Circ J 2017; 81: 245 – 267 JCS GUIDELINES doi: 10.1253/circj.CJ-66-0135
Guidelines for Perioperative Cardiovascular Evaluation and Management for Noncardiac Surgery (JCS 2014) ― Digest Version ―
Shunei Kyo; Kazuhito Imanaka; Munetaka Masuda; Tetsuro Miyata; Kiyozo Morita; Tetsuro Morota; Minoru Nomura; Yoshikatsu Saiki; Yoshiki Sawa; Taijiro Sueda; Yuichi Ueda; Kenji Yamazaki; Ryohei Yozu; Mari Iwamoto; Shunsuke Kawamoto; Isamu Koyama; Mikihiko Kudo; Goro Matsumiya; Kazumasa Orihashi; Hideki Oshima; Satoshi Saito; Yoshimasa Sakamoto; Kunihiro Shigematsu; Tsuyoshi Taketani; Issei Komuro; Shinichi Takamoto; Chuwa Tei; Fumio Yamamoto on behalf of the Japanese Circulation Society Joint Working Group
Table of Contents Introduction to the Second Revision∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 245 3. Treatment of Congenital Heart Disease Before I. Outline∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 246 Corrective Surgery∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 255 1. Introduction∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 246 4. Adults With Congenital Heart Disease∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 255 2. Outline of Diagnosis and Evaluation∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 246 5. Aortic Diseases∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 257 3. Outline of General Management∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 248 6. Peripheral Arterial Disease∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 259 4. Prevention of Cardiac Complications During 7. Pulmonary Artery Disease∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 260 Emergency Surgery∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 250 8. Idiopathic Cardiomyopathy∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 260 5. Pregnancy/Delivery and Heart Disease∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 251 9. Arrhythmias∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 261 II. Descriptions∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 252 References∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 262 1. Ischemic Heart Disease∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 252 Appendix∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 266 2. Valvular Heart Disease∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ 253
Introduction to the Second Revision
The first edition of the “Guidelines for Perioperative Car- As the credibility of randomized clinical studies on the diovascular Evaluation and Management for Noncardiac perioperative use of beta blockers, such as the Dutch Surgery” was created in 2002,1 and was revised after five Echocardiographic Cardiac Risk Evaluation Applying years.2 As more and more elderly patients undergo surgery, Stress Echocardiography (DECREASE) study,2a was ques- and techniques for diagnosis and treatment of cardiovas- tioned2b and became a major issue, the American College cular disorders have advanced substantially, the second of Cardiology and American Heart Association revised revision has become necessary. their ACC/AHA guidelines on the perioperative use of In this second revision, the guidelines were revised sub- beta blockers for patients undergoing noncardiac surgery stantially in terms of the positioning of coronary interven- in August 2014. At the same time, the European Society of tions for patients undergoing non-cardiac surgery, especially Cardiology and the European Society of Anesthesiology those using drug-eluting stents (DES), and aortic stent also revised their ESC/ESA guidelines on this matter.3,4 grafting, and how to use these new techniques with con- The guidelines for the use of beta blockers were revised in ventional procedures. Guidelines for other cardiovascular this version according to the above guidelines. disorders were revised to reflect new findings.
Released online January 20, 2017 Mailing address: Scientific Committee of the Japanese Circulation Society, 18F Imperial Hotel Tower, 1-1-1 Uchisaiwai-cho, Chiyoda-ku, Tokyo 100-0011, Japan. E-mail: [email protected] This English language document is a revised digest version of Guidelines for perioperative cardiovascular evaluation and management for noncardiac surgery reported at the Japanese Circulation Society Joint Working Groups performed in 2014 (Website: http:// www.j-circ.or.jp/guideline/pdf/JCS2014_kyo_d.pdf). Refer to Appendix 1 for the details of members. JCS Joint Working Groups: The Japanese Circulation Society, The Japanese Coronary Association, The Japanese Association for Thoracic Surgery, The Japan Surgical Society, The Japanese Society of Pediatric Cardiology and Cardiac Surgery, The Japanese Society for Cardiovascular Surgery, The Japanese College of Cardiology, The Japanese Heart Failure Society, and The Japanese Society of Anesthesiologists ISSN-1346-9843 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: [email protected]
Circulation Journal Vol.81, February 2017 246 KYO S et al.
I. Outline
1. Introduction present guidelines may include many biases.
As the population ages, more elderly patients are undergo- 2. Outline of Diagnosis and Evaluation ing surgery. An increasing number of patients with heart disease are undergoing noncardiac surgery, and guidelines for perioperative cardiovascular evaluation and manage- In order to determine treatment strategies of noncardiac ment for patients undergoing noncardiac surgery have surgery and obtain information necessary to ensure safe become necessary. The Committee on Preparation for the surgery, history taking and physical examination should be “Guidelines for Perioperative Cardiovascular Evaluation performed to identify patients in whom the risk for cardio- and Management for Noncardiac Surgery” was established vascular complications is high, and diagnosis and evaluation in 2001 at the request of the Scientific Committee of the should then be performed. Physicians should at this point Japanese Circulation Society. also consider the long-term risk of cardiovascular disease While the ACC/AHA Guidelines on Perioperative Car- as well. In general, the risk for cardiac complications is diovascular Evaluation for Noncardiac Surgery published high among patients with a marked decrease in exercise in 2007 highlighted the perioperative management of capacity (≤4 metabolic equivalents [METs]), and careful patients with ischemic heart disease,5 our guidelines were evaluation of such patients is often necessary. intended to comprehensively describe ischemic heart disease and other common heart diseases which physicians often ▋2.1 Risk Assessment for Cardiac Complications encounter during noncardiac surgery, and include risk ▋ management during pregnancy and delivery. In the present The risk of cardiac complications during noncardiac surgery guidelines, the evidence and general agreement on the effi- should be assessed on the basis of the type of noncardiac cacy of diagnostic and treatment procedures are classified surgery (Table 1) and severity of underling cardiac disor- into Class I to III to help practitioners use the guidelines ders.5,6 Patients with an active cardiac condition (Table 2)5 efficiently. should be considered to receive treatment for the cardiac condition before noncardiac surgery when they are going Classification of Recommendations to undergo non-urgent noncardiac surgery. Those without Class I: Conditions for which there is evidence for and/ it should be considered to undergo noncardiac surgery first. or general agreement that the procedure/treat- The Revised Cardiac Risk Index (RCRI), a scoring system ment is useful. using 6 factors to predict the risk of cardiovascular com- Class II: Conditions for which there is conflicting evi- plications and cardiovascular death, is useful to assess the dence regarding the usefulness of a procedure/ risk of cardiac complications in patients undergoing non- treatment. cardiac surgery (Table 3).7 Class IIa: Weight of opinion is in favor of usefulness. ▋2.2 Preoperative Evaluation Class IIb: Usefulness is less well established by ▋ evidence. In principle, preoperative cardiovascular evaluation should Class III: Conditions for which there is evidence and be performed using noninvasive techniques. However, general agreement that a procedure/treatment Holter ECG and echocardiography are not useful in evalu- is not useful. ating the risk of perioperative myocardial infarction (PMI). Appropriate techniques must be used, even if they are However, it is quite difficult to conduct prospective ran- invasive. Since the incidence of serious complications of domized clinical studies in patients undergoing surgery, invasive examinations such as cardiac catheterization and who are often in critical condition, and the data from such cervical angiography is about 1%,8,9 such examinations studies are also limited in many countries. Please note that should be reserved for patients in whom the results of the data obtained in this area of study described in the examination will significantly contribute to the improve-
Table 1. Cardiac Risk Stratification for Noncardiac Surgical Procedures Based on the Risk of Cardiac Complications Low (<1%) Intermediate (1% to 5%) High (>5%) Breast surgery Intraperitoneal surgery Aortic and other major vascular surgery Dental surgery Carotid endarterectomy Peripheral vascular surgery Endoscopic procedures Peripheral arterioplasty Ophthalmic surgery Endovascular aneurysm repair Gynecological surgery Head and neck surgery Reconstructive surgery (plastic surgery) Neurosurgery/major orthopedic surgery (hip joints or spine) Minor orthopedic surgery (knee surgery) Lung, kidney, or liver transplantation Minor urological surgery Major urological surgery (Source: Prepared based on Fleisher LA, et al. Circulation 2007; 116: e418 – e499,5 and European Society of Cardiology, et al. Eur Heart J 2009; 30: 2769 – 2812.6)
Circulation Journal Vol.81, February 2017 JCS Guidelines for Perioperative Cardiovascular Evaluation and Management for Noncardiac Surgery 247
Table 2. Active Cardiac Condition Table 3. Revised Cardiac Risk Index Condition Examples Ischemic heart disease (history of myocardial infarction, positive Unstable coronary Unstable or severe angina (CCS Class exercise test, current complaint of ischemic chest pain or use of syndromes III or IV) nitrate therapy, or ECG with Q waves) Recent MI (7 to 30 days after onset) History of heart failure Decompensated HF History of cerebrovascular disease (transient ischemic attack, or (NYHA functional cerebral infarction) Class IV, worsening Insulin therapy for diabetes or new-onset HF) Renal dysfunction (serum creatinine >2.0 mg/dL) Significant High-grade atrioventricular block arrhythmias Mobitz II atrioventricular block High-risk type of surgery (major vascular surgery) Third-degree atrioventricular heart block Cardiovascular Symptomatic ventricular arrhythmias Number of Cardiovascular complications (%) Supraventricular arrhythmias (including risk factors death (%) atrial fibrillation) with uncontrolled (95% CI) ventricular rate (>100 bpm) 0 0.5 (0.2–1.1) 0.3 Symptomatic bradycardia 1 1.3 (0.7–2.1) 0.7 Newly recognized ventricular tachycardia 2 3.6 (2.1–5.6) 1.7 Severe valvular Severe aortic stenosis (mean pressure disease gradient >40 mmHg, aortic valve area ≥3 9.1 (5.5–13.8) 3.6 <1.0 cm2, or symptomatic) CI, confidence interval. (Source: Prepared based on Lee TH, et Symptomatic mitral stenosis (progressive al. Circulation 1999; 100: 1043 – 1049.7) dyspnea on exertion, exertional presyn- cope, or HF) CCS, Canadian Cardiovascular Society; HF, heart failure; HR, heart rate; MI, myocardial infarction; NYHA, New York Heart Association. (Adapted from Fleisher LA, et al. Circulation 2007; (BNP) correlates well with the severity of heart failure, and 116: e418 – e499,5 with permission from the American College of is useful in predicting the occurrence of cardiac complica- Cardiology Foundation and the American Heart Association, Inc.) tions during perioperative10 and medium-term and long- term postoperative11 periods.12 Stress ECG and stress myocardial perfusion imaging, and other techniques com- monly considered noninvasive, may cause death in patients ment of prognosis and results of noncardiac surgery. with severe left main coronary artery stenosis or severe aortic stenosis in rare cases. Recommendations for Coronary Angiography in Patients Undergoing Noncardiac Surgery ▋2.3 Perioperative Monitoring Class I ▋ - Evidence for high risk of adverse outcome based on Although it is important to promptly detect perioperative noninvasive test results cardiac complications in patients undergoing noncardiac - Angina unresponsive to adequate medical therapy surgery, appropriate monitoring