GREAT LAKES HEART CENTER OF ALPENA

Current review of the literature suggests that PCI before noncardiac surgery is of no value in preventing perioperative cardiac events, except in those patients in whom PCI is independently indicated for an acute coronary syndrome.

there are reports of ACE inhibitors or angiotensin II receptor antagonists being associated with perioperative hypotension and renal impairment.

• if the ACEI or ARB is stopped before surgey, it should be restarted when the patient is euvolemic. 

• preoperative arrhythmias should initiate an evaluation for cardiopulmonary diseases, drug toxicity or metabolic derangements
• asymptomatic ventricular arrhythmias, including nonsustained ventricular  tachycardia is not associated with increased cardiac complications after noncardiac surgery
• treatment of ventricular arrhthmias is warranted only if symptoms arise or if it causes hemodynamic compromise
• electrophysiologic testing and catheter ablation may be indicated to prevent recurrenct arrhythmias in  patients with documented hemodynamically significant or symptomatic arrhythmias
• acute treatment,  including electrical or pharmacological cardioversion, is indicated for hemodynamically significant or symptomatic arrhythmias  
• in atrial fibrillation or atrial flutter, a rate control strategy can be accomplished with beta-adrenergic blockers, calcium channel blockers, or digoxin 
• in patients with chronic or paroxysmal atrial fibrillation before surgery,  bridging anticoagulation,with either low-molecularweight or unfractionated heparin, if the thromboembolic risk assessment warrants
• physicians should not hesitate to initiate prophylactic beta-blocker therapy in patients at increased risk supraventricular or ventricular tachyarrhythmias
• high-grade cardiac conduction abnormalities, i.e., complete atrioventricular block can increase risk and may require temporary or permanent transvenous pacing
• intraventricular conduction delays, esuch as a left or right bundle-branch block, and no history of advanced heart block or symptoms rarely progress to complete heart block perioperatively

• CHF is associated with  poorer outcomes after noncardiac surgery.
• an effort must be made to detect unsuspected CHF by history and physical examination.
• it is also important to identify the cause of heart failure, as this may have beaqring on the risk of death or perioperative heart bfailure.
•  preoperative assessment of LV function may be recommended to quantify the severity of systolic and diastolic dysfunction in .patients with a history or signs of CHF.
• hypertrophic obstructive cardiomyopathy (HCM) poses special problems. These  these patients had a significant incidence of adverse cardiac events, frequently manifested as HF.
• in HCM echocardiographic features are not associated with adverse cardiac events.
• Beta adrenergic agonists should be avoided as they can increase the degree of dynamic obstruction and decrease diastolic filling..

• in patients who are pacemaker dependen, the device should be reprogrammed to VOO or DOO or a magnet should be placed over the device during surgery
• An ICD should have its tachyarrhythmia treatment algorithms programmed off and turned on after surgery to prevent unwanted shocks
• during the time when device therapy has been inactivated, the patient should be monitored continuously for a life-threatening arrhythmia
• minimize the chance of electromagnetic interference by: 1) use of a bipolar electrocautery, 2) the use of short and intermittent bursts of electrocautery at the lowest possible energy levels, 3) maximizing the distance between the electrocautery and the device, 4) placement of the ground patch so as to minimize current flow through the device.
• if emergency cardioversion is required, the paddles should be placed as far from the implanted device as possible and in an orientation likely to be perpendicular to the orientation of the device leads (preferrably in the anterior-posterior position)
• if the pacemaker or ICD was reprogrammed before surgery, it should be programmed back to its original settings after

Pulmonary Hypertension and Congenital Heart Disease

• There are no reported studies that specifically assess the perioperative risk of patients  with pulmonary vascular disease
• with severe pulmonary hypertension and a cardiac shunt, systemic hypotension results in increased right-to-left shunting, leading to acidosis, which can lead to further decreases in systemic vascular resistance
• in women with Eisenmenger syndrome due to a congenital intracardiac shunt, peripartum mortality was reported to be between 30% and 70%; howevert no recent data exist
• patients with congenital heart disease have reduced cardiac reserve in response to stress
• patients receiving primary cardiac repair at a young age may be less prone to postoperative ventricular dysfunction

• severe aortic stenosis is associated with the greatest risk during noncardiac surgery.
• in symptomatic aortic stenosis, elective noncardiac surgery should generally be postponed or canceled pending aortic valve replacement 
• in asymptomatic severe aortic stenosis surgery should be deferred unless the valve has been evaluated within the past  year
• patients with severe aortic stenosis who refuse or are  not candidates for aortic valve replacement, noncardiac surgery is associated with  a mortality risk of approximately 10%
• percutaneous balloon aortic valvuloplasty may be a nreasonable bridge to surgery in hemodynamically unstable patients or in patients whom aortic valve replacement cannot be performed due to  serious comorbid conditions
• in mild - moderate mitral stenosis, ensure heart rate control during the perioperative period to avoid severe pulmonary congestion
• in severe mitral  stenosis severe, patients may benefit from balloon mitral valvuloplasty or open surgical repair before high-risk surgery
• for aortic regurgitation (AR), attention to volume control and afterload reduction is recommended
• if AR is suspected, qualification of the severity is recommended to assist with follow-up and guide therapy 
• the 2 most common caus of mitral regurgitatgion are mitral valve prolapse that results from myxomatous degeneration and functional mitral regurgitation
• patients with  severe mitral regurgitation may benefit from afterload reduction and administration of diuretics to produce maximal hemodynamic stabilization before high-risk surgery
• in mitral regurgitation, a mild reduction of the LV ejection fraction (LVEF) may be a sign of reduced ventricular reserve
• in patients with  atrial fibrillation and at high risk for thromboembolism, preoperative and postoperative therapy with intravenous heparin or subcutaneous lowmolecular- weight heparin may be considered
• in patients with a mechanical prosthetic valve, review the need for endocarditis prophylaxis 
• for minimally invasive procedures (e.g. dental work, superficial biopsies), reduce the international normalized ratio (INR) to the low or subtherapeutic range and resume the normal dose of oral anticoagulation immediately after the procedure
• perioperative unfractionated heparin therapy is recommended for patients at high risk of thromboembolism without anticoagulation .