deep venous thrombosis, pulmonary embolism, or cerebral sinus thrombosis.22 Following CABG, HIT may present as graft occlusion, left atrial thrombus, valvular thrombosis, or pulmonary embolism.23 On average, 25% to 50% of cardiopulmonary bypass patients who receive heparin acquire HIT-IgG, but only approximately 7% develop HIT.24,25

Many surgeons still prefer to use unfractionated heparin (UFH) during cardiopulmonary bypass because of familiarity, the need to employ specialized monitoring when using alternative agents, and the lack of antidotes for alternative agents. Besides the use of lepirudin, an irreversible antithrombin, or argatroban, a reversible direct thrombin inhibitor, reduction of thrombosis during cardiopulmonary bypass in patients with known HIT can be achieved by limiting UFH exposure time or by delaying surgery until 3 months after the patient's UFH exposure.26 Otherwise, after receiving UFH, platelet counts should be monitored every 3 days from day 3 to day 14 of UFH exposure. In patients with HIT, warfarin initiation should be done in the presence of lepirudin or argatroban due to warfarin's association with limb gangrene when used as the sole agent.27

Hypercoaguable Disorders

Management of patients with hypercoaguable syndromes can be especially challenging in the setting of cardiac surgery where the need to control postoperative bleeding is crucial in preventing potentially life-threatening complications such as pericardial tamponade. Common (factor V Leiden, G20210A prothrombin gene) and relatively uncommon (antithrombin deficiency, protein C and protein S deficiency) causes of thrombosis have different risk associations. For example, the relative risk of venous thrombosis in the Caucasian population can range from 2.5 for the prothrombin gene mutation to 25 in the presence of antithrombin deficiency.28 Furthermore, approximately 50% of cases of venous thrombosis associated with these hereditary disorders are provoked by known risk factors such as surgery. Therefore, aggressive prophylaxis with subcutaneous UFH or LMWH is warranted prior to surgery for patients who are not taking long-term anticoagulation.29 In contrast, for those on long-term anticoagulation, the decision to continue treatment for thrombosis in the cardiac surgery setting should be individualized. In general, warfarin therapy can be switched to LMWH 3 to 5 days prior to cardiac surgery. Anticoagulation using UFH as a bridge should be resumed as soon as the bleeding risks associated with cardiac surgery have been stabilized, usually within 2 to 3 days postoperatively. The patients at highest risk for venous thrombosis are those within 3 months of an episode of thrombosis and those with conditions that predispose to the highest risk of thrombosis, such as antithrombin deficiency.28

Patients with antiphospholipid antibody syndrome (lupus anticoagulant/anticardiolipin antibodies, history of arterial or venous thrombosis, and/or recurrent fetal loss) deserve special mention because this syndrome can be associated with valvular heart disease (32% to 36% requiring replacement).3032 Perioperative management, including the choice of prosthetic valve, is challenging and requires a multidisciplinary approach due to the risk of thrombophilia, abnormal prolongation in clotting times, and the presence of thrombocytopenia. During cardiopulmonary bypass, anticoagulation monitoring is difficult using standard means. Therefore, preoperative in vitro testing to identify the most reliable assay for heparin monitoring during cardiopulmonary bypass may be necessary.33 Potential heparin assays include protamine titration, kaolin, and the anti-Xa methods that measure heparin's in vitro effects differently.32

Multiple Anticoagulants in the Setting of Failed Percutaneous Intervention

Advances in cardiology have resulted in the almost standard use of glycoprotein IIb/IIIa inhibitors, aspirin, and intravenous heparin UFH or subcutaneous LMWH in patients with nonST and ST-elevation myocardial infarction (STEMI) who undergo early percutaneous intervention (PCI).1,2 However, prospective, randomized evidence involving patients who have received multiple anticoagulants for PCI who subsequently required urgent or semi-urgent cardiac surgery is lacking. Clinical decisions should therefore be based on the known bleeding risks and pharmacology associated with individual agents, available subgroup analyses, and surgical urgency.