should be performed in - Unstable angina selected patients in whom cardiac complications are likely - Equivocal noninvasive test results in patients at high to occur for an appropriate period of time. Excessive use clinical risk and undergoing high-risk surgery of invasive monitoring must be avoided. Class III - Low-risk noncardiac surgery with known coronary ▋▋ 2.3.1 ECG artery disease and no high-risk results on noninvasive ECG monitoring is best performed for patients with testing arrhythmia or coronary artery disease. Although periop- - For screening of patients not undergoing appropriate erative myocardial infarction is a serious complication that noninvasive testing may lead to an early or late death, angina is absent in many - Asymptomatic after coronary revascularization with cases. ST-segment monitoring of more than one lead is excellent exercise capacity recommended. It is preferable that ECG monitoring should - Mild stable angina with good left ventricular function be continued until preoperative drug regimens for cardiac and no high-risk noninvasive test results complications have been completely resumed. ECG moni- - Noncandidate for coronary revascularization owing toring before, during, immediately after surgery, and suc- to concomitant medical illness, or severe left ventricu- ceeding 2 days is a cost-effective strategy. Arrhythmias lar dysfunction during the early postoperative period are often caused by - Undergoing adequate coronary angiography within 5 factors other than problems of the heart. Since supraven- years tricular arrhythmia often disappears spontaneously and - Refusal to consider coronary revascularization heart rhythm returns to sinus rhythm after causal factors have been eliminated, cardioversion is not recommended However, recent advancements in technology, including as a routine procedure for patients with it. those in coronary angiography, have changed the process of diagnosis of cardiovascular conditions. There is little ▋▋ 2.3.2 Blood Pressure pathological significance to a slight increase in cardiotho- Patients at risk for abrupt hemodynamic changes during racic ratio, or a single extrasystole, atrial fibrillation, or noncardiac surgery should be continuously monitored for first-degree atrioventricular block in patients with good blood pressure using an arterial line. Although blood pres- exercise capacity. Unnecessary examinations should be sure, when used as a single measure, does not accurately avoided. The plasma level of brain natriuretic peptide reflect hemodynamic condition and cardiovascular events,13
Circulation Journal Vol.81, February 2017 248 KYO S et al. continuous blood pressure monitoring during a limited block the mechanism to maintain cardiac output in response period of time is indicated for certain types of patients such to reduced intravascular volume. Beta blockers reduce the as those at high risk of perioperative myocardial infarction. incidence rate of perioperative myocardial infarction (PMI), while they elevate the rates of severe hypotension and cere- ▋▋ 2.3.3 Central Venous Line, Pulmonary Artery (Swan- bral infarction. No consensus exists as to the risk or benefit Ganz) Catheter of perioperative beta-blocker therapy. When beta blocker A central venous line is inserted and placed in patients therapy is introduced before noncardiac surgery, the dose whom significant hemodynamic changes can occur during should be adjusted carefully.19 Patients who have been on the perioperative period for inotropic support and rapid beta blockers for a long period of time should continue beta fluid administration. However, central venous pressure blocker therapy during the perioperative period if hemo- provides limited information about hemodynamic condi- dynamics allow, as abrupt interruption of treatment may tions. Monitoring using a pulmonary artery catheter may stimulate sympathetic nerve activity. As the credibility of enable detailed evaluation of hemodynamics in high-risk randomized clinical studies on the perioperative use of beta patients, though there are problems associated with its blockers that supported recommendations in the ACC/ insertion and placement.14–17 As the ACC/AHA guidelines3 AHA guidelines in 20075 and the ESC/ESA guidelines in and the ESC/ESA guidelines4 described in 2014, it is gener- 20096 was questioned, these guidelines were revised in ally considered that the perioperative use of pulmonary August 2014.3,4 artery catheters brings more demerits than merits. Periop- erative use of pulmonary artery catheters is not recom- Recommendations for Perioperative Beta-Blocker Therapy mended as a routine procedure (Class III). in Patients Undergoing Noncardiac Surgery
Circulation Journal Vol.81, February 2017 JCS Guidelines for Perioperative Cardiovascular Evaluation and Management for Noncardiac Surgery 249
Class III the therapeutic range. 1. Initiation of perioperative high-dose beta blockers without titration is not recommended. [Level of (ii) Direct Thrombin Inhibitors and Xa Inhibitors Evidence: B] These novel oral anticoagulants that are indicated for the 2. Preoperative initiation of beta blockers is not recom- treatment of non-valvular atrial fibrillation differ substan- mended in patients scheduled for low-risk surgery. tially in terms of pharmacokinetics, while no studies have [Level of Evidence: B] been conducted to provide evidence on the effect of discon- Level B, Data derived from a single randomized trial or tinuing drug therapy on patients undergoing noncardiac large-scale, non-randomized studies; Level C, Only con- surgery.25 sensus opinion of experts or small-size clinical studies (including retrospective studies and registries). ▋3.2 Management of Anesthesia and Peri- and (Adapted from Kristensen SD, et al. Eur Heart J 2014; 35: ▋ 2383 – 2431,4 with permission from European Society of Postoperative Management Cardiology) ▋▋ 3.2.1 Selection of the Methods and Agents of Anesthesia There are no particular anesthetic methods that yield ▋▋ 3.1.2 Management of Antithrombotic Therapy significant myocardial protection during surgery. The most a. Antiplatelet Drugs important prognostic factors are complications and surgical (i) Aspirin techniques.26 As volatile anesthetics inhibit cardiac contrac- No consensus exists on whether aspirin should be discon- tion and reduce afterload,27 these agents should be used tinued before surgery or not.20,21 It has been suggested that carefully for patients with cardiac diseases. Narcotic anes- aspirin should be discontinued for 7 to 14 days before major thetics have a stable effect on the cardiovascular system but surgery, including superficial surgery with difficulty in con- may inhibit the respiratory system. Recently, intravenous trolling bleeding during surgery,22 and that aspirin should propofol anesthesia has been established as a useful proce- be discontinued only in patients where the risk of bleeding dure. However, long-term, high-dose administration of complications outweighs the risk of cardiovascular events.23 propofol is contraindicated for children.28 Mask anesthesia, when performed by experienced anesthesiologists, is often (ii) Thienopyridines (Ticlopidine, Clopidogrel) safer than local anesthesia, during which respiratory and It is recommended that clopidogrel should be discontinued circulatory management is often difficult. Local anesthesia 5 to 7 days before surgery, and ticlopidine 10 to 14 days in combinations of intravenous anesthetics or analgesics before surgery.24 had been considered safe in the past, but a recent analysis has reported that 30-day mortality is higher in patients (iii) Antiplatelet Therapy for Ischemic Heart Disease anesthetized with this technique.26 Only limited patients Although it depends on the severity of intraoperative are indicated for epidural or spinal anesthesia when they bleeding during noncardiac surgery, it is desirable that are using anticoagulants or have poor cardiac function. patients with ischemic heart disease who are taking aspirin However, ultrasound guided nerve block may be performed continue aspirin therapy before and after noncardiac sur- for patients on anticoagulants, and is safer and produces a gery. As patients who received drug-eluting stents (DES) more consistent analgesic effect than other procedures. are taking more than one antiplatelet drug, and the risk of in-stent thromboembolism increases substantially when they ▋▋ 3.2.2 Perioperative Pain Control discontinue antiplatelet therapy, they are recommended Most cardiac events in patients undergoing noncardiac not to undergo major surgery with the risk of bleeding for surgery occur during the postoperative period. In facilitating 1 year after DES placement (however, it has been reported early ambulation, normalizing blood coagulation, and that the risk of in-stent thromboembolism differs by type preventing postoperative pulmonary embolism, adequate of DES). postoperative pain control is quite important. Patient- controlled analgesia (PCA) is a method with high patient b. Anticoagulants satisfaction, and pain scores achieved with PCA are lower (i) Vitamin K Blockers than with other analgesic methods. For example, epidural When patients on anticoagulant therapy such as those after or spinal anesthesia with narcotics is beneficial in many mechanical valve replacement are at a risk of serious com- respects, and physicians should consider use of this method plications due to discontinuation of anticoagulants before when it is possible. noncardiac surgery, they should be switched to heparin before surgery.22 Specifically, warfarin should be discontin- ▋▋ 3.2.3 Perioperative Nitroglycerin ued 3 to 5 days before surgery, and intravenous or subcu- Perioperative nitroglycerin therapy may be beneficial in taneous heparin therapy should be initiated at a dose of high-risk patients with signs of myocardial ischemia with- 10,000 to 25,000 units/day. In high-risk patients, the heparin out hypotension who have received nitroglycerin,29–32 but dose should be adjusted to achieve an activated partial is contraindicated for patients with hypovolemia or signs thromboplastin time (APTT) of 1.5 to 2.5 times the normal of hypotension. control value. Heparin should be discontinued 4 to 6 hours before surgery, or should be neutralized with protamine ▋▋ 3.2.4 Maintenance of Body Temperature During Surgery sulfate immediately before surgery. In either case, APTT Hypothermia during surgery is an obvious risk factor for should be measured immediately before surgery. After perioperative cardiac events in patients at risk for heart surgery, heparin should be restarted without delay. After disease.33 Active warming to maintain body temperature is the patient’s condition has stabilized, warfarin should be recommended.34 restarted. Heparin should be discontinued when prothrom- bin time international normalized ratio (PT-INR) reaches
