detailed clinical evaluation and analysis of investigations for adult cardiac surgery

1. FOR ADULT CARDIAC SURGERY
Dr Mukesh Godara

2.  Comprehensive evaluation of the patient’s overall
medical condition and comorbidities is essential once
the patient is considered for cardiac surgery.
 Includes detailed history and physical examination,
which may identify cardiac and non-cardiac problems
that might need to be addressed perioperatively to
minimize postoperative morbidity.
 Also helps in identifying new cardiac elements which
may arise since the initial cardiac evaluation.
 A cardiac anesthesiologist should interview and
examine the patient and discuss issues related to
sedation, anesthetic medication, monitoring lines,
awakening after surgery and mechanical ventilation.

3.  History of present illness.
 The nature duration and pattern of patient’s cardiac
symptoms should be briefly summarized to allow
symptomatic classification using either Canadian
classification system for angina or the NYHA system
for both angina and heart failure symptoms.
 History of previous MI/ACS, hospital admissions for
cardiac elements , h/o coronary
interventions(CAG/PTCA), and recent worsening of
symptoms should be asked thoroughly.

6.  Review of the patient’s PRIOR and CURRENT
MEDICATIONS.
 Particular attentions for antiischemic and antiplatelet/
anticogulant medications.

7.  1. ASPIRIN
 Given routinely for the primary and secondary
prevention of cardiovascular disease and also to
patients with ACS.
 Irrversibly acetylates platelet cyclooxygenase,
impairing TXA2 formation and inhibits platelet
aggregation for 7-10 days.
 Advisable to continue aspirin 81 mg daily upto the day
of surgery in ACS patients.
 Benefits by reducing the risk of perioperative MI and
mortality.

8.  2. CLOPIDOGREL
 Theinopyridine that act through an active metabolite.
 Irreversibly modifies the platelet ADP receptor P2Y12 ,
inhibiting ADP mediated activation of the GP IIb/ IIIa
receptor.
 for elective surgeries should be stopped 7 days
preoperatively.
 If clinically indicated emergency surgery should not be
delayed because of clopidogrel but risk of increased
bleeding and requirement of platelet transfusions
should be kept in mind.
 For patients with coronary stents, stopping
clopidogrel increases the risk of stent thromobsis
within first month with BMS and within one year for
DES. So its reasonable to continue the clopidogrel upto
the time of surgery and use platelets for excessive
bleeding.

9.  3. PRASUGREL
 Irreversible antagonism of ADP receptor P2Y12
receptor. 10 times more potent and rapid onset of
action than clopidogrel.
 Must be stopped 7 days before surgery.
 4. TICAGRELOR
 Reversible inhibitor of receptor P2Y12 .
 More rapid onset of action and more pronounced
action than clopidogrel.
 Should be stopped 1-2 days prior to surgery because of
reversible effect and short half life of 7-8 hrs.
 5 CANGRELOR
 Intravenous reversible inhibitor of receptor P2Y12
 Rapid onset of action with short half life of 3-6 minutes
with reversal of effect within 30-60 minutes.

10.  6. HEPARIN
 Given to pt with an ACS before and after catheterization if
urgent surgery is recommended.
 Also used in pt with IABP placed preoperatively and also as a
bridge to surgery in patients taking preoperative warfarin.
 a) un fractionated heparin.
o requires PTT monitoring with a therapeutic range of
approx 50-60 seconds.
o usually stopped about 4 hrs before surgery.
o may be continued in critical coronary artery disease.
o platelet count should be checked on daily basis, if heaprin
is given for several days, to prevent HIT.
 b) LMWH(enoxaparin)
o commonly used in pt with ACS (1 mg/kg SC BD), also for
VTE prophylaxis (40 mg once daily)
o no requirement for blood monitoring.
o Half life of 4.5 hrs
o Should be stopped 18-24 hrs before surgery.


11.  7. FONDPARINUX
 Indirect factor Xa inibitor,
 Half life – 17-21 hrs
 Should be stopped 48 hrs before surgery.
 8 BIVALIRUDIN
 Direct thrombin inhibitor.
 Half life 25 minutes.
 Increases the risk of bleeding for emergency
surgery within 1-2 hrs of administration.

12.  9. WARFARIN
 Usually given to pt with mechanical valves, atrial
fibrillation , h/o VTE or pulmonary embolism.
 Should be stopped 4-5 days prior to surgery.
a) pt with increased risk of thromboembolism
LMWH should be given.
b) if urgent surgery is required with elevated INR
injection of VIT K 5 mg IV may reduce INR in 12-
24 hrs.

