Patient Selection & Risk Stratification Soltani GH, MD

Indication for surgeryIndication for surgery  Symptomatic Indications  Prognostic Indications

Ischemic heart diseaseIschemic heart disease Indication Survival benefit Left main coronary artery stenosis (>50%) +++ Proximal stenosis (>50%) of the three major coronary arteries (‘Triple vessel disease’) ++ Stenosis (>50%) of two major coronary arteries including a high- grade stenosis of the proximal LAD + -North America study (CASS) -European study

Aortic valve diseaseAortic valve disease  Symptomatic : Failure of medical treatment to control symptoms.  Prognostic : Depends to lesion

Aortic stenosisAortic stenosis  Prognosis is directly related to symptoms  The comments cause of death in asymptomatic is valve replacement!  The best time to operate is the day before symptoms appear!  Relatively urgent surgery

Aortic RegurgitationAortic Regurgitation  Many are asymptomatic  Difficult to predict future decompensation  Combination of 3 factors for prognostic indication  Severity of regurgitations  Echo evidence of LV dilatation  LV strain pattern on ECG

Mitral valve diseaseMitral valve disease  Symptomatic : Failure of medical treatment  Prognostic : Depends on the lesion

M.S & M.RM.S & M.R  Hemodynamically important  Current thinking :  Treat on prognostic grounds with early  Development of PHT & LV dilatation  Even if symptoms are well controlled on medical treatment

Risk assessmentRisk assessment  Having defined symptomatic & prognostic indication, a method of quantifying operative risk is required

The Stratification model Parsonnet additive riskThe Stratification model Parsonnet additive risk PointsFactor Age ≥80 3Diabetes 3Hypertension 3Morbid obesity 1Female LV function (LVEF %) Good(≥50) Moderate (30-49) Poor (<30) 5LV aneurysm PointsFactor 5 10 Redo procedure First Second 2Preoperative intra-aortic balloon 10Catheter Laboratory complication 10On dialysis 10-15‘Catastrophic state’ 2-10‘Rare condition’ Valve surgery Mitral PA pressure≥ 60mmHg Aortic AV gradient>120mmHg With CABG

The EuroSCOREThe EuroSCORE PointsComments Per 5 years or part thereof over 60 Female Long-term use of bronchodilators or steroids for lung disease Any one or more of following: claudication, carotid occlusion or>50% stenosis, previous or planned intervention on the abdominal aorta, limb arteries or carotids Several affecting ambulation or day-to-day functioning Requiring opening of the pericardium >200 µmoll -1 preoperatively Patient still under antibiotic treatment for endocarditis at the time of surgery Any one or more of the following: VT or VF or aborted sudden death, preoperative cardiac massage, preoperative inotropic support, IABP or preoperative ARF (anuria or oliguria<10 ml h -1 ) General factors age Sex Chronic pulmonary disease Extracardiac arteriopathy Neurological dysfunction Pervious Cardiac surgery Serum creatinin Active endocarditis Critical preoperative state Rest angina requiring IV nitrates until arrival in the anaestethic room Moderate (LVEF 30-35%) Poor (LVEF<30%) Within 90 days Systolic PA pressure>60 mmHg Cardiac factors Unstable angina LV dysfunction Recent myocardial infarct Pulmonary hypertension Carried out on referral before the beginning of the next working day Major cardiac procedure other than or in addition to CABG For disorder of ascending arch or descending aorta Operative factors Emergency Other than isolated CABG Surgery on thoracic aorta Postinfarct septal rupture

EuroScore IIEuroScore II