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▋▋ 3.2.5 Intraaortic Balloon Pumping tion, and may in fact represent heart failure. The use of intra-aortic balloon pumping (IABP) for the Physicians should carefully examine the ECG for findings prevention of surgical complications is not recommended suggestive of myocardial ischemia, and consider coronary for patients with unstable angina or severe coronary artery artery disease a possible cause of ventricular extrasystole, disease who are going to undergo noncardiac surgery. bradycardia, and/or blocks. When left ventricular hyper- trophy is present, the presence of aortic stenosis or cardio- ▋▋ 3.2.6 Blood Glucose Control myopathy should be suspected. Although the benefit of tight blood glucose control at 90 Chest X-ray should be carefully evaluated for cardio- to 100 mg/dL in the critical care setting had been empha- megaly, pulmonary congestion, and aortic calcification. It sized,35 there is no consensus on the benefit of tight blood is quite important to improve the general condition before glucose control in patients with cardiovascular disorders surgery. Anemia, hypovolemia, poor oxygenation, and who are going to undergo noncardiac surgery.36,37 Recently, peripheral hypoperfusion must be treated to the extent the risk of hypoglycemia is considered to outweigh the possible. benefits of tight blood glucose control. Guidelines in Western countries recommend milder blood glucose control at ▋4.2 Intraoperative Management around 180 mg/dL. ▋ The ECG is often the only continuous monitor available ▋▋ 3.2.7 Venus Thromboembolism during surgery. Since bleeding and evaporation may exac- The use of compression elastic stockings, low-dose heparin, erbate hypovolemia and anemia, patients should be care- low-molecular-weight heparin, warfarin, and/or intermittent fully monitored for myocardial ischemia. When ST change, pneumatic compression, among other measures to prevent hypotension, or frequent arrhythmia occurs, hemodynamics venous thromboembolism during the perioperative period and cardiac function should be evaluated using the ECG of noncardiac surgery are recommended for elderly patients, and transesophageal echocardiography, and appropriate bedridden patients, those with paralysis, those with a history treatment should be given. When heart failure or arrhyth- of thromboembolism, those with malignant tumor, those mia occurs, it is essential to control water balance, electro- undergoing abdominal/pelvic/lower limb surgery, obesity lyte balance, and anemia, if present. Since the incidence of patients, those with varicose vein, those with chronic heart ventricular fibrillation increases when the body temperature failure, those with pelvic/femoral fracture, those with coag- is 34°C or lower, hypothermia should be prevented.40 ulation disorder, those receiving high-dose estrogen, and Patients are especially prone to develop hypothermia during other high-risk patients.38 surgery with large-volume transfusion and/or rapid fluid administration and extensive surgery. It should be noted ▋▋ 3.2.8 Prevention of Infective Endocarditis that rapid transfusion may cause hypocalcemia. When fever of unknown origin develops in a patient implanted with mechanical valves or devices, the patient ▋4.3 Postoperative Management should be assessed for the cause, and receive with preventive ▋ antimicrobial therapy, considering the possibility of infec- Appropriate postoperative management including adjust- tive endocarditis.39 ment of fluid volume is important to prevent cardiac over- load, especially in critically ill patients. Postoperative 4. Prevention of Cardiac Complications hyperglycemia may cause osmotic diuresis and consequent dehydration. Following emergency surgery, water and During Emergency Surgery electrolyte balance are prone to be out of order. If hypoka- lemia is present, patients are more prone to develop atrial Patients who require emergency surgery often have condi- fibrillation and ventricular extrasystole.41 tions that may affect the heart, such as anemia and hypo- Prolonged bed rest after emergency surgery may induce volemia. Physicians must often start emergency surgery venous thrombosis and pulmonary embolism. If a venous without appropriate evaluation of the risk of surgery and line was placed in the femoral vein or leg vein before sur- obtaining information on previous treatment of heart gery, it should be changed to a new position in the upper disease. In this situation, patients are likely to develop extremities after the patient’s condition has stabilized. complications including cardiac complications. Physicians must pay special attention to possible ischemic heart disease, ▋4.4 Injuries to the Heart or Thoracic Great Vessels since emergency surgery is often initiated without perform- ▋ ing coronary angiography, namely, the only method for its Associated With Multiple Trauma definitive evaluation. Thoracic aorta injury accounts for many deaths after blunt trauma, although their frequency among total cases is not 42,43 ▋4.1 Preoperative Management high. Thoracic aorta injury often occurs in the ascending ▋ aorta and the proximal descending aorta. Since patients Especially in patients with trauma, it is often difficult to with ascending aorta injury often fall into catastrophic obtain sufficient information before emergency surgery. It condition rapidly, physicians treat patients mainly with is preferable that physicians be aware of the possibility of injuries of the proximal descending aorta. When chest heart disease. Physicians should assess the presence/absence X-ray reveals a widened mediastinum and a large volume of known risk factors for heart disease whenever possible. of pleural effusion or when echocardiography reveals peri- When arteriosclerotic lesions or other findings known to cardial effusion, CT and transesophageal echocardiography be associated with heart disease are present, physicians should be performed to exclude aortic injury prior to non- should assume that the patient has heart disease and man- cardiac surgery. age them as such. A history of “asthma” is a word of cau- Priority of treatment in patients with multiple trauma
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44,45 depends on individual cases. When the aorta is repaired Table 4. Pregnancy and Delivery in Patients With first, blood loss during extracorporeal circulation will be a Uncorrected Congenital Heart Disease concern, while if noncardiac surgery is performed first, Atrial septal defect No problem in most cases perioperative aortic rupture may develop. When aortic Ventricular septal defect No problem in most cases injury is managed conservatively, the patient should be Patent ductus arteriosus No problem in most cases carefully evaluated to find out conditions requiring aggres- Congenital aortic stenosis Pressure gradient of ≤50 mmHg sive surgical treatment. CT is the most useful method for (No problem if ≤25 mmHg) objective evaluation in such circumstances. Coarctation of the aorta Pressure gradient of 20 to ≤30 mmHg, asymptomatic 5. Pregnancy/Delivery and Heart Disease Pulmonary artery stenosis Pressure gradient of ≤80 mmHg Tetralogy of Fallot Pregnancy and delivery are ▋5.1 Pregnancy and Delivery in Patients With dangerous if hematocrit is ≥60%; ▋ arterial oxygen saturation is ≤80%; Congenital Heart Disease or increased right ventricular pres- Pregnancy and delivery pose no serious threats in women sure had developed or syncope has occurred. who had undergone corrective surgery for simple heart Cyanotic complex cardiac No consensus malformation or tetralogy of Fallot and have New York anomalies Heart Association (NYHA) Class II or better cardiac func- Eisenmenger syndrome Contraindicated tion.46 However, women should be carefully evaluated for Marfan syndrome No expansion of the ascending remaining defects, since heart failure and/or arrhythmia aorta may develop and cyanosis may be exacerbated during pregnancy and delivery.47,48 Table 4 outlines the safety of pregnancy and delivery for women with uncorrected con- genital heart disease. Although cases of pregnancy and delivery in women Table 5. Recommendations for Anticoagulation Therapy with cyanotic complex cardiac anomalies such as complete During Pregnancy in Patients With Mechanical transposition of the great arteries, tricuspid atresia, and Prosthetic Valves univentricular heart who have or have not undergone cor- Weeks 1 through 35 49,50 rective surgeries have been reported, the risk of death Class I and complications including fetus associated with preg- 1. The decision whether to use heparin during the first trimester nancy is quite high in this population. Live birth is rare or to continue oral anticoagulation throughout pregnancy among women with an arterial oxygen saturation ≤85%.51 should be made after full discussion with the patient and her Among women with complete transposition of the great partner; if she chooses to change to heparin for the first trimester, she should be made aware that heparin is less arteries who have undergone the atrial switch operation, safe for her, with a higher risk of both thrombosis and special care should be taken for those with a decrease in bleeding, and that any risk to the mother also jeopardizes function of the anatomical right ventricle, those compli- the baby.58a cated with atrioventricular valve regurgitation, and those 2. High-risk women (a history of thromboembolism or an older- complicated with sinus dysfunction. Data are limited on generation mechanical prosthesis in the mitral position) who choose not to take warfarin during the first trimester should pregnancy and delivery in women following the Fontan receive continuous unfractionated heparin intravenously in procedure. a dose to prolong the mid-interval (6 hours after dosing) In women with Ebstein’s malformation, the type and aPTT to 2 to 3 times control. Transition to warfarin can incidence of complications such as right heart failure, par- occur thereafter. adoxical embolism, and infectious endocarditis depend on Class IIa the severity of tricuspid insufficiency, presence/absence of 1. In patients receiving warfarin, INR should be maintained existing right heart failure, and severity of cyanosis52 of between 2.0 and 3.0 with the lowest possible dose of complications of pregnancy and delivery,53 a number of warfarin, and low-dose aspirin should be added. Class IIb successful pregnancies and deliveries in women with Class IIb Ebstein’s malformation have been reported.54 1. Women at low risk (no history of thromboembolism, newer low-profile prosthesis) may be managed with adjusted-dose subcutaneous heparin (17,500 to 20,000 U BID) to prolong ▋▋5.2 Pregnancy and Delivery in Women With the mid-interval (6 hours after dosing) aPTT to 2 to 3 times Valvular Disease control. Pregnant women with mild or moderate mitral stenosis may After the 36th week receive diuretics and beta blockers to prevent and treat Class IIa congestive heart failure and tachycardia, respectively.55 1. Warfarin should be stopped no later than week 36 and Diuretics should be used carefully, since excessive use of heparin substituted in anticipation of labor. them may cause hypovolemia and result in suboptimal 2. If labor begins during treatment with warfarin, a Caesarian uteroplacental circulation.49,56 Percutaneous mitral valvu- section should be performed. loplasty may be indicated for severe mitral stenosis before 3. In the absence of significant bleeding, heparin can be resumed 4 to 6 hours after delivery and warfarin begun orally. pregnancy. When heart failure not responding to medical therapy develops during pregnancy, physicians should aPTT, activated partial thromboplastin time; INR, international 49 normalized ratio; U, unit; BID, twice a day. (Adapted from ACC/ consider percutaneous mitral valvuloplasty. Pregnancy AHA guidelines for the management of patients with valvular heart and delivery in women with acquired aortic stenosis should disease, J Am Coll Cardiol 1998; 32: 1486 – 1588,58 with permis- be treated similarly to that in those with congenital aortic sion from Elsevier. [http://www.sciencedirect.com/science/article/ stenosis. Mitral insufficiency and aortic insufficiency may pii/S0735109798004549])
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Table 6. Antibiotic Prophylaxis During Labor and Delivery farin, which passes through the placenta, increases the incidences of spontaneous abortion, premature birth, and 1. Standard regimen (Ampicillin, gentamicin, and amoxicillin) stillbirth, and causes fetal malformation in 0 to 20% of Initial dose 30 minutes before procedure: Ampicillin 2 g plus gentamicin mothers receiving warfarin (the average incidence in the 56 1.5 mg/kg (maximal dose 80 mg) IV or IM four most recent reports is 1.6%). The risk of fetal mal- Next dose formation is especially high when warfarin is administered 6 hours after initial dose: Amoxicillin 1.5 g PO (if this is not during weeks 6 to 12 of gestation.56,58 Although heparin possible, repeat the initial-dose regimen 8 hours after initial dose) therapy is considered safe, since it does not pass through the placenta, long-term heparin therapy may cause condi- 2. Allergic to ampicillin, amoxicillin, or penicillin (Vancomycin and gentamicin) tions such as noninfective abscess, osteoporosis, throm- 58 Initial dose bocytopenia, and bleeding. It has been reported that 1 hour before procedure: Vancomycin 1 g IV (over ≥1 hour) thromboembolism occurs in 4 to 14% of patients receiving plus gentamicin 1.5 mg/kg (maximal dose 80 mg) IV or IM adequate anticoagulation therapy with heparin.59–61 Next dose (if necessary) Bioprosthetic valves are believed to be a good option for 8 hours after initial dose: Repeat the initial-dose regimen women who wish to become pregnant, since anticoagulation 3. Low-risk patients (Amoxicillin) therapy is not necessary in patients with such valves unless Initial dose they have a history of atrial fibrillation or thromboembo- 1 hour before procedure: Amoxicillin 3 g PO Next dose lism. However, it is known that bioprosthetic valves dete- 6 hours after initial dose: Amoxicillin 1.5 g PO riorate more rapidly in young patients, and reports have
49 noted that deterioration of bioprosthetic valves is further (Adapted from Elkayam U. 1997, Dajani AS, et al. JAMA 1990; 56,57,61 264: 2919 – 2922,49a with permission from American Medical promoted during pregnancy. Physicians should ade- Association) quately explain to patients the fact that they may have to undergo reoperation earlier as a result of pregnancy.