13.  10. GLYCOPROTEIN IIb/IIIa INHIBITORS.
 usually continued with heparin post catheterization if early
CABG is to be considered.
o a) Eptifibatide and Tirofiban
should be stopped 4 hrs prior to surgery.
o b) Abxiximab
monoclonal antibody that binds to IIb/IIIa receptors.
half life 12 hrs and platelet function may take 48 hrs to
recover.
 Surgery should be delayed by 24 hrs after abciximab. in case of
emergency surgery risk of significant bleeding is there and
platelet transfusions are effective in producing hemostasis.

14.  11. THROMBOLYTIC THERAPY
 If given for acute evolving NSTEMI ; surgery should be
delayed for 24 hrs.
 For an emergency surgery antifibrinolytic agents
(EACA, tranaxemic acid, aprotinin) and various
clotting factors are necessary to control mediastinal
hemorrhage.
 12. NSAIDs
 Reversible effect on platelet cyclo oxygenase.
 Only need to be stopped a few days before surgery

15.  13. omega-3 fatty acids(fish oils)
 Enhance platelet inhibition
 Flaxseed oil, garlic, vit E, ginkgo preparations and
flavonoids in purple grape juice ; they all have
antiplatelet activity and should be stopped as soon
as possible.
 In PAC one should specifically ask for theses
preparations as they are not usually volunteered
when a list of medications is reviewed.

16.  1. Antiphospholipid syndrome.
 APL antibodies and/or lupus
anticogulants produce a hypercogulable
state that may cause arterial and venous
thrombosis.
 Affect kaolin-activated clotting time(ACT)
so celite ACTs are recommended.

17.  2. factor V leiden mutation or protein C
or S deficiency.
 Usually not identified until the patients suffers a
postoperative thrombotic event.
 If history of these states is present and patient is on
warfarin ; aggressive anticogulation measures should
be taken to reduce the risk of postoperative
thrombosis.
 Preoperative heparinization should be done to keep
INR in therapeutic range.
 For patients with antithrombin III def , FFP or
antithrombin III concentrate may be required to
achieve adequate heparinization during CPB.

18.  Term often applied to patients with a significant
smoking history independent of degree of
respiratory impairment.
 The degree of COPD is best defined by PFTs.
o a. Mild: FEV1 60 -75% of predicted and/or on
chronic inhaled or oral bronchodilator therapy.
o b. Moderate: FEV1 50-59% of predicted and/or
chronic steroid therapy.
o C. Severe: FEV1 <50% of predicted and /or room
or PO2 < 60 torr or PCO2> 50 torr.

19.  Significant COPD especially in elderly pt and those
on steroids is associated with an increased
incidence of prolonged ventilation, sternal wound
complications, longer ICU stays and increased
operative mortality.
 Baseline pulse oximetry should be obtained in
every patient. If oxygen saturation is less than 90%
ABG on room air should be done. These values can
be valuable for comparison with postoperative
values while weaning pt from ventilator.
 Patient's physiologic reserve and functional status
should also be assessed. this clinical decision
becomes more useful in pt with valve disease and
with CHF where it's difficult to determine the
cardiac contribution to abnormal PFTs.

20.  In addition to COPD, pulmonary complications
are more common in pt with active smoking,
advance age, obesity, DM, preoperative cardiac
instability, PAH, history of CVA, productive
cough or lower respirator colonization.
 Active smoking should be stopped at least 4
weeks and preferably 2 month before surgery.
 An active pulmonary or bronchitis process
should be resolved with antibiotics .
Bronchospasm should be treated with
bronchodilator and if severe with steroids.

21.  BNP levels are helpful in differentiating
whether dyspnea is primarily of cardiac origin
or pulmonary origin.
 BNP < 100pg/ml dyspnea mainly of
pulmonary origin
 BNP>500pg/ml dyspnea mainly caused by
decompensated heart failure.
 Pt with chronic high dose amiodarone therapy
are prone to develop pulmonary toxicity and
ARDS after surgery.

22.  A history of heavy alcohol abuse the potential
problems associated with liver dysfunction that
may cause excess intra op bleeding, post op
LIVER dysfunction, agitation and alcohol
withdrawal.
 Prevention of post op delirium tremens with
thiamine, folate, and benzodiazapines should
be considered.
 Bioprosthetic valve should be selected to avoid
post op anticogulation.