In the PURSUIT trial, patients who received the glycoprotein IIb/IIIa inhibitor eptifibatide within 30 days of CABG did not experience higher rates of bleeding, probably due to the short half-life of the drug.1 However, the CURE trial showed that the antiplatelet agent clopidogrel was beneficial in patients with acute coronary syndromes undergoing PCI but was associated with a concomitant increased risk of major bleeding.34 Though clopidogrel can decrease mortality, it may potentially pose serious problems with major perioperative bleeding (clopidogrel vs. placebo groups: 3.7% vs. 2.7%; relative risk [RR] = 1.38; 95% CI, 1.131.67; p = .001). In further subgroup analysis, there was no significant increase in bleeding after CABG (1.3% vs. 1.1%; RR = 1.26; 95% CI, 0.931.71). The median time between discontinuation of clopidogrel and CABG was 5 days. For those patients who stopped taking clopidogrel within 5 days prior to CABG, the rate of major bleeding was 9.6% in the clopidogrel-treated patients and 6.3% in the placebo group (RR = 1.53, p = .06). However, these studies were not designed to address bleeding complications with CABG, and the surgeon often relies on experience with the respective agents to dictate the timing of cardiac surgery.

Yende et al investigated the effect of clopidogrel on bleeding complications after CABG, and noted that clopidogrel use increased the need for reexploration and blood product transfusion after CABG.35 By contrast, Grubitzsch et al found no significant increase in reexploration rate or transfusion requirement after CABG in patients who had received excessive preoperative anticoagulation.36 Overall, it is presumably safer to have patients wait at least a week after discontinuing these agents before undergoing elective cardiac surgery. One exception may be when clopidogrel is being taken in the context of new stent implantation for coronary artery restenosis. In this instance, the risk of stent thrombosis may outweigh the risk of bleeding complications.

Limited data are available regarding the use of fibrinolytic agents prior to CABG. However, in a subgroup analysis of the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries trial (GUSTO I), patients who underwent PCI or CABG after receiving fibrinolytics had a lower rate (0%) of intracranial hemorrhage than those treated with repeat fibrinolysis (1.3%) or medical therapy (0.5%) (p = .046).37 By contrast, in the Assessment of the Safety of a New Thrombolytic Study (ASSENT 2), no difference in the rate of intracranial hemorrhage was observed among the revascularization, repeat fibrinolysis, and conservative treatment groups.37


?? PREOPERATIVE ESTIMATION OF MORBIDITY AND MORTALITY RISK
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Preoperative risk assessment has important implications for patient well-being, containment of hospital costs, and provision of data to identify perioperative issues in need of improvement. Several scoring systems have been developed to assess perioperative risk, particularly in the setting of isolated CABG. Figure 8-1 shows the most commonly used clinical severity scoring system from the Northern New England Cardiovascular Disease Study Group. The major risk factors for adverse outcome during CABG include advanced age, emergency surgery, history of prior CABG, dialysis dependency, and creatinine of 2 mg/dL or higher.



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FIGURE 8-1 Preoperative estimation of risk of mortality, cerebrovascular accident, and mediastinitis, developed by the Northern New England Cardiovascular Disease Study Group. (Adapted with permission from Eagle KA, Guyton RA, Davidoff R, et al: ACC/AHA guidelines for CABG. J Am Coll Cardiol 1999; 34:1262.)

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Due to the changing profile of patients undergoing cardiac surgery, accurate preoperative risk stratification has become increasingly difficult. Factors affecting outcome data include surgery type, follow-up time, and medical therapy after hospitalization, as well as geographic, cultural, social, and economic issues.38,39 Immer et al compared three different scores (Parsonnet, French, and Higgins scores) used for preoperative risk stratification of postoperative morbidity, mortality, and hospital length of stay for 1299 consecutive patients undergoing CABG and/or heart valve surgery.40 All three scoring systems performed well, with c-statistics between 0.76 and 0.79. The Higgins and French scores were especially useful in predicting postoperative outcome. Both of these scoring systems showed a progressive increase in cardiac risk class with increasing cardiac risk score. Rumsfeld et al examined a nontraditional approach to cardiac surgical risk stratification that involved assessment of a patient's self-perceived health status using the physical component summary (PCS) scores from the preoperative short-form 36 (SF-36) health status survey.41 After adjustment for known clinical risk factors of mortality following CABG, the PCS from the preoperative SF-36 was found to be an independent predictor of mortality such that a 10 point or 1 SD decrement in baseline PCS was associated with a 39% increase in 6-month mortality (95% CI, 1.111.77; p = .006). As noted by the authors, this study may have had a selection bias towards lower risk elective cases and did not determine the predictors of the baseline PCS. While the role of these data in the preoperative evaluation of cardiac surgery patients remains unclear, they illustrate that in addition to physician-determined components of risk stratification, patient self-report may provide a complementary, noninvasive, cost-effective measurement of mortality prediction.