▋5.4 Prevention of Infection During Pregnancy and often be treated with medical therapy when the patient’s ▋ condition is not severe. Angiotensin converting enzyme Delivery in Patients With Heart Disease (ACE) inhibitors must be avoided during pregnancy, since The incidence of infective endocarditis after uncomplicated these drugs will affect the development of the fetus.49,57 vaginal delivery in women with heart disease is believed to Surgery before pregnancy should be considered when women be low, and it is not generally recommended that patients with severe valvular disease wish to become pregnant.56 in this population receive antibiotic prophylaxis. However, antibiotic prophylaxis during delivery is performed in ▋5.3 Pregnancy and Delivery in Patients With patients with prosthetic valves, those with a history of ▋ endocarditis, those following corrective surgery of congeni- Prosthetic Valves tal heart malformation (depending on condition), those Table 5 shows the recommendations for anticoagulation following shunt surgery, and those with mitral prolapse or therapy in pregnant women with mechanical prosthetic insufficiency.49 Table 6 shows common methods of antibi- valves.58 Both warfarin and heparin may pose the risk of otic prophylaxis.49 bleeding and thrombosis in the mother and the fetus. War-
II. Descriptions
1. Ischemic Heart Disease nary lesions may undergo low-risk noncardiac surgery first in many cases. However, those who are going to undergo Perioperative myocardial infarction (PMI) may develop intermediate- or high-risk noncardiac surgery and are indi- when perioperative stress causes increases in blood pressure cated for cardiac revascularization should be considered and heart rate, resulting in acute coronary occlusion or for revascularization before noncardiac surgery. Procedures prolonged imbalance between myocardial oxygen demand of revascularization should be the same for patients who and supply. As acute coronary occlusion is often caused by receive revascularization only. the rupture of a non-hemodynamically significant athero- The ACC/AHA guidelines and the ESC/ESA guidelines sclerotic plaque,62 patients often show no significant symp- were revised in August 2014 as the credibility of randomized toms of ischemic heart disease before surgery, and do not clinical studies on the perioperative use of beta blockers, exhibit abnormal findings even when a detailed coronary which provided evidence for recommendations in these assessment is performed. Imbalance between myocardial guidelines, was questioned.3,4 oxygen demand and supply is often observed in patients with chronic myocardial ischemia. Recommendations for Coronary Revascularization Before Noncardiac Surgery ▋1.1 Prevention of PMI Class I ▋ - Patients with unstable angina Patients with unstable angina and hemodynamically sig- - Patients with stable angina, and nificant coronary lesions should be treated for the heart left main coronary artery disease, condition before noncardiac surgery, in principle. Patients severe triple-vessel disease, or with stable angina and hemodynamically significant coro- Double-vessel disease affecting the proximal left ante-
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rior descending artery, and low left ventricular ejec- Table 7. Recommendations Regarding PCI and Patient tion fraction (or poor cardiac function) Management Prior to Noncardiac Surgery Class III 1. Dual antiplatelet therapy using aspirin and thienopyridine - Patients with stable angina who are going to undergo (ticlopidine or clopidogrel) is the most beneficial regimen for low-risk noncardiac surgery preventing in-stent thrombosis. It is recommended that, following stenting, especially using drug-eluting stents (DES), patients undergo dual antiplatelet therapy for 12 months. Early discon- Patients who underwent coronary artery bypass grafting tinuation of this regimen significantly increases the risks of (CABG) in the past 5 years may undergo noncardiac sur- in-stent thrombosis, myocardial infarction, and death. gery relatively safely when their clinical symptoms are 2. Physicians should be aware that dual antiplatelet therapy is stable.63 Those receiving aspirin should continue aspirin required after stenting, and consider avoidance of DES therapy during endoscopic procedures. Table 7 lists recom- implantation in patients who cannot complete 12-months mendations for anticoagulant therapy for patients using thienopyridine therapy. Physicians should well consider 64 whether to use DES or not in patients who have or are coronary stents especially drug-eluting stents (DES). suspected to have malignant disease. They are at a risk of acute coronary occlusion even if 3. For patients who are to undergo PCI and who may require they do not have hemodynamically-significant coronary invasive procedures or surgery within 12 months after PCI, legions, but its occurrence during the perioperative period physicians should consider the use of bare metal stents or of noncardiac surgery cannot be predicted. Patients with balloon angioplasty rather than DES implantation. severe atherosclerosis should receive careful perioperative 4. Physicians should fully explain to patients the importance of management considering their risk of PMI to ensure suf- antiplatelet therapy with thienopyridine, and instruct them to consult a physician when they need to discontinue antiplatelet ficient postoperative pain control, which is important to therapy. prevent reactive coronary spasm, maintain stable blood 5. When invasive procedures are performed in patients with pressure using antihypertensive drugs, treat tachycardia, stents on antiplatelet therapy, physicians should be aware that and stabilize plaques using statins. Patients with evidence early discontinuation of antiplatelet therapy after stenting may of coronary spasms should be treated with calcium channel have serious complications, and should carefully discuss with blockers, but excessive antihypertensive therapy should be cardiologists over the optimal treatment strategy. avoided. 6. It is preferable that elective surgery with a high risk of bleeding during and after surgery be avoided during the 12-month period after implantation of DES and at least one month after implan- Recommendations for Aspirin Therapy During the tation of bare metal stents. 21,65,66 Perioperative Period of Noncardiac Surgery 7. When patients with DES must discontinue thienopyridine Class IIa therapy for surgical procedures, they should continue aspirin - Continuation of aspirin therapy during the periopera- therapy whenever possible, and should resume thienopyridine tive period of noncardiac surgery in patients already therapy promptly after surgery. When all antiplatelet agents must be discontinued, it is preferable that patients be treated receiving aspirin with heparin.* *However, there is no evidence of prevention of in-stent thrombosis Recommendations for Statin Therapy During the by heparin therapy in patients receiving DES or bare metal stents, 67,68 Perioperative Period of Noncardiac Surgery and heparin therapy is empirically conducted in many institutions Class I in Japan. PCI, percutaneous coronary intervention; DES, drug- - Continuation of statin therapy during the perioperative eluting stents. (Adapted from Grines CL, et al. Circulation 2007; 64 period of noncardiac surgery in patients already 115: 813 – 818. ) receiving statins - Initiation of statin therapy before high-risk noncardiac surgery. sion, while CABG may be indicated for only limited patients with PMI due to an imbalance between myocardial demand and supply considering their risks comprehensively. ▋▋1.2 Diagnosis of PMI 69 Most PMIs start within 48 hours of surgery. Many 2. Valvular Heart Disease patients do not complain of typical chest pain.70 Only about 10% of patients show typical ST elevation on ECG,71 and ST depression is a common ECG finding. Continuous When cardiac murmur is heard prior to noncardiac surgery, 12-lead ECG monitoring and measurement of myocardial physicians must identify the cause of the murmur, consider biomarkers (e.g., serum creatinine kinase-MB isoenzyme whether the murmur reflects a serious condition or not, (CK-MB), and myocardial troponin) provide useful infor- whether further assessment is needed to investigate its mation.70,72–74 severity, and whether prevention of infectious endocarditis is required. Diastolic murmurs are almost always patho- ▋1.3 Treatment of PMI logically significant, and diagnosis and investigation of them ▋ are required. It is quite rare for functional murmurs with a Cardiologists specialized in the medical treatment of isch- grade ≥III to IV on the Levine scale to be heard, but the emic heart disease should support the treatment of periop- loudness of murmurs depends on body size and does not erative PMI. Treatment with oral aspirin, heparin infusion, accurately reflect the severity of valvular disease. or treatment with nitrates should be considered, and arrhythmias, if present, should be managed appropriately. ▋2.1 Valvular Diseases and Noncardiac Surgery If pump dysfunction develops in the acute phase of PMI, ▋ circulatory support with IABP should be considered. ▋▋ 2.1.1 Aortic Stenosis Emergency percutaneous coronary intervention (PCI) Severe aortic stenosis is one of the most important risk may be effective for the treatment of acute coronary occlu- factors for cardiac complications during noncardiac sur-
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Figure 1. Treatment strategies for noncardiac surgery in patients with aortic stenosis (AS). TAVI, transcatheter aortic valve implan- tation.