23.  Mildly elevated LFT do not require further
evaluation. A common cause this is statins . But a
patient with history of alcohol should assessed
with GI consultation.
 A history of GI bleeding, raised PT/INR , low
serum albumin , low platelet may indicate severe
cirrhosis with portal hypertension.
 Two risk models have been used in cirrhotic pt to
predict outcomes....
o Child-turcotte-pugh (CTP)
o mayo endstage liver disease(MELD) score

26.  DM is associated with more extensive and diffuse
atherosclerotic disease due to metabolic
derangements and a proinflammatory and
prothrombotic state.
 The more severe and uncontrolled the diabetes the
greater the risk of obesity, CHF, PVD, extensive
coronary artery disease and chronic kidney
disease.
 Generally DM is associated with increased
postoperative risk of stroke, infection, renal
dysfunction, increased operative mortality, a
decreased great saphenous vein patency and a
worse long term survival.

27.  NIDDM tend to fare somewhat better with a lower
immediate risk of postop complications.
 Raised HbA1c >7% is a marker of poorly controlled
diabetes in last 3-4 months and had been associated
with more adverse outcomes.
 To optimize Perioperative care, attention should be
paid to diabetic related complications:
o a) pre existing infection must be treated
o b) oral hypo glycemics and insulin are held the
morning of surgery. Target of blood sugar <180 mg/dl
is essential to reduce neurologic morbidity and
infections.

28. o c) in patient with CKD sterile precautions
must be taken during catheterization and
surgery to optimize renal function.
o d) patient taking NPH insulin are at increased
risk of allergic reaction to protamine.
o e) management of post operative hyper
glycemia is an essential element of care and
must be done according to a defined protocol.

29. Blood sugar Regular insulin IV
bolus
Infusion rates
151-200 No bolus 2 units/hr
201-240 4 units 2 units/hr
241-280 6 units 4 units/ hr
281-320 10 units 6units/ hr

30.  Whether present ( TIA) or past ( h/o stroke)
increases the risk of Perioperative stroke.
 Generally carotid non invasive study with ultra
sound imaging and flow velocities measurement
are done.
 Selective screening is limited to patients>65yrs,
those with carotid bruits, TIA, or stroke,
hypertension, PVD, and particularly woman with
left main disease or calcified aorta.
 Carotid angiography is done if further evaluation
is required.

31.  A history of saphenous vein striping and/or ligation or
distal vascular reconstructive procedures warrants non
invasive mapping of lower extremities.
 Doopler assessment of Palmer arch or digital
plethysmography with radial compression can be done
to assess the feasibility of using the radial artery as a
bypass conduit. In that case patient should be informed
regarding the potential complications of radial artery
harvesting.

32.  An active UTI must be treated before surgery.
 In men with history of surgery for prostate
surgery or symptoms suggestive of prostatic
hypertrophy , problems may be encountered
during Foley catheter placement in OT.
 Prolonged post op urinary drainage should be
anticipate d until the pt is fully ambulatory or
until further urologic evaluation is performed.

33.  History of significant ulcer disease or GI bleed
may require further evaluation by endoscopy
especially if there patient will require post op
anticogulation. But invasive test should be
avoided in pt with significant coronary artery
disease.
 Proper assessment of preoperative bowel habit
is necessary for postoperative management.
For example h/o reflux disease or constipation.

34.  The risk of infections is increased if another
infectious source of present in body.
Concurrent infections must be identified and
treated before surgery.
 URI may increase the risk of pulmonary
infections and a bacterial infection must
increase the risk of a hematogenous sternal
wound infection and can seed a prosthetic
valve. Pt at risk of MRSA infections or positive
nasal swabs should receive additional
prophylaxis with nasal mupirocin with use of
vancomycin for Perioperative prophylaxis.

35.  most cardiac medications should be continued upto the
time of surgery.
 Some must be stopped in advance like warfarin ,
angioplasties drugs, metformin and ACE inhibitors.
 Some drugs may require special attention . eg. Steroids,
insulin, alternative antibiotics for antibiotic allergies.
 All antianginals should be continued upto and
morning of surgery
 Diuretics, beta blockers or CCBs can be given
preoperatively. ACE inhibitors and ARBs should be
withheld the morning of surgery.
 Digoxin should be given on the morning of surgery if
being used for rate control.

36.  Patient’s general appearance, mental status and affect
should be evaluated and noted in medical record as
BASELINE for comparison with postoperative period.
 An active skin infection or rash that might be
secondarily infected must be treated before surgery to
minimize the risk of sternal wound infection.
 Dental carries must be treated before surgeries during
which prosthetic material will be placed.
 Carotid bruits, a marker of carotid disease, are present
in 10-15% of significant coronary disease. In all patients
with bruits , carotid non-inavasive studies are required
to assess for high grade unilateral or bilateral disease.

