From the Guidelines
Preoperative clearance for patients with coronary artery disease (CAD) and mitral valve prolapse requires a comprehensive cardiac evaluation before surgery, including coronary angiography if there is a history of CAD, suspected myocardial ischemia, or other specified risk factors, as recommended by the 2014 ESC/EACTS guidelines 1. This evaluation should include a detailed history and physical examination, assessment of functional capacity, electrocardiogram (ECG), and possibly stress testing depending on the patient's symptoms and exercise tolerance.
- Echocardiography is essential to evaluate mitral valve function and severity of prolapse, particularly to assess for regurgitation.
- Patients should continue their cardiac medications including beta-blockers, statins, and antiplatelet agents through the perioperative period, with aspirin typically maintained unless bleeding risk is excessive.
- For patients on dual antiplatelet therapy following coronary stenting, management depends on stent type and placement timing - drug-eluting stents generally require 6-12 months of dual therapy before elective surgery, as suggested by previous guidelines 1.
- Perioperative beta-blockade should be continued if the patient is already taking these medications.
- The anesthesiologist should be informed about the cardiac conditions to guide appropriate monitoring during surgery. The 2014 ESC/EACTS guidelines 1 provide the most recent and highest quality evidence for managing patients with CAD and valvular heart disease, including those with mitral valve prolapse, and should be followed to minimize perioperative cardiac complications.
- Additionally, the ACC/AHA 2007 guidelines 1 emphasize the importance of assessing functional capacity and identifying risk factors associated with increased perioperative cardiovascular risk.
- A comprehensive approach, considering both the cardiac status and the surgical procedure risk, is crucial for optimizing outcomes in these patients.
From the Research
Preoperative Clearance Requirements
To determine the preoperative clearance requirements for a patient with coronary artery disease (CAD) and mitral valve prolapse undergoing surgery, several factors must be considered.
- The patient's overall health and medical history, including the severity of CAD and mitral valve prolapse, must be evaluated 2, 3.
- Preoperative tests such as low-dose multidetector computed tomography coronary angiography (MDCT) or invasive coronary angiography (ICA) may be necessary to assess the presence and severity of CAD 2.
- Echocardiography may also be used to detect mitral valve prolapse and assess left ventricular function 3.
- The patient's coronary artery anatomy must be known preoperatively to avoid damage to the circumflex coronary artery during mitral valve repair 4.
- Combined minimally invasive mitral valve repair and direct coronary artery bypass may be a suitable alternative to sternotomy for patients with significant single-vessel coronary artery disease and severe mitral valve regurgitation 5.
Determinants of Survival
The determinants of survival after surgery for mitral valve regurgitation in patients with and without CAD have been assessed in several studies.
- Mortality and its determinants were found to be significantly different in patients with CAD and mitral valve regurgitation compared to those without CAD 6.
- Preoperative renal dysfunction, high right atrial pressure, ejection fraction less than 45%, and left ventricular end-diastolic volume index greater than 120 ml/m2 were associated with decreased survival in patients with CAD and mitral valve regurgitation 6.
- The type of valve prosthesis and the etiology of valve disease were also found to be independent predictors of survival in patients without CAD 6.