gery.75 It is preferable that noncardiac surgery be avoided ▋▋ 2.1.4 Aortic Insufficiency or aortic valve replacement be performed prior to non- In patients with aortic regurgitation of grade II or less, cardiac surgery in patients with symptomatic aortic noncardiac surgery may be performed before cardiac sur- stenosis with a left ventricular-aortic pressure gradient of gery when appropriate measures including the prevention ≥50 mmHg, syncope, anginal pain, and/or left heart failure of infectious endocarditis are taken.81 In patients with aortic (Figure 1).76,77,77a The safety of transcatheter aortic valve regurgitation of grade III or higher and those with clinical implantation (TAVI) and transcatheter aortic valve replace- symptoms, physicians should be aware that the risk of ment (TAVR) has advanced recently, and these techniques noncardiac surgery is, depending on the type of surgery are increasingly considered as effective options for patients performed, often significantly high when performed prior for whom conventional valvule replacement is difficult.78–80 to surgical treatment of aortic regurgitation. Fatal arrhyth- mia may often occur in this patient population, and peri- ▋▋ 2.1.2 Mitral Insufficiency operative management is difficult. Although the risk of No specific measures are required during noncardiac sur- noncardiac surgery varies according to the type of proce- gery in patients with mild or moderate mitral regurgitation dure, it is preferable that surgical treatment of aortic valves and without signs/symptoms of heart failure. However, be performed first before left heart function has significantly antibiotic prophylaxis is needed to prevent infectious endo- exacerbated.82–84 carditis.81 Mitral valve surgery such as valvuloplasty and prosthetic valve replacement should be performed first in ▋▋ 2.1.5 Mitral Stenosis patients with moderate or severe mitral regurgitation and Most noncardiac surgical procedures may be performed in signs/symptoms of heart failure. It should be noted that patients with mitral stenosis with a systolic pulmonary mitral insufficiency often causes a seemingly favorable left artery pressure of ≤50 mmHg or a valve orifice area of ventricular ejection fraction. Perioperative antibiotic ther- ≥1.5 cm2. However, heart rate should be controlled during apy is required to prevent infections not only in patients the perioperative period, since tachycardia may induce with clinically significant mitral valve prolapse but also in serious pulmonary congestion. It is preferable that patients asymptomatic patients in whom echocardiography reveals with severe mitral stenosis undergo percutaneous transcath- findings of mitral regurgitation or thickened valve leaflets.81 eter balloon mitral commissurotomy, or surgical commis- surotomy or mitral valve replacement before undergoing ▋▋ 2.1.3 Tricuspid Insufficiency high-risk noncardiac surgery. Since patients with severe tricuspid insufficiency may exhibit significant hepatic congestion possibly resulting in hepatic ▋▋ 2.1.6 After Prosthetic Valve Replacement disorders such as hepatic cirrhosis, modification of treat- In order to prevent infectious endocarditis during the peri- ment strategies is often required if high-risk noncardiac operative period, antibiotics should be administered to surgery is to be performed. patients with prosthetic valves from the day before noncar-
Circulation Journal Vol.81, February 2017 JCS Guidelines for Perioperative Cardiovascular Evaluation and Management for Noncardiac Surgery 255 diac surgery until laboratory data, such as leukocyte count among those with esophageal atresia,88–93 9 to 12.1% among and C-reactive protein (CRP), normalize, for example, 7 those with anal atresia,88 13.9 to 45.5% in those with exom- days after surgery.81 Anticoagulation therapy should be phalos,88 17.9 to 33% in those with duodenal atresia,88,93–95 adjusted according to individual patient condition, consid- and 14 to 25% in those with diaphragmatic hernia.96 Chil- ering the effects of anticoagulants that have been decreased dren born with conditions requiring surgical treatment in dose and the effects of heparin initiated during the peri- immediately after birth should be evaluated with echocar- operative period. Although patients with prosthetic valves diography. used to discontinue anticoagulation therapy for about 3 Although the methods of surgical correction of anal days prior to less invasive procedures (such as dental treat- atresia and intestinal atresia/stenosis are well established, ment and surface biopsy), it is becoming a common practice the mortality rates of neonates and infants with large exom- that anticoagulation therapy is continued for less invasive phalos and diaphragmatic hernia are still high. In such procedures such as dental treatment. Perioperative heparin infants, it is quite difficult to perform surgical correction of therapy is recommended for patients in whom the risk of heart disease during early infancy.94 In children with esoph- bleeding is high when receiving oral anticoagulants and the ageal atresia and heart disease, correction of esophageal risk of thromboembolism is also high in the absence of atresia is often performed first. However, no consensus has anticoagulant (e.g., patients with a mitral valve prosthesis been reached regarding the timing of heart surgery (before are to undergo major surgery).24 or after correction of esophageal atresia) or the strategy of treatment for esophageal atresia (one- or two-stage correc- ▋2.2 Treatment of Valvular Disease Before tive surgery). ▋ In neonates with congenital heart diseases that increase Noncardiac Surgery pulmonary blood flow, surgical correction of noncardiac In general, patients with asymptomatic valvular disease disease may be performed during the first several days of may undergo low- or intermediate-risk noncardiac surgery life, during the period when pulmonary vascular resistance safely. Cardiac surgery is the only option available for remains high, while in neonates with congenital heart patients with severe valve insufficiency. Catheter balloon diseases that decrease pulmonary blood flow, noncardiac valvuloplasty for the treatment of severe mitral stenosis is surgery may be performed when cyanosis has improved by effective in appropriately indicated patients.85,86 Patients treatment with prostaglandin (PG) E1 (0.05 to 0.1 mcg/kg/ complicated with atrial fibrillation or left atrial thrombosis min) to a stable hemodynamic condition. No consensus and those with particularly severe valvular disease need exists regarding treatment strategy or the order of cardiac mitral valvular replacement. Indications of TAVI for the and noncardiac surgeries in patients with complex heart treatment of aortic stenosis are expected to be expanded disease who exhibit cyanosis and increased pulmonary further as a rational treatment option to be performed blood flow. before noncardiac surgery. Many types of congenital heart diseases can be diagnosed with echocardiography, and cardiac catheterization and/or angiography is rarely required. ▋▋2.3 Management of Patients With Valvular Disease During Noncardiac Surgery ▋3.2 Young Children In patients with valve regurgitation, low peripheral vascular ▋ resistance is important. As hypertension is harmful, vaso- Baum et al reported that, in children ≥1 year of age, the dilators should be used if necessary. On the other hand, mortality after noncardiac surgery was slightly higher in patients with severe valve stenosis are often unable to those with cardiac disease, though the difference was not accommodate hemodynamic changes due to fluid overload. significant.87 Pulmonary hypertension (PH) and severe cya- Volume overload induces congestive heart failure, while nosis and so on are considered as risk factors for mortality excessive dehydration may cause circulatory collapse. Water after noncardiac surgery, though no evidence has been balance should be managed strictly, especially in patients obtained for this. Clinical experience has suggested that with aortic and mitral stenoses regardless of the severity of children following palliative surgeries such as shunt surgery valve lesions. Since arrhythmia often occurs in patients with and the Glenn procedure can tolerate noncardiac surgery valvular diseases, appropriate antiarrhythmic therapy and well. When anesthetic procedures requiring mechanical heart rate control play key roles during the perioperative ventilation are performed, prompt extubation may be pref- period. erable for ensuring favorable hemodynamics.
3. Treatment of Congenital Heart Disease 4. Adults With Congenital Heart Disease Before Corrective Surgery ▋▋4.1 Cardiovascular Evaluation Prior to Noncardiac The mortality after noncardiac surgery in neonates and Surgery infants with congenital heart disease is about twice that in Patients with congenital heart disease planned to undergo those without it,87 and it has been reported that the presence noncardiac surgery should be evaluated for history of car- of congenital heart disease significantly increases the risk diac surgery and the procedures used, presence/absence of mortality even after minor noncardiac surgery.87 and type of persistent heart lesions, complications and sequelae of heart disease, clinical course after heart surgery, ▋3.1 Noncardiac Surgery Commonly Conducted and current condition. In patients planned to undergo low- ▋ risk noncardiac surgery as defined in the ACC/AHA Guide- During Neonatal and Infancy Period lines, routine preoperative evaluation is sufficient.5,6 When The prevalence of heart disease in neonates is 13.2 to 43% high- or intermediate-risk noncardiac surgery is planned,
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Table 8. Cardiac Risk Factors in Adult Patients With patients should be evaluated for cardiovascular abnormality Congenital Heart Disease in detail. If the results are poor, cardiac surgery or catheter Major risk - Severe pulmonary hypertension, including intervention prior to noncardiac surgery may be considered. factors Eisenmenger syndrome - Significant persistent lesions followingrepara- tive surgery (e.g., patients positively indicated ▋▋4.2 Cardiac Risk Factors During the Perioperative for reoperation or catheterization) Period5,97 - Decompensated heart failure, NYHA Class III or IV Table 8 lists common risk factors in adult patients with - Severe systemic ventricular dysfunction, EF congenital heart disease. <35% - Severe hypoxemia (untreated cyanotic heart disease, following palliative surgery) ▋▋4.3 Examinations Used in Preoperative Evaluation - Severe arrhythmia (those with arrhythmia not responding to drug therapy, and those indi- of Risk Factors cated for catheterization or pacing) All patients with congenital heart disease require preopera- Intermediate - Moderate persisntent lesions following repar- tive evaluation with 12-lead ECG, chest X-ray, and echo- risk factors ative surgery cardiography. While arterial blood gas analysis, pulmonary - Compensated heart failure - Following Fontan operation ventilation/perfusion scintigraphy, and Holter ECG may - Following palliative surgery (hypoxemia is be necessary in some cases, exercise stress testing and car- present) diac catheterization are indicated for only a small number Mild risk - Congenital heart disease not requiring repair of patients. factors - Patients after cardiac repair in whom continued treatment is not required - Arrhythmia currently treated with oral drugs ▋▋4.4 Problems Following Corrective Surgery NYHA, New York Heart Association; EF, ejection fraction. (Source: Following corrective surgery for acyanotic congenital heart Prepared based on Warnes CA, et al. Circulation 2008; 1118: e714 – e833.97) disease, patients may experience embolism secondary to atrial arrhythmia/fibrillation; congestive heart failure due to a residual shunt; severe PH; mitral insufficiency/stenosis or left ventricular outflow obstruction following correction of atrioventricular septal defect; and restenosis of repaired Table 9. Cardiac Conditions Associated With Endocarditis aortic coarctation, among other conditions. (Endocarditis Prophylaxis Recommendations by Patients born with cyanotic complex cardiac anomaly the American Heart Association) may often require reoperation at a later age even if they are Endocarditis prophylaxis recommended treated with corrective surgery. Depending on the procedure High-risk category of the corrective surgery, patients may exhibit characteristic - Prosthetic cardiac valves, including bioprosthetic and homograft hemodynamic changes for which special management may valves be needed during noncardiac surgery. Patients with the - Previous bacterial endocarditis conditions listed in Table 8,97 valvular regurgitation, or - Complex cyanotic congenital heart disease (eg, single ventricle serious arrhythmia must be treated especially carefully. states, transposition of the great arteries, tetralogy of Fallot) Patients with following conditions need special care: for - Surgically constructed systemic pulmonary shunts or conduits patients after atrial switch operation, vena cava obstruction, Moderate risk category pulmonary venous stenosis, right ventricular dysfunction - Most other congenital cardiac malformations (other than above which acts as systemic ventricle. For patients after atrial and below) switch operation, pulmonary artery stenosis. Patients who - Acquired valvar dysfunction (eg, rheumatic heart disease) had undergone Fontan operation are prone to heart failure. - Hypertrophic cardiomyopathy About 10 years after the Fontan operation, patients are - Mitral valve prolapse with valvar regurgitation and/or thickened prone to develop supraventricular arrhythmias, thrombo- leaflets embolism, protein-losing gastroenteropathy, hepatic con- Endocarditis prophylaxis not recommended Negligible-risk gestion, hepatic dysfunction, decrease in cardiac function, category (no greater risk than the general population) or other abnormal conditions, and thus require careful - Isolated secundum atrial septal defect management. - Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 months) ▋▋4.5 Problems With Uncorrected Congenital Heart - Previous coronary artery bypass graft surgery Disease - Mitral valve prolapse without valvular regurgitation - Physiologic, functional, or innocent heart murmurs No special perioperative management is required for non- - Previous Kawasaki disease without valvular dysfunction cardiac surgery in patients with congenital heart disease not indicated for surgery such as small atrial or ventricular - Previous rheumatic fever without valvular dysfunction septal defect and acyanotic tetralogy of Fallot. Many - Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators patients with large uncorrected left-to-right shunt exhibit Eisenmenger syndrome, and the risk of noncardiac surgery (Adapted from Dajani AS, et al. Circulation 1997; 1997: 96: is quite high in these patients. Patients with cyanosis must 358 – 366,98 with permission from American Heart Association.) be carefully managed for hypoxemia, polycythemia, pre- vention of visceral disorder, brain abscess, and infectious endocarditis.
