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Home | Critical Care Compendium | Indications for Adult Cardiac Surgery

Indications for Adult Cardiac Surgery

by Chris Nickson, Last updated March 23, 2016

This page is undergoing revision

OVERVIEW

Common disorders requiring cardiac surgery:

  • coronary artery disease
  • aortic valve disease
  • mitral valve disease

CORONARY ARTERY DISEASE

General – based on:

(1) symptoms
(2) left ventricular function (improves post surgery if reduced)
(3) area of ischaemia
(4) anatomic localisation of coronary artery stenosis

Specific Lesions

(1) left main stem > 50% stenosis
(2) proximal LAD or proximal LCx > 70%
(3) triple vessel disease with >70% stenosis in all 3 coronary territories
(4) significant proximal LAD stenosis with 2 vessel disease

Trials

  • early 1990’s
  • three large MRCT comparing CABG vs medical treatment -> all showed benefit
  • important differences in current practice: patients < 65 years, no arterial grafts, newer medical therapies (statins) not available which have been shown to prolong life after CABG.

Risk Predictors (can use Euroscore)

  • age
  • DM
  • COPD
  • renal failure
  • previous surgery
  • left ventricular dysfunction
  • pulmonary hypertension
  • emergency operation

AORTIC VALVE

Aortic stenosis

  • symptomatic
  • valve area (severe < 1cm2)

Aortic regurgitation

  • NYHA class III or IV symptoms due to AR
  • LVEF <25% or end systolic dimension >60mm or both
  • LVEF 25-50% (controversial)
  • AR with root dilatation

MITRAL VALVE

Mitral stenosis

  • valve area (severe < 1.5cm2) and symptomatic (NYHA III or IV)

Mitral regurgitation

  • symptomatic
  • asymptomatic patients with LV dysfunction
  • acute AF due to MR

References and Links

  • Maganti K, Rigolin VH, Sarano ME, Bonow RO. Valvular heart disease: diagnosis and management. Mayo Clinic proceedings. 85(5):483-500. 2010. [pubmed] [free full text]
  • Nishimura RA, Otto CM, Bonow RO. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology. 63(22):e57-185. 2014. [pubmed] [free full text]
  • Vahanian A, Alfieri O, Andreotti F. Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 42(4):S1-44. 2012. [pubmed] [free full text]

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About Chris Nickson

An oslerphile emergency physician and intensivist suffering from a bad case of knowledge dipsosis. Key areas of interest include: the ED-ICU interface, toxicology, simulation and the free open-access meducation (FOAM) revolution. @Twitter | + Chris Nickson | RAGE | INTENSIVE| SMACC

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