?? RISK FACTORS FOR MORBIDITY AND MORTALITY
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Atrial Fibrillation

Commonly encountered after cardiac surgery, atrial fibrillation occurs in as many as 10% to 40% of patients after CABG and in up to 65% of patients undergoing combined CABG and valve surgery.4245 Atrial fibrillation occurs most frequently within 24 to 48 hours after surgery, and, although usually considered benign and self-limited, it is associated with prolonged hospitalization, hemodynamic instability, and thromboembolization.4649 For example, the risk of stroke increases 3-fold in patients with postoperative atrial fibrillation. Many patients (25% to 80%) spontaneously convert to sinus rhythm within 24 hours.50

The mechanism of atrial fibrillation following cardiac surgery is not well understood, but possible etiologies include multiple wavelet reentry in the atria, rapid firing of an atrial focus, and less likely atrial ischemia.45,51 Preoperative clinical predictors of atrial fibrillation after cardiac surgery include increased age, history of hypertension, male sex, and a previous history of atrial fibrillation and congestive heart failure.43,45,46,52 Less well characterized predictors of postoperative atrial fibrillation include aortic cross-clamp time, pulmonary vein venting, respiratory disease, and prolonged ventilation.45

The prophylactic use of beta-blocker therapy decreases the incidence of postCABG atrial fibrillation by as much as 70% to 80%.53 Preoperative initiation of beta-blocker therapy probably attenuates the high sympathetic tone associated with cardiac surgery. Prophylactic use of calcium channel blockers and digoxin does not reduce the incidence of atrial fibrillation.45 Several studies have demonstrated the efficacy of amiodarone in decreasing the incidence of postoperative atrial fibrillation when started one week prior to surgery and continued until hospital discharge.54,55 Sotalol, a class III antiarrhythmic drug, also reduces the incidence of postoperative atrial fibrillation compared to placebo and half-dose beta blockade.56,57 Additionally, prophylactic continuous atrial overdrive pacing via temporary epicardial wires or from the right atrium also shows promise in decreasing the incidence of atrial fibrillation postCABG.58,59

For patients with persistent atrial fibrillation after cardiac surgery, priority should be given to electrolyte repletion and rate control. While beta blockers are considered first-line therapy, calcium channel blockers such as verapamil and diltiazem are also useful in controlling ventricular rate. Amiodarone is also useful in the provision of rate control, particularly in those individuals who are unable to tolerate beta blockers or calcium channel blockers because of hypotension. Antiarrhythmic therapy is usually reserved for those individuals who have persistent or recurrent atrial fibrillation. Class IA (disopyramide, quinidine, procainamide), IC (propafenone, flecainide), and III agents (sotalol, amiodarone, ibutilide, dofetilide) all have varying degrees of efficacy for conversion of postCABG atrial fibrillation.45 Cardiology consultation is prudent prior to using any of these agents since they are contraindicated in select patient populations and the risk for drug-induced proarrhythmia is high. Electrical cardioversion should be performed if the patient demonstrates hemodynamic instability and in those patients with persistent symptoms or rapid ventricular rate despite optimal drug therapy. Figure 8-2 outlines an algorithm for the prevention and management of atrial fibrillation after cardiac surgery.



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FIGURE 8-2 Algorithm for the prevention and management of atrial fibrillation after cardiac surgery. (Adapted with permission from Maisel WH, Rawn JD, Stevenson WG: Atrial fibrillation after cardiac surgery. Ann Intern Med 2001; 135:1061.)