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▋▋4.6 Important Aspects of Perioperative Table 10. Items for Assessment of Aortic Aneurysm Management 1. Assessment of aortic aneurysm Perioperative management of patients with a history of - Maximal diameter congenital heart disease who are undergoing noncardiac - Location/growth surgery is performed mainly to prevent heart failure, hypox- - Shape emia, and arrhythmias. Selective pulmonary vasorelaxants - Changes over time are effective in patients with right ventricular failure. It is 2. Vascular assessment important to prevent infectious endocarditis (Table 9)98 and - Presence/absence of carotid artery lesions brain abscess in patients with cyanotic heart disease. - Presence/absence of cerebrovascular disorder - Presence/absence of arteriosclerosis obliterans 5. Aortic Diseases 3. Systemic assessment - Cardiac function ▋▋5.1 Evaluation and Treatment Priorities of Aortic - Presence/absence of coronary artery disease Aneurysm During Noncardiac Surgery - Respiratory function Tables 10 and 11 list considerations for patients with aortic - Presence/absence of renal dysfunction aneurism who are going to undergo noncardiac surgery. - Assessment of hypertension Patients with an abdominal aneurysm ≥6 cm in diameter should undergo aortic aneurysm surgery first even though noncardiac surgery is planned for the treatment of malig- nant tumors. Patients who are going to undergo abdominal Table 11. Items for Assessment of Noncardiac Vascular surgery should undergo aortic aneurysm surgery and Disorders abdominal surgery at the same time. Treatment of aortic 1. Risk factors associated with acute-phase treatment aneurism should be prioritized in patients with acute aortic - Presence/absence of bleeding, intestinal obstruction, and infec- dissection, symptomatic patients with ruptured (or ruptur- tion ing) aortic aneurysm, and those with pseudoaneurysm, - Surgical procedure, posture, surgical field, duration of surgery, except cases where the noncardiac disease needs prompt volume of bleeding, and cleanliness treatment. Figure 2 illustrates a flow chart of treatment for - Presence/absence of supportive treatment (radiotherapy/ patients complicated with noncardiac disease and abdom- chemotherapy) inal/thoracic aortic aneurysm. However, priority of treat- 2. Assessment of long-term prognosis ment depends on individual cases, and further research - Staging should be conducted. Patients with the following anatomical - Assumed life prognosis characteristics should be considered for the indication of thoracic endovascular aortic repair (TEVAR) or endovas- cular abdominal aortic aneurysm repair (EVAR). It is expected that EVAR may minimize the surgical invasion in simultaneous surgery for the treatment of abdominal to undergo emergency surgery, intravenous infusion of aortic aneurism and noncardiac disorder, and shorten the antihypertensives is recommended.104,105 After aortic aneu- time lag from the treatment of aortic aneurysm and the rism surgery, the patient should be assessed carefully to noncardiac disorder in patients undergoing two-phase rule out abnormalities of the treated site (e.g., anastomotic surgery.99–101 However, the preventive use of EVAR for false aneurysm and endoleak), and be treated appropriately patients who do not meet the criteria is not supported. to prevent bacteriemia and graft infection. There is no sufficient evidence to support the use of TEVAR. However, this technique is worth considering ▋5.3 Rare Heart Diseases/Conditions because early results are favorable,101–103 and its surgical ▋ invasion is minimal. ▋▋ 5.3.1 Aortitis Syndrome (Takayasu Disease) Surgical treatment is required in 13% of patients with aor- 106 ▋5.2 Management of Aortic Aneurysm During the titis syndrome. To ensure the safety of noncardiac sur- ▋ gery, patients should be carefully observed for hypertension Perioperative Period of Noncardiac Surgery due to renal artery stenosis and heart failure associated During the perioperative period of noncardiac surgery, with aortic regurgitation. Patients with active inflammation patients with aortic aneurysms should be carefully observed as suggested by a high CRP level should be treated with for ischemic heart disease and severe hypertension that corticosteroids to control inflammation and corticosteroid frequently co-exist. Pain control is also important to ensure therapy should be reduced before noncardiac surgery when stable blood pressure. Although there have been few reports it is not urgently required.105 about aortic aneurysm rupture during the perioperative period of noncardiac surgery, perioperative blood pressure ▋▋ 5.3.2 Marfan Syndrome control has been reported to be effective in preventing the The outcome of cardiovascular surgery in patients with rupture of aortic aneurysms. When hypertension is mild or Marfan syndrome is excellent.107,108 When appropriate car- moderate and no abnormal findings related to hypertension diovascular evaluation does not reveal abnormal findings, are observed, noncardiac surgery may not be postponed. patients with Marfan syndrome may usually undergo con- However, patients with severe hypertension require careful ventional noncardiac surgery. blood pressure control throughout the perioperative period. In patients who cannot take drugs orally and who are going
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Figure 2. Guidelines for priority of thoracic/abdominal aortic aneurysm surgery and noncardiac surgery.
Table 12. Guidelines for Noncardiac Vascular Surgery in Patients Complicated With Peripheral Artery Disease Evaluation Treatment Class I Class II Class III Extracranial stenosis of Perform carotid surgery first - Symptomatic carotid - Symptomatic carotid - Symptomatic carotid carotid artery (or simultaneously in some stenosis ≥70% stenosis 50 to 69% stenosis ≥49% noncardiac diseases) - Asymptomatic carotid stenosis ASO of the lower Treat ASO of the lower - Severe limb ischemia - Intermittent claudica- extremities extremities first (or simulta- tion neously in some noncardiac diseases) AAA, abdominal aortic aneurysm; ASO, arteriosclerosis obliterans.