37.  For asymptomatic carotid lesions , first CABG
should be done and than carotid lesions should be
managed .
 For a unilateral carotid stenosis >90%and
presenting with an acute ACS, most surgeons
performing combined CABG-CEA procedure. The
risk of stroke in combined operation for
asymptomatic disease is very low.
 For patients with bilateral carotid disease > 75%
b/l carry a significant risk of stroke during isolated
CABG. So the CEA should be performed first if
cardiac condition permits. If cardiac conditions are
not permissible preliminary carotid stenting or
combined CABG-CEA should be performed.

38.  Bilateral arm blood pressures should be measured.
Differential pressures may identify subclavian
artery stenosis, a contraindication to use of a
pedicled ITA graft.
 The presence of heart murmur needs preoperative
echocardiogram if valvular abnormality had not
been identified during catheterization or had been
developed recently because of new ischemic
events. It may be helpful for valve selection, risk
assessment and informed consent taken
preoperatively rather than being done
peropratively.

39.  An abdominal aortic aneurysm detected upon
palpation should be evaluated by USG. In these
cases IABP placement through femoral artery
should be avoided. Palpation should also be
done to assess the secondary change because of
CHF and valvular diseases for example
hepatomegaly, splenomegaly or signs of
chronic liver failure.

40.  Should be done carefully to diagnose PVD if
present. As PVD is a risk factor for operative
mortality and an independent predictor for
long term survival.
 PVD is often associated with cerebrovascular
disease.
 Weak femoral pulses may be indicative of
aortoiliac disease which may render it
unsuitable for canulation or IABP placements.
 PVD may contribute to poor leg wound
healing.

41.  The presence of varicose veins identifies the
potential problems with conduits for CABG.
 Noninvasive venous mapping should be done
to identify a normal greater saphenous vein.
Lesser saphenous vein distribution should be
inspected and assessment of radial artery
should be done in cases with varicose veins.

42. o A. CBC, PT, PTT, and PLATELET COUNT
 Pt with moderate anemia (hb<10g/dl) have a significant
higher risk of postoperative adverse event as well as
higher mortality.
 Patient with unstable ischemic syndromes should be
transfused to Hct of at least 28%. This is beneficial in
reducing Preoperative cardiac ischemia as well as
reducing the extent of hemodilution during surgery.
 An elevated WBC may be associated with infectious
process.
 Daily platelet count should be checked in the pt
maintained on heparin to diagnose HIT. if suspected
further work up should be done.

43. o B. ELECTROLYTES, BUN, CREATININE,
BLOOD GLUCOSE.
 Pt with serum creat> 1.4 mg/ dl or GFR <
60ml/ min , especially if diabetic, are more
prone to AKI after surgery and have a high
operative mortality. Measures should be taken
to minimize renal toxicity.
 Specific intra operative and post operative
measures should be taken to minimize renal
insult.

44. o C. LIVER FUNCTION TEST
 Should be done baseline in all patients.
 Abnormalities may be suggestive of hepatitis
or cirrhosis.
 Sometimes emergency surgery is indicated in
pt with cardiogenic shock and an acute hepatic
insult with markedly raised liver enzymes. In
these cases there is higher risk of severe hepatic
dysfunction after surgery.

45. o D. Other lab test
 1. TSH:. Levels should be measured preoperatively in
case of clinical suspicion of thyroid dysfunction or there is
a probability of use of prophylactic or therapeutic
amiodarone after surgery.
 2. BNP levels are to differentiate the cause of dyspnea.
Levels are raised in patients with systolic and diastolic
dysfunction. it is associated with postoperative ventricular
dysfunction .
 3. C- reactive protein levels are elevated in infections or
inflammatory processes. An elevated Preoperative
level>10mg/dl is associated with increased incidence of
graft occlusion and also with reduced long term survival
after CABG.

46. o E. Urinalysis
 If the initial urinalysis shows contamination, a
clean-catch specimen with proper cleansing
should be examined. If infection is suspected
culture should be done and antibiotic should
be given for several days before surgery.
 For emergency bypass surgery one or two dose
of gram negative covering antibiotic
Preoperative is sufficient but few days of
treatment should be given in case of valve
surgery.

47. o G. Electrocardiogram
 A baseline ECG is must for comparison with post
op ECGs.
 Evidence of ne ischemia after catheterization or
surgery may warrant reevaluation of ventricular
function or some times a repeat coronary
angiogram.
 Patient being considered for elective surgery with
active ischemia on ECG should be hospitalized
and undergo prompt surgery.
 1. If AF is present it should be rate controlled and
it Duration is to be determined. Rate of conversion
to sinus rhythm after surgery is 80% for pt in AF
less than 6 months but this is less likely in AF with

48.  2. The presence of LBBB raised the risk of CHB
during PA catheter insertion. Advancement of
catheter in PA may be delayed until there chest
is open. LBBB also makes it more difficult to
detect ischemia.
 3. Patients with significant Preoperative brady
cardia, especially if not on beta blocker, may
require pacing after surgery.

