surgery risks
low- endoscopic, superficial, cataract, breast, ambulatory surgery
-intermediate- intraperitoneal and intrathoracic, carotid endarectomy, head/neck surgery, ortho, prostate
high- aortic and other major vascular surgery, peripheral vascular surgery
patient risks
major-
intermediate-
minor-
cardiac surgery risk assessment
- euroscore
- bayes model
non cardiac surgery risk assessment
- ACC/AHA stepwise approach
- RCRI
- ACS-NSQIP
PCI
- early phase
- granulation and tissue remodeling
- in stent restenosis-peaks 4-12 months
echocardiography
most widely used cardiac diagnostic tool for structural/functional capabilities
-regional wall motion abnormalities- diagnostic for CAD. assess wall thickening
1=normal
2=hypokinetic
3=akinetic
4=dyskinetic
METs
1 met= BMR (3.5ml O2/kg/min)
Valvular lesions
Mitral: normal 4-6 mild stenosis: 1.5-4 mod. stenosis: 1-1.5 severe stenosis: <1 mild regurg: <30% mild-severe: 30-50% Severe regurg: >50% *preload dependent *conduction abnormalities *a. fib
aortic: normal 2.6-3.5
mild: >1.5
moderate: 1-1.5
severe: <1
mild regurg: <30%
moderate: 30-50
severe: >50%
stress echo
add hemodynamic stressor during echo
manifests as wall motion abnormalities
myocardial nuclear scintigraphy
most common diagnostic tool for evaluation of myocardial ischemia and variability in preop.
- radioactive substance is injected. decay of substance around heart is picked up. poorly perfused areas have less decay because agent cant get to it.
- negative study is a strong indicator for no CAD
Cardiac CT
only validated in patients without CAD.
lots of radiation but good for high risk patients to avoid angio
good for eval of prosthetic valves
Cardiac MRI
gold standard for quantitative assessment of biventricular volumes, EF, and mass
gold standard for right side evaluation, chronic thoracic aneurysm evaluation
-highest negative predictive value
coronary angiography/hybrid OR considerations
- angio is gold standard for coronary anatomy and extent/severity of CAD
- lots of contrast- allergy, kidney disease, metformin
- max dose contrast= 4ml/kg
Left sided cath
- femoral artery approach- sheaths introduced- 2 coronary catheters: L/R coronary and L ventricle
- anticoagulate if more than 30min
- complications: MI, VT, embolism, stroke, hematoma, contrast injury
right sided cath
- brachial, femoral, or IJ vein approach
- complications: RBBB, heart block, valve damage
coronary arteriography
- direct assessment of coronary vessel/structure and stenosis
- stenosis= % of diameter reduction 50% is significant
EP lab considerations
- place external cardioversion electrodes
- femoral vessel cannulated
- systemic heparin
- long procedures
- usually MAC
- volatiles depress AV node and accessory pathways (physician needs to see those to know where to ablate)
- avoid sympathetic stimulation
