What is the recommended cardiac assessment protocol post cardiac surgery?

Post Cardiac Surgery Cardiac Assessment Protocol

The recommended cardiac assessment protocol after cardiac surgery should include early detection and assessment of mechanisms of perioperative cardiovascular dysfunction, beginning with echocardiography to assess heart function, followed by pulmonary artery catheter monitoring especially in right heart dysfunction. 1

Initial Assessment

• Upon arrival to the cardiovascular intensive care unit (CVICU), obtain a comprehensive handoff from the surgical and anesthesia team regarding the procedure performed and any intraoperative events that might impact postoperative course 2
• Perform a thorough physical examination as part of the initial evaluation, avoiding focus on any single issue to get a global picture of the patient's clinical status 2
• Review monitoring and drug delivery lines, drain placements, and identify specific issues to be prioritized 2

Hemodynamic Monitoring

• Assess volume status through "dynamic" measurement of hemodynamic parameters 1
• First evaluate heart function by echocardiography, which is the primary diagnostic tool for cardiac assessment 1
• Use pulmonary artery catheter monitoring for patients with right heart dysfunction or when more detailed hemodynamic data is needed 1
• If volemia and heart function are in normal range but cardiovascular dysfunction persists, vascular dysfunction is likely the cause 1

Surveillance for Myocardial Ischemia and Infarction

• Perform serial ECGs at baseline, immediately after surgery, and daily for the first 2 days postoperatively 1
• Monitor for ST-segment changes which are strong predictors of perioperative myocardial infarction in high-risk patients 1
• Measure cardiac biomarkers (troponin or CK-MB) in patients at high risk or those with ECG or hemodynamic evidence of cardiovascular dysfunction 1
• Note that perioperative myocardial infarction carries a 40-70% mortality rate and requires prompt intervention 1

Management of Myocardial Dysfunction

• For myocardial dysfunction, consider the following treatment options (alone or in combination):
  • Low-to-moderate doses of dobutamine and epinephrine 1
  • Milrinone or levosimendan 1
• For vasoplegia-induced hypotension, use norepinephrine to maintain adequate perfusion pressure 1
• Exclude hypovolemia in patients under vasopressors through repeated volume assessments 1
• Target maintaining cardiac index above 3 L/min/m² throughout the perioperative period 3

Management of Complications

• For heart dysfunction with suspected coronary hypoperfusion, an intra-aortic balloon pump is highly recommended 1
• Consider a ventricular assist device before end-organ dysfunction becomes evident 1
• Extra-corporeal membrane oxygenation (ECMO) may serve as a bridge to recovery or decision-making in severe cases 1
• For patients who experience symptomatic perioperative ST-segment elevation MI, consider angioplasty after weighing risks versus benefits 1

Classification of Cardiac Impairment

• Classify perioperative cardiac impairment based on:
  • Time of occurrence: precardiotomy, failure to wean, post-cardiotomy 1
  • Hemodynamic severity: crash and burn, deteriorating fast, stable but inotrope dependent 1

Long-term Management

• For patients who sustain perioperative MI, evaluate left ventricular function before hospital discharge 1
• Prescribe standard post-infarction therapeutic medical therapy as defined in ACC/AHA acute MI guidelines 1
• Ensure appropriate cardiovascular medical therapy for long-term risk reduction, including:
  • Statin therapy to achieve LDL levels less than 100 mg/dL 1
  • Control of blood pressure to less than 140/90 mm Hg 1
  • Smoking cessation and antiplatelet therapy 1

Common Pitfalls and Caveats

• Avoid focusing on a single issue during initial assessment, as cardiac surgery patients often present with multiple rapidly changing clinical problems 2
• Recognize that failure to detect and rescue patients from potentially reversible complications is a major cause of perioperative morbidity and mortality 2
• Be aware that postoperative arrhythmias are often due to remedial non-cardiac problems such as infection, hypotension, metabolic derangements, and drugs 1
• Do not rely solely on cardiac biomarkers without considering clinical context, as CK-MB can be released from non-cardiac sources in patients with ischemic limbs undergoing aortic surgery 1

By following this structured approach to post-cardiac surgery cardiac assessment, clinicians can optimize patient outcomes by promptly identifying and addressing cardiovascular dysfunction in this high-risk population.