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Anticoagulation in patients with postoperative atrial fibrillation for 48 hours or more should be individualized. Heparin therapy as a bridge to a therapeutic INR (2 to 3) with warfarin is troublesome because it is associated with higher rates of large pericardial effusion and cardiac tamponade compared to aspirin or placebo.45 Generally, most patients with persistent atrial fibrillation at discharge will spontaneously convert to sinus rhythm within 6 weeks.60

Renal Disease

Acute renal failure develops in approximately 1% to 5% patients after cardiac surgery.61 Morbidity and mortality related to renal disease after cardiac surgery are heavily dependent on comorbid disease. Risk factors for acute renal failure include advanced age, baseline renal dysfunction, left ventricular dysfunction, peripheral vascular disease, clinical signs of poor cardiac function such as pulmonary rales, and the use of an intra-aortic balloon pump.6163 Dialysis is necessary in 1% of patients who develop acute renal failure; the 30-day mortality is almost 64% for those patients with acute renal failure compared to 4.3% for those with normal renal function.61 The VA Continuous Improvement in Cardiac Surgery Program developed a recursive partitioning clinical risk algorithm that performs well across different patient populations.64 It helps to identify individuals who are at high risk of developing acute renal failure (Fig. 8-3).



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FIGURE 8-3 Recursive partitioning analysis of the risk of renal failure after CABG. CrCl = estimated creatinine clearance; LVEF = left ventricular ejection fraction; IABP = intra-aortic balloon pump; PVD = peripheral vascular disease. (Adapted and modified with permission from Fortescue EB, Bates DW, Chertow GM: Predicting acute renal failure after coronary bypass surgery: cross-validation of two risk-stratification algorithms. Kidney Int 2000; 57:294.)

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Age

The prevalence of cardiac surgical procedures in the elderly continues to increase as life expectancy improves and procedural benefits outweigh the risks. Moreover, the outcome of surgical coronary revascularization has progressively improved despite increased numbers of elderly patients and worsened preoperative risk profiles over the past several decades. Operative mortality in patients more than 70 years old still remains higher than in younger patients, with octogenarians having the highest operative risk (Table 8-3).6 Identified risk factors for poor operative outcome include lower BMI, advanced NYHA class, and higher prevalence of diabetes, renal dysfunction, peripheral vascular disease, and previous CABG. Mortality statistics may also vary based on multiple socioeconomic and demographic factors. For example, whereas a study by Zacek et al reported higher mortality in patients who were aged 70 years and older versus those younger than 70 (7.3% vs. 2.3%; p<.005 a canadian study reported>operative mortality declining from 7.2% in 19821986 to 4.4% in 19871991 in the elderly.5,8 The latter study also stratified patients by risk and demonstrated that while the prevalence of high-risk elderly patients increased significantly over time, operative mortality decreased for medium- and high-risk patients. Possible reasons for better outcomes include improved myocardial protection and anesthetic techniques perioperatively, as well as greater use of arterial grafts. However, patients aged 75 years and older tend to have a higher incidence of mental confusion and reduced quality of life compared to their younger counterparts.65


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TABLE 8-3 Operative mortality by age group

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By contrast, younger women have a higher mortality after CABG compared with their male counterparts. Vaccarino et al reported that despite having higher ejection fractions and fewer diseased coronary arteries, women less than 50 years old had in-hospital mortality rates that were 3 times higher than men (3.4% vs. 1.1%).66 Although the reason for this difference is uncertain, the women had more comorbidities compared with men.

Ventricular Dysfunction

Viable myocardium that has not been revascularized in persons with ischemic heart disease and congestive heart failure promotes the development of further functional and myocardial disability.6769 Though poor left ventricular function is considered a major risk factor for cardiac surgery, surgical revascularization improves ventricular function in those individuals with hibernating myocardium.67 For individuals with ejection fractions less than 30%, low cardiac output syndrome and supraventricular arrhythmias are the most common complications, and in this group mortality rates approach 10%.70 However, CABG improves both ventricular function and the 3-year survival rate, making adequate assessment of myocardial viability via thallium reperfusion imaging, positron-emission tomography, or stress echocardiography necessary prior to surgery.67,68,71

Despite advances in surgical techniques, 1% of cardiac surgery patients develop postoperative ventricular dysfunction.72 In these individuals, implantation of ventricular assist devices as either a bridge to recovery or to transplantation can be beneficial, particularly in the bridge to transplant subgroup, often resulting in successful discharge from the hospital.72

