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]