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]
  • 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]
  • 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]

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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