Patients with left ventricular dysfunction and valvular disease such as mitral regurgitation or aortic stenosis require special preoperative management. Individuals with mitral regurgitation and heart failure should receive preoperative afterload reduction with angiotensin-converting enzyme (ACE) inhibitors or intravenous sodium nitroprusside to maintain systolic blood pressures in the 90 to 100 mm Hg range. While patients with aortic stenosis and hemodynamically significant cerebral or renovascular disease should not receive the latter therapies, intra-aortic balloon counterpulsation (IABP) may be useful in such subgroups. Intra-aortic balloon support can also be used in the setting of acute mitral regurgitation due to papillary muscle rupture as well as in infarct-related ventricular septal defect. Preoperative IABP use in high-risk patients decreases mortality and shortens ICU stay due to enhanced hemodynamic performance.73

Right ventricular dysfunction also increases perioperative risk and patients should be assessed for pulmonary hypertension (pulmonary artery systolic pressure >60 mm Hg), documentation of a history of inferior myocardial infarction, or chronic tricuspid regurgitation. Right ventricular dysfunction caused by increased pulmonary vascular resistance should be treated with inotropes that have vasodilator properties such as dobutamine (5 ?g/kg/min) and milronone (5 ?g/kg/min). Intravenous nitrates, prostacyclin (0.52.0 ng/kg/min), and nitric oxide (1020 ppm) are also effective agents for lowering pulmonary vascular resistance with resultant improvement in right ventricular function.74

Pulmonary Disease

In patients with chronic obstructive pulmonary disease (COPD), prolonged weaning from mechanical ventilation postoperatively is common if FEV1 is less than 65% of VC or if FEV1 is less than 1.5 L. CABG patients with severe COPD are more likely to develop ventilatory failure and have higher mortality rates than those with mild-to-moderate or no COPD (death: 19% vs. 4% vs. 2%, p = .02).75 Preoperative screening of arterial oxygen concentration on room air can provide guidance in respiratory management postoperatively. The role of preoperative spirometry and perioperative bronchodilators remains unclear in stable patients and cannot be recommended on a routine basis.

Reoperation

Approximately 3% to 20% of patients who undergo CABG will require reoperation within a decade; reoperations represent roughly 20% of CABG operations performed yearly.76 With aging of the population, the number of reoperations is expected to increase. Operative mortality for reintervention is almost two times higher than for the initial procedure, hovering between 1% and 6% in most case series.77,78 Furthermore, emergency reoperations increase the baseline operative mortality rate 4-fold.76 One study demonstrated that reoperations in patients over 70 years old were associated with a 7% operative mortality and 90% survival rate at approximately 2.8 years, suggesting that reintervention in this subset of patients has an acceptable morbidity and mortality profile.79 Preoperative risk factors for reoperation include female sex, a history of diabetes, hypertension, renal insufficiency, hyperlipidemia, smoking, and reduced ventricular function.

Nutrition and BMI

The postoperative hypermetabolic state requires increased nutrition in order to facilitate wound healing and to meet corporal metabolic demands. Consequently, patients who are malnourished preoperatively should receive at least 2 to 4 weeks of intensive nutritional bolstering prior to elective surgery, and all patients should resume an oral diet within 24 hours after uncomplicated surgery. Since perioperative stroke may limit the ability of some patients to protect their airway, a swallowing evaluation is mandatory in this subset of patients. Early enteral feeding is warranted in those individuals who have no contraindications to feeding. Low body mass index (2) and hypoalbuminemia (g/dL) are independently associated with increased risk of morbidity and mortality after cardiac surgery.80 Patients with decreased albumin levels are at increased risk for bleeding, renal failure, prolonged ventilatory support, and reoperation. While obesity is not associated with increased mortality, patients with high percent body fat and poor aerobic capacity are at higher risk for sternal wound infection (OR = 2.3; p<.001 saphenous>vein harvest site infection, and atrial arrhythmias.8082

Diabetes

Diabetes is an important independent risk factor for atherosclerotic heart disease. Although the BARI trial did not evaluate stented patients, it demonstrated that diabetic patients with multivessel disease have greater survival with CABG compared to those who receive PCI.83 Furthermore, Morricone et al showed that although diabetic CABG patients did not have higher mortality rates compared to nondiabetics, diabetics tended to have more renal and neurologic complications, experienced longer ICU stays, required more blood transfusions, and had higher reopening rates.84 Diabetics who underwent valve operations had a 5-fold increased risk of having a major pulmonary complication.