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▋▋5.4 Management of Aortic Aneurysms in Patients Table 13. Updated Clinical Classification of Pulmonary With Other Heart Diseases Hypertension [a Draft Dana Point/Nice Classification] Group 1: Pulmonary arterial hypertension (PAH) ▋ 5.4.1 Ischemic Heart Disease ▋ 1) Idiopathic PAH (IPAH) It has been reported that coronary lesions are observed in 2) Heritable PAH (HPAH) one-eighth of patients with aortic dissection and one-third 1. Mutations in bone morphogenetic protein receptor type 2 of patients with true aortic aneurysm.104 Ischemic heart (BMPR2) disease is more common among patients with AAA.109,110 2. Mutations in activin receptor-like kinase 1 (ALK1), endoglin, Hemodynamics during the perioperative period of aortic Smad Family Member 9 (SMAD9), and caveolin-1 (CAV1) genes, KCNK3 aneurism are often unstable due to underlying hypertension 3. Unknown and systemic arteriosclerosis, but IABP cannot be used in 3) Drug- and toxin-induced PAH patients with aortic aneurysm. The presence or absence of 4) Associated with (APAH): coronary artery lesions significantly affects the treatment 1. Connective tissue diseases plans for patients undergoing aortic surgery. 2. Human immunodeficiency virus (HIV) infection Patients with aortic disease requiring elective, nonurgent 3. Portal hypertension surgery and symptomatic or severe coronary artery disease 4. Congenital heart disease (CHD) 5. Schistosomiasis should undergo coronary surgery first, coronary surgery Group 1’: Pulmonary veno-occlusive disease (PVOD) and/or and aortic aneurysm surgery simultaneously, or coronary pulmonary capillary hemangiomatosis (PCH) intervention first. DES, which require long-term treatment Group 1”: Persistent pulmonary hypertension of the with potent antiplatelet drugs, are not feasible in patients newborn (PPHN) planned to undergo aortic aneurysm surgery after coronary Group 2: Pulmonary hypertension due to left heart diseases stenting. When simultaneous surgery is selected, hybrid 1) Systolic dysfunction treatment, namely, off-pump coronary bypass surgery and transcatheter coronary intervention should be consid- 2) Diastolic dysfunction ered.111–114 Patients with aneurysms in the descending aorta 3) Valvular disease or thoracoabdominal aorta may simultaneously undergo 4) Congenital or acquired left heart inflow/outflow tract obstruction aortic surgery and bypass surgery to the left anterior Group 3: Pulmonary hypertension due to lung diseases and/ descending artery and/or the circumflex coronary artery. or hypoxia 1) Chronic obstructive pulmonary disease (COPD) ▋▋ 5.4.2 Valvular Heart Disease 2) Interstitial lung disease (ILD) When aortic surgery and valve surgery can be performed 3) Other pulmonary diseases with mixed restrictive and through the same incision, simultaneous surgery is feasible obstructive pattern provided that cardiac function is normal. Although no 4) Sleep-disordered breathing consensus has been reached regarding the optimal surgical 5) Alveolar hypoventilation disorders treatment of aortic lesions and valvular lesions which can- 6) Chronic exposure to high altitude not be treated through the same incision, it is important to 7) Developmental abnormalities consider stent grafting as an option. Group 4: Chronic thromboembolic pulmonary hypertension (CTEPH) 6. Peripheral Arterial Disease Group 5: Pulmonary hypertension with unclear multifactorial mechanisms 1) Hematological disorders: chronic hemolytic anemia, myelo- Table 12 shows guidelines for evaluation and management proliferative disorders, splenectomy of patients who have carotid artery stenosis or peripheral 2) Systemic disorders: sarcoidosis, pulmonary Langerhans cell arterial disease of the lower extremities and are to undergo histiocytosis, lymphangioleiomyomatosis, neurofibromatosis, noncardiac surgery under general anesthesia (cases of vasculitis emergency surgery for noncardiac diseases are excluded). 3) Metabolic disorders: glycogen storage disease, Gaucher disease, thyroid disorders Since peripheral arterial disease may develop as a result of 4) Others: tumoral obstruction, fibrosing mediastinitis, chronic arteriosclerosis, patients diagnosed with a vascular lesion renal failure on dialysis must be examined for other vascular lesions. Segmental pulmonary hypertension (Adapted from the Guidelines for the Treatment of pulmonary hyper- ▋▋6.1 Carotid Artery Stenosis tension (JSC2012),119 Simonneau G, et al. J Am Coll Cardiol 2013; 62: D34–D41,119a with permission from Elsevier. [http://www. The carotid artery should be checked in patients with a sciencedirect.com/science/article/pii/S0735109713058725]) history of cerebral infarction and those suspected to be experiencing a transient ischemic attack (TIA). Patients with carotid artery stenosis are at risk for cerebral infarction during the perioperative period of noncardiac surgery. Since approach to the carotid artery is difficult, those with a high the risk of cerebral infarction is high in males, patients with risks associated with surgery, those with carotid artery a history of cerebral infarction rather than TIA, and patients stenosis after radiotherapy, and those with carotid artery with cerebral hemisphere signs and symptoms rather than restenosis after surgery.115 When patients with carotid artery amaurosis, carotid surgery should be considered. No benefit stenosis undergo noncardiac surgery without treating of carotid surgery has been observed in patients with mild carotid artery stenosis, patients should be managed carefully stenosis with or without symptoms. Carotid endovascular to prevent dehydration and hypotension and thus prevent treatment may be considered in patients with symptomatic cerebral infarction. severe carotid artery stenosis, those in whom the surgical
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▋6.2 Atherosclerosis Obliterans of the Lower resting mean pulmonary arterial pressure in catheterization ▋ is ≥25 mmHg, and hypocapnia with hypoxemia are observed Extremities on arterial blood gas analysis, while no significant pulmo- Noncardiac surgery should be prioritized in patients with nary parenchyma diseases or airway disorders are observed intermittent claudication, but patients in the perioperative on respiratory function testing. Prior to noncardiac surgery, period should be monitored carefully for the development physicians should consider that the natural history of mod- of acute deterioration of blood flow in the lower extremities. erate or severe PH is quite poor. Careful monitoring should be performed, particularly in No systematic criteria are available to evaluate the risk patients with severe chronic leg ischemia whose blood of perioperative complications in noncardiac surgery in pressure is of ≤50 to 70 mmHg in the foot joint and ≤30 to patients with PH.5,6 Since patients with PH tend to have 50 mmHg in the toes. When acute ASO of the lower extrem- hypoxemia and right heart failure, careful monitoring ities develops, amputation of the lower extremities may be (ECG, arterial line placement, and pulse oximetry) should required, or reperfusion injury followed by multi-organ be performed from the induction of anesthesia through the failure may occur. postoperative period. Although pulmonary arterial cath- eterization provides important information, it is difficult to ▋6.3 Management of Inferior Vena Cava Filters place the catheter at an appropriate position, and lung ▋ injuries due to puncture and vessel injuries due to balloon Thrombosis in the inferior vena cava is not a rare condition. dilatation may cause serious outcomes.120 Transesophageal Whenever possible, patients who have been using an inferior echocardiography is very useful for monitoring the right vena cava (IVC) filter for a long period of time should ventricular function.121 continue anticoagulant therapy during the perioperative The effects of decreasing pulmonary vascular resistance period. Patients in whom an IVC filter was placed recently during the perioperative period of noncardiac surgery with should continue anticoagulant therapy whenever possible. inhaled nitric oxide, dipyridamole, phosphodiesterase After temporary IVC filter placement, patients should be (PDE) III inhibitors, PGI2, calcium blockers, and intrave- carefully monitored for catheter infection, filter thrombosis nous nitroglycerin have been reported. Endothelin-1 recep- (capture of thrombus), and catheter fracture.116 When a tor antagonist are effective but not appropriate during the thrombus greater than 25% of the filter volume is observed perioperative period, since only oral forms of them are in angiography or contrast CT, urokinase should be admin- available. istered through the filter at a dose of 240,000 to 480,000 units/day to debulk the thrombus before the removal of the 8. Idiopathic Cardiomyopathy filter. When the thrombus cannot be debulked, suctioning the thrombus or placing a permanent IVC filter should be considered. Cardiomyopathy is typically defined as “heart muscle dis- ease associated with cardiac dysfunction” and is classified 7. Pulmonary Artery Disease into dilated cardiomyopathy, hypertrophic cardiomyopa- thy, restrictive cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, and other unclassifiable car- At the 4th World Symposium on Pulmonary Hypertension, diomyopathy [Report of the 1995 World Health Organiza- which took place in Dana Point, California, in 2008, a new tion/International Society and Federation of Cardiology definition of pulmonary hypertension was proposed. The Task Force on the Definition and Classification of Cardio- proposed new definition of pulmonary hypertension is a myopathies, 1995].122 “Heart muscle disease with known resting mean pulmonary arterial pressure (PAP) of etiology or clearly related to systemic disease” is defined as ≥25 mmHg, and the exercise and pulmonary vascular resis- specific cardiomyopathy, and is not included into the above tance criteria were eliminated.117 The Venice Clinical Clas- classification. Although new classifications have recently sification of Pulmonary Hypertension was revised, and the been proposed, the WHO/ISFC classification is still com- Dana Point classification was published in 2008.118 A minor mon in Japan and useful in the clinical setting. Figure 3 revision was made at the 5th World Symposium held in shows a flow chart of preoperative examinations for car- Nice, France, in 2013 (Table 13).119 diomyopathy. Diagnostic criteria for pulmonary hypertension are out- In management during the perioperative period of non- lined in the following table. cardiac surgery, arrhythmia and low cardiac output syn- drome require special attention in patients with any type of Clinical Exertional dyspnea, cyanosis, jugular venous dis- cardiomyopathy. Extra vigilance is needed in patients with findings: tention, hepatomegaly, leg edema, ascites severe ventricular arrhythmia, which may cause sudden Auscultation: Pulmonary diastolic murmur and apical holosys- death. Patients often have been treated with oral antiar- tolic murmur rhythmic drugs and may receive continuous intravenous Chest X-ray: Left second arc protrusion and decrease in pe- lidocaine infusion during the perioperative period as needed, ripheral vessel shadow, left fourth arc protrusion and many cases of arrhythmia are intractable. It is impor- ECG: Right axis deviation, pulmonary P wave, right tant to maintain normal sinus rhythm by adjusting electro- ventricular overload/hypertrophy lyte levels. If such treatment is impossible, heart rate should Echocardiogra- Right ventricular enlargement, paradoxical mo- be controlled while in atrial fibrillation. phy: tion of the interventricular septum, increase in Low cardiac output syndrome in patients with dilated right ventricular pressure and/or pulmonary arte- cardiomyopathy is treated by decreasing afterload with rial pressure vasodilators and increasing cardiac contractile force with catecholamines and PDE III inhibitors, while such treatment Pulmonary artery disease is strongly suspected when is contraindicated in patients with hypertrophic cardiomy-
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Figure 3. Flow chart of evaluation for cardiomyopathy. NYHA, New York Heart Association; EF, ejection fraction.
opathy and should be performed with care in patients with Table 14. Types and Causes of Perioperative Arrhythmias restrictive cardiomyopathy. Physicians should attempt to optimize intravascular volume to increase cardiac output Arrhythmia Causes regardless of the type of cardiomyopathy by managing Sinus bradycardia - Vagal stimulation (e.g., stomach traction) intravascular fluid volume. However, since the range of the Sinus arrest - Carotid sinus reflex (during esophageal target intravascular volume is narrow, a pulmonary artery surgery) - Hyperkalemia catheter should be placed to monitor hemodynamics care- Supraventricular - Atrial overload (excessive water intake) fully during the perioperative period, in which intravascular extrasystoles volume may change significantly, and diuretics should be Atrial fibrillation - Hypokalemia administered whenever necessary. - Mitral regurgitation Patients who had received warfarin to prevent embolism - Hypertensive cardiac hypertrophy should be switched from warfarin to heparin infusion during Premature - Ventricular overload (excessive water the perioperative period. Adequate pain control is neces- ventricular intake, pulmonary embolism) sary, since postoperative pain increases afterload by increas- contraction - Myocardial ischaemia (coronary vaso- spasm, coronary embolism) ing sympathetic activity. - Mitral regurgitation, aortic regurgitation Ventricular - Aortic regurgitation 9. Arrhythmias tachycardia - Myocardial ischemia (myocardial infarction) - Cardiomyopathy (e.g., arrhythmogenic right ventricular dysplasia, long QT syndrome) In addition to myocardial infarction, arrhythmias and con- Ventricular - Myocardial ischemia (myocardial infarction) duction disorders are quite common perioperative cardiac fibrillation - Cardiomyopathy - Long QT syndrome complications of noncardiac surgery. Arrhythmia may not - Brugada syndrome occur as a single disorder. It is important to check for all possible heart diseases associated with arrhythmia when examining patients with perioperative arrhythmia.
