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Improved outcomes and advances in surgical techniques have enabled the application of cardiac surgery in patient populations previously considered ineligible for an intervention of this magnitude. During the previous decade, the in-hospital mortality rate for coronary artery bypass surgery (CABG), the most common surgical procedure in the world, declined from 2.8 to 1.6% (43% relative reduction) despite an older and sicker patient population.1,2 Thorough preoperative risk assessment by the medical and surgical team is of critical importance in minimizing perioperative and long-term morbidity and mortality. It also enables physicians to counsel patients and families on what they can expect postoperatively, thus allowing them to make informed decisions regarding the treatment options available to them. This chapter reviews the essential information that the cardiologist and surgeon must collect and review to evaluate a patient for cardiac surgery. This information includes patient and disease characteristics, medications, and surgical considerations that can be integrated into scoring systems to provide a semiquantitative risk assessment (Table 9-1).
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Patient Characteristics and Conditions
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The volume of cardiac surgical procedures in elderly people continues to increase as life expectancy improves and benefits outweigh risks. Although perioperative mortality does not vary significantly by age, 1-year mortality is greater in patients greater than 75 years of age.3 Octogenarians have nearly double the mortality rate compared with younger patients (4.1 versus 2.3%) and more than 60% have at least one nonfatal postoperative complication.4,5 The most prevalent complications include prolonged ventilation in intensive care units, reoperation for bleeding, and pneumonia—all of which result in longer hospital stays.5 A higher proportion of complications occur in elderly patients with low body weight (BMI <23).6 There is evidence that off-pump (OP) surgery using only arterial conduits may confer a survival benefit and improve long-term quality of life.7,8 With improved surgical techniques and careful patient selection, nonagenarians can safely undergo cardiac surgery with a 95% 30-day survival and 93% survival to hospital discharge.9
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Some but not all epidemiologic studies suggest that female gender is an independent predictor of postoperative morbidity and mortality.10–12 Gender differences are present in both traditional CABG and off-pump surgery.13 Several large retrospective cohort studies of patients undergoing CABG ...