49.  I . Echocardiogram
 J. Coronary angiogram
 K. Most test results are acceptable when
performed within 1 month of surgery. But it's
beneficial to have CBC, electrolytes, BUN, and
creatinine checked within few days of surgery.

50.  This defines the requirement of arrangement of
blood for per operative and postoperative blood
transfusion
 Potential need of transfusion can be determined
based upon patient’s blood volume and preop Hb
and Hct levels. More blood transfusions are
required during complex procedures requiring
long durations of CPB.
 Comorbid conditions that increase the need of BT
include older age, urgent or emergent surgeries,
poor ventricular function, reoperations, elevated
INR,IDDM, PVD, elevated creatinine , and
albumin< 4mg/dl, consistant with poor nutrition.

51. BLOOD ARRANGEMENT GUIDELINES FOR OPEN
HEART SURGERY
PROCEDURE PRBC SET UP
Minimally invasive CABG Type and screen
Wt> 70 kg and Hct >35% One unit
Wt <70 kg and Hct <35% Two units
Reoperations Three units
Ascending aortic surgeries Three units
Descending aortic surgeries Six units

52. o A. General considerations
 This is an important part of preop preparation
of patient for cardiac surgery.
 Risk stratification can afford patients and their
families into the real risk of complications and
mortality.
 Documentation in the PAC chart of an
informed- consent discussion is mandatory
prior to any cardiac surgery.

53. o Based on four categories…
 1. patient demographics
 2. patient related comorbidities
 3. cardiac and procedure related factors
 clinical presentation , nature and extent of
disease, associated valve disease, pulmonary
hypertension, and degree of ventricular
dysfunction
 4. preoperative status
 Especially for patient who require emergency
surgery for unstable cardiac disease like
ongoing ischemia, hemodynamic compromise

54.  These factors have been analyzed in several large
databases and numerous risk models have been
designed.
 The most common risk factors in decreasing order of
significance are
a. Emergency surgery
b. renal dysfunction
c. reoperations
d. older age.( >75-80 yrs)
e. poor LVEF( < 30%)
f. female gender
g. left main disease
h. other systemic co morbidities

55.  The most common bedside models for
calculation of individuals operative risk are
1. Parsonnet model
2. Northen new england (NNE) model
3. additive EuroSCORE model
4. Society of Thorasic Surgeons(STS) database
5. CARE score
 Postoperative morbidity can also be predicted
preoperatively by using these models.

57. Low risk : 0-2 points estimated risk =1.3%
Medium risk : 3-5 points estimated risk
=3%

59.  CARDIAC ANESTHESIA RISK EVALUATION SCORE
o 1= stable cardiac disease with no other medical problem
for noncomplex surgery
o 2= stable cardiac disease with one or more controlled
medical problems for noncomplex cardiac surgery
o 3= uncontrolled medical problem or complex cardiac
surgery
o 4 = uncontrolled medical problem and complex cardiac
surgery
o 5= chronic or advance cardiac disease and cardiac surgery
is done as a last hope to save or improve life
o E= emergency surgery. As soon as the diagnosis is made
and OT is available

60.  1. recognize preexisting organ dysfunction or
risk factors for their development
 2. Renal failure
dialysis if required.
optimizing renal function before, during
and after surgery.
 3. prolonged ventilation requirement for
over24 hrs is considered as postoperative
complication. In patients with compromised
pulmonary functions , preoperative treatment
of remediable conditions is essential.

61.  4 . Preexisting cerebrovascular disease. Wheather
symptomatic or not increases the risk of stroke.
Some measures which may help to reduce the risk
of stroke and neurocognitive dysfunction are
o identifying carotid disease in high risk patients
o epiaortic imaging in OT
o cerebral oximetry
o maintaining a high BP on pump
o performing off-pump surgery

62.  5. Medistinal bleeding
 preoperative modification of antiplatelet therapy or
anticogulants, use of antifibrinolytic drugs or
arrangement of FFP or platelet transfusion if required.
 6. Deep sternal wound infections
 treat infection noted preoperativly
 perioperative mupirocin nasal carriers of staph aureus
 prophylactic antibiotics appropriately in OT and
continuing no more than 48 hrs.
 proper invasive line care
 strict control of hyperglycemia

63. Thank you