What is the primary recommendation for managing cardiovascular abnormalities in an adult-gerontology or acute complex chronic patient with perioperative risk factors?

Management of Cardiovascular Abnormalities in Perioperative Adult-Gerontology Patients

The primary recommendation for managing cardiovascular abnormalities in adult-gerontology or acute complex chronic patients with perioperative risk factors is to perform a thorough preoperative assessment and coordinate care with cardiovascular specialists at centers experienced in managing complex cardiac conditions, especially for high-risk patients. 1

Risk Assessment and Stratification

• Preoperative assessment should include systemic arterial oximetry, ECG, chest x-ray, transthoracic echocardiography, complete blood count, and coagulation screening 1
• Major perioperative risk indicators include unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and valvular disease 1
• Clinical risk factors include history of heart disease, compensated heart failure, cerebrovascular disease, diabetes mellitus, renal insufficiency, and high-risk surgery 1, 2
• For patients with known or suspected coronary artery disease, use a stepwise approach to risk assessment, including tools like the Revised Cardiac Risk Index or American College of Surgeons NSQIP risk calculator 1
• Patients with poor functional capacity (<4 METs or inability to climb ≥2 flights of stairs) may require additional cardiac testing if results would change perioperative management 1, 2

High-Risk Patient Populations

Certain patient populations should be managed at specialized centers for adult congenital heart disease (ACHD) or cardiovascular care unless surgery is an absolute emergency 1:

• Patients with prior Fontan procedure
• Patients with severe pulmonary arterial hypertension
• Patients with cyanotic congenital heart disease
• Patients with complex congenital heart disease with residua such as heart failure, valve disease, or need for anticoagulation
• Patients with congenital heart disease and malignant arrhythmias
• Patients with left ventricular assist devices (LVADs) 1

Perioperative Monitoring and Management

• For patients with cardiovascular abnormalities undergoing high-risk procedures, obtain ECGs at baseline, immediately after surgery, and on the first two postoperative days 1
• Monitor cardiac biomarkers in high-risk patients and those with clinical, ECG, or hemodynamic evidence of cardiovascular dysfunction 1
• Assess heart function first by echocardiography, then using a pulmonary artery catheter (especially in right heart dysfunction) 1
• Volume status should be assessed by dynamic measurement of hemodynamic parameters 1
• Postoperatively, patients with congenital heart disease may need intensive care unit monitoring even for relatively minor procedures 1

Pharmacological Management

• For myocardial dysfunction, consider low-to-moderate doses of dobutamine and epinephrine, milrinone, or levosimendan, either alone or in combination 1
• For vasoplegia-induced hypotension, use norepinephrine to maintain adequate perfusion pressure 1
• For patients experiencing perioperative ST-segment elevation MI, consider aspirin, beta-blockers, and angiotensin-converting enzyme inhibitors 1
• Statins are associated with fewer postoperative cardiovascular complications and lower mortality in patients with atherosclerotic cardiovascular disease 2
• High-dose beta-blockers administered 2-4 hours before surgery are associated with higher risk of stroke and mortality and should not be routinely used 2

Special Considerations for Congenital Heart Disease

• Adult congenital heart disease patients should be risk-stratified based on anatomy and complexity of their condition 1
• For cyanotic patients, bleeding risk can be reduced by preoperative phlebotomy if hematocrit exceeds 65% 1
• Anesthetic management is critical in cyanotic patients, as a fall in systemic vascular resistance can worsen hypoxia and lead to hemodynamic collapse 1
• Fluid balance is critical in cyanotic and single-ventricle patients and those with heart failure due to occult renal failure 1

Mechanical Support Considerations

• In heart dysfunction with suspected coronary hypoperfusion, an intra-aortic balloon pump is highly recommended 1
• Consider ventricular assist devices before end-organ dysfunction becomes evident 1
• Extra-corporeal membrane oxygenation can serve as a bridge to recovery or decision-making 1

Common Pitfalls and Caveats

• Routine coronary revascularization does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery 2
• Routine perioperative use of low-dose aspirin does not decrease cardiovascular events but increases surgical bleeding 2
• Perioperative MI carries a 40-70% mortality rate and high risk for future cardiac events 1
• The risk of perioperative myocardial infarction and major adverse cardiovascular events is greater in adults aged 75 years or older and in patients with coronary stents 2
• Long operations with hemodynamic instability requiring large-volume fluid replacement are associated with increased perioperative mortality in patients with congenital heart disease 1