Carotid Artery Disease

Approximately 1% to 6% of persons develop neurologic complications after cardiac surgery.8587 Stroke is the most debilitating of these complications, with an estimated 15,000 victims yearly.87 Carotid artery disease is present in up to as many as 30% of patients who have postoperative strokes. Cerebral microembolization from the arterial tree during CABG is likely the most common culprit. In fact, atherosclerosis of the ascending aorta is an independent predictor of long-term neurologic insult and mortality.88 For patients undergoing CABG, the incidence of carotid artery disease can be as high as 22% (3% in unselected populations), depending on multiple factors including screening method, age, diabetic status, the presence of left main disease or left ventricular dysfunction, female sex, and a history of smoking or prior cerebrovascular attacks.89

Indeed, patients with concomitant carotid and coronary disease often present a management challenge to physicians because they have decreased long-term survival compared to their counterparts who have only coronary disease.89 Generally, perioperative stroke risk is believed to be highest (>5%) in patients with more than 80% unilateral stenosis, bilateral stenoses of at least 50%, and unilateral occlusion with at least a 50% carotid artery lesion on the contralateral side.89 Consequently, all patients who fall into one of these categories should be considered for combined carotid endarterectomy (CEA) and CABG. Several authors report operative mortalities between 0% and 5%, and perioperative neurologic and myocardial events of approximately 3%.8993 At 5 years, over 85% of these patients are stroke-free.9 In selected patients with asymptomatic significant carotid artery disease, CEA results in a lower incidence of subsequent long-term neurologic events.94 Hence, screening of cardiac surgical candidates via carotid artery ultrasound is advisable to enable detection of significant carotid stenoses prior to surgery in those individuals at increased risk of perioperative stroke.

Though the treatment of patients with asymptomatic severe carotid artery stenoses undergoing CABG remains controversial, combined CABG/CEA is recommended in symptomatic patients with carotid artery stenosis. Although perioperative myocardial infarction and mortality are generally higher with combined CABG/CEA than with CABG alone, the former is still preferred in this group.95,96 Similarly, selected asymptomatic patients with unilateral or bilateral high-grade stenoses benefit from combined CABG/CEA due to long-term neurologic protection.9698

The timing of CEA in relation to CABG is institution-dependent; however, there appears to be no demonstrated difference in mortality or morbidity whether CEA is done before or during CABG.99 Carotid artery stenting can also be performed in close proximity to CABG. Potential advantages of carotid artery stenting include minimizing the need for systemic heparinization prior to CABG. At present, stenting can be safely performed 4 weeks prior to CABG. Thus carotid artery stenting might be advantageous in patients with stable carotid and coronary disease, in elderly patients who are at high risk for thoracotomy, and in patients who have concomitant carotid artery disease and single-vessel left anterior descending artery disease for which minimally invasive surgery is planned. Babatasi et al reported 97% procedural success with coronary artery stenting in a series of 36 patients treated with carotid stenting and CABG.100 In this study, CABG was performed within a mean of 24.3 days after carotid artery stenting with no embolizations or deaths and a minor stroke rate of 3.6%; 2 patients developed restenosis at 23?2 months. However, the data regarding CABG/CEA continue to evolve.

Bradyarrhythmias and Atrioventricular and Intraventricular Block

Preoperative temporary transvenous pacemaker wire insertion is recommended in patients with hemodynamic instability and high-grade heart block (third degree or Mobitz II). Permanent epicardial pacing lead implantation should be done intraoperatively for patients undergoing tricuspid valve replacement with a mechanical prosthesis, due to the contraindication of passing a transvenous lead through the latter. For individuals with permanent pacemakers, information regarding patient pacemaker dependency as well as the make, model, and settings of the device should be clearly documented in the medical record. Previously implanted automatic cardioverter-defibrillator devices should be disabled before surgery to minimize inappropriate shocks caused by electrocautery signal sensing intraoperatively. Bedside external defibrillation equipment must therefore be readily available.


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