Indications for Adult Cardiac Surgery

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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]