▋9.1 Perioperative Arrhythmia and Its Treatment Atrial fibrillation ▋ → mitral valve disease, hypertensive cardiac hypertro- ▋▋ 9.1.1 Assessment and Management of Preoperative phy, constrictive pericarditis Arrhythmias When arrhythmia occurs in patients planned to undergo There are reports suggesting that detailed monitoring and noncardiac surgery, physicians should check for the pres- specific treatment are unnecessary in patients with preop- ence/absence of an underlying disease causing the arrhyth- erative ventricular extrasystole when myocardial infarction mia and consider how to manage the patient should or other heart disease is absent.122a However, since arrhyth- arrhythmia worsen during the perioperative period. The mia may worsen during the perioperative period in patients following types of organic heart disease may play roles in with ischemic heart disease, appropriate examination should preoperative arrhythmia. be performed to exclude possible diseases and uncover undiagnosed diseases. Sick sinus syndrome, atrioventricular block For patients who have been diagnosed with arrhythmia → Coronary heart disease and are taking antiarrhythmic drugs, physicians should Ventricular extrasystole (multifocal, sequential) consult with anesthesiologists to determine whether antiar- → Coronary heart disease, previous myocardial infarc- rhythmic drugs should be given intravenously or be sus- tion, cardiomyopathy, aortic insufficiency pended during the perioperative period. Many believe that
Circulation Journal Vol.81, February 2017 262 KYO S et al. beta blockers used before surgery should be continued be familiar with the possible effects of use of electric knives during the perioperative period. In patients receiving anti- at a surgical site distant from the pacemaker. Use of bipolar coagulation therapy to control atrial fibrillation, physicians electric knives is in all cases the safest procedure, though should consider the benefits and risks of bleeding with such devices may make surgical procedures more compli- anticoagulation therapy in determining a strategy of treat- cated than unipolar devices. Pacing mode must be adjusted ment for the perioperative period. during surgery if the surgical site is close to the pacemaker and requires frequent use of electric knives to stop bleeding. ▋▋ 9.1.2 Arrhythmias That May Occur During Surgery In patients who depend on a pacemaker to maintain heart Table 14 lists conditions that may cause arrhythmias during rate, AOO, VOO, or DOO mode may be used during sur- the perioperative period. Although arrhythmias existing gery. In patients in their own rhythm with the pacemaker before surgery and underlying heart disease affect the type in sense mode, the pacemaker is not used or is used with a and incidence of arrhythmias during surgery, myocardial low pacing rate during surgery. ischemia, overload on the heart, hypokalemia,41 and hypo- In patients using an ICD, electromagnetic interference magnesemia123 during surgery may induce arrhythmia. by electric knives may trigger the device, which may deliver Anesthetics, surgical procedures, and bleeding control also a shock during surgery. In such patients, external patch affect the incidence of arrhythmia during surgery. Since electrodes should be placed on the chest wall to prepare for cardiac arrest may occur at the time of reperfusion during prompt electrocardioversion, and the ICD should be turned surgical treatment of intestinal ischemia or lower extremity off during surgery. After surgery, the ICD should promptly ischemia, appropriate measures such as exsanguination of be turned on. Continuous administration of antiarrhythmic venous blood may be required. drugs should be considered in patients susceptible to ven- Intraoperative bradycardia may be improved for a short tricular tachycardia. In any case, physicians and medical period of time with atropine sulfate and beta-agonists. engineers with expertise in adjusting programs of implant- However, when bradycardia is prolonged or severe, patients able pacemakers and ICD should be present to support the may need ventricular pacing using transvenous leads surgery. inserted from the internal jugular vein, transesophageal In patients undergoing gastrointestinal surgery and pacing, or external pacing using chest patch electrodes. patients with traumatic open wounds, bacteremia may develop. When leads are exposed to venous blood for a long ▋▋ 9.1.3 Arrhythmias That May Occur After Surgery period of time, lead infection may occur, and the pacemaker The incidence of cardiac complications is highest during may need to be removed. In patients with implantable the first several days after surgery. Arrhythmias that may pacemakers and ICD, antibiotic treatment should be initi- occur after surgery include those immediately after recovery ated during surgery to minimize the occurrence of pace- from anesthesia, fatal arrhythmias due to pulmonary maker infection. [end of part 2]-checked. embolism, which is prone to occur during the first several days after surgery, and atrial fibrillation, the incidence of ▋9.3 Management of Perioperative Arrhythmias in which is high during the first week after surgery. ▋ Atrial fibrillation is clinically significant, since thrombus Patients With Long QT Syndrome and Brugada may develop in the left atrium and cause arterial embolism. Syndrome Transesophageal echocardiography is useful to exclude An implantable cardioverter defibrillator (ICD) is indicated possible arterial thrombus. Patients with atrial fibrillation for patients with long QT syndrome (QTc >440 msec) and may exhibit severe bradycardia requiring temporary pacing. a history of ventricular fibrillation or cardiac arrest. Con- Since severe and prolonged bradycardia may reflect the genital long QT syndrome consists of a group of conditions. presence of latent conduction disorder, physicians should Patients with congenital long QT syndrome associated consider prompt implantation of permanent pacemakers. with ventricular arrhythmia should be treated with beta blockers, mexiletine, or verapamil, according to the type of ▋9.2 Perioperative Management of Patients Using condition. Treatment with magnesium sulfate is effective ▋ for the treatment of acquired long QT syndrome. Implantable Pacemakers and Implantable Patients with Brugada syndrome are at risk of sudden Cardioverter Defibrillators death due to ventricular fibrillation.124 Oral drugs such as In patients with implantable pacemakers and implantable amiodarone and beta blockers are not effective in the treat- cardioverter defibrillators (ICD), electromagnetic interfer- ment of Brugada syndrome. An ICD should be implanted ence and infection are the most important complications before noncardiac surgery when the patient meets at least of noncardiac surgery. The use of electric knives may inter- two of the following three conditions: (1) signs/symptoms fere with pacemakers, which will then not function properly. of ventricular fibrillation or cardiac arrest; (2) a family Unipolar devices are more susceptible to interference than history of sudden death; and (3) ventricular fibrillation bipolar devices. Physicians should be aware of the risk of induced during electrophysiological testing. Electrical defi- electromagnetic interference when the surgical site is in close brillation should be carried out when ventricular fibrillation proximity to the pacemaker or leads. Physicians should also develops.
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Appendix 1 Chair: City University Hospital • Shunei Kyo, Tokyo Metropolitan Geriatric Hospital and Institute • Shunsuke Kawamoto, Department of Cardiovascular Surgery, of Gerontology/Department of Therapeutic Strategy for Heart Tohoku University Graduate School of Medicine Failure, The University of Tokyo Graduate School of Medicine • Isamu Koyama, Department of Gastroenterological Surgery, Saitama Medical University International Medical Center Members: • Mikihiko Kudo, Department of Cardiovascular Surgery, Keio • Kazuhito Imanaka, Department of Cardiovascular Surgery, University School of Medicine Saitama Medical Center, Saitama Medical University • Goro Matsumiya, Department of Cardiovascular Surgery, Chiba • Munetaka Masuda, Department of Surgery, Yokohama City University Graduate School of Medicine University • Kazumasa Orihashi, Department of Surgery II, Kochi Medical • Tetsuro Miyata, Vascular Center, Sanno Medical Center School • Kiyozo Morita, Department of Cardiac Surgery, Jikei University • Hideki Oshima, Department of Cardiothoracic Surgery, Nagoya School of Medicine University Graduate School of Medicine • Tetsuro Morota, Department of Cardiovascular Surgery, Nippon • Satoshi Saito, Department of Cardiovascular Surgery, Tokyo Medical School Hospital Women’s Medical University • Minoru Nomura, Department of Anesthesiology, Tokyo Women’s • Yoshimasa Sakamoto, Department of Cardiac Surgery, Jikei Medical University University School of Medicine • Yoshikatsu Saiki, Department of Cardiovascular Surgery, Tohoku • Kunihiro Shigematsu, Department of Vascular Surgery, The University Graduate School of Medicine University of Tokyo Graduate School of Medicine • Yoshiki Sawa, Division of Cardiovascular Surgery, Department of • Tsuyoshi Taketani, Department of Cardiovascular Surgery, Mitsui Surgery, Osaka University Graduate School of Medicine Memorial Hospital • Taijiro Sueda, Department of Surgery, Hiroshima University Graduate School of Biomedical Sciences Independent Assessment Committee: • Yuichi Ueda, Nara Prefecture General Medical Center • Issei Komuro, Department of Cardiovascular Medicine, The • Kenji Yamazaki, Department of Cardiovascular Surgery, Tokyo University of Tokyo Graduate School of Medicine Women’s Medical University • Shinichi Takamoto, Mitsui Memorial Hospital • Ryohei Yozu, Harajuku Rehabilitation Hospital • Chuwa Tei, Dokkyo Medical University Hospital • Fumio Yamamoto, Akita University Collaborators: (The affiliations of the members are as of June 2014) • Mari Iwamoto, Department of Pediatric Cardiology, Yokohama
Appendix 2 Disclosure of Potential Conflicts of Interest (COI): Guidelines for Perioperative Cardiovascular Evaluation and Management for Noncardiac Surgery (JCS 2014) Potential COI of the marital Employer/ Scholarship partner, first- leadership Payment Stake- Patent Research (educational) Other degree family Author position Honorarium for holder royalty grant grant/endowed rewards members, or (private manuscripts chair those who company) share income and property Member: Ono Edwards Lifesciences Yoshiki Sawa Pharmaceutical Konishi Medical Instruments Otsuka Pharmaceutical Nipro Astellas Pharma Terumo Member: Taisho Toyama Tetsuro Miyata Pharmaceutical Mitsubishi Tanabe Pharma Sanofi Member: Sun Medical Edwards Lifesciences Sun Medical Kenji Yamazaki Technology Technology Research Research Collaborator: Amco Isamu Koyama Collaborator: Mitsubishi Chemical Kunihiro Holdings Shigematsu Collaborator: Edwards Lifesciences Goro Matsumiya St. Jude Medical
Circulation Journal Vol.81, February 2017 JCS Guidelines for Perioperative Cardiovascular Evaluation and Management for Noncardiac Surgery 267
Companies are listed only by name. No relevant COIs were declared by other members or collaborators. The following members and collaborators have no relevant COIs. Chair: Shunei Kyo, none Member: Kazuhito Imanaka, none Member: Yuichi Ueda, none Member: Yoshikatsu Saiki, none Member: Taijiro Sueda, none Member: Minoru Nomura, none Member: Munetaka Masuda, none Member: Kiyozo Morita, none Member: Tetsuro Morota, none Member: Ryohei Yozu, none Collaborator: Mari Iwamoto, none Collaborator: Hideki Oshima, none Collaborator: Kazumasa Orihashi, none Collaborator: Shunsuke Kawamoto, none Collaborator: Mikihiko Kudo, none Collaborator: Satoshi Saito, none Collaborator: Yoshimasa Sakamoto, none Collaborator: Tsuyoshi Taketani, none
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