Guidelines for Perioperative Cardiovascular Evaluation and Management for Noncardiac Surgery (JCS 2008) – Digest Version

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Circulation Journal JCS GUIDELINES Official Journal of the Japanese Circulation Society http://www.j-circ.or.jp Guidelines for Perioperative Cardiovascular Evaluation and Management for Noncardiac Surgery (JCS 2008) – Digest Version – JCS Joint Working Group

Table of Contents Introduction to the Revised Guidelines··············· 989 4. Adults With Congenital Heart Disease··················· 1000 I Outline········································································ 990 5. Aortic Diseases······················································ 1001 1. Outline of Diagnosis and Evaluation························ 990 6. Peripheral Arterial Disease 2. Outline of General Management······························ 992 (Abdomen, Neck, and Lower Extremities)············· 1003 3. Pregnancy/Delivery and Heart Disease··················· 994 7. Pulmonary Artery Disease····································· 1004 8. Idiopathic Cardiomyopathy···································· 1005 II Descriptions···························································· 996 9. Arrhythmias···························································· 1005 1. Ischemic Heart Disease··········································· 996 References································································· 1007 2. Valvular Heart Disease············································ 998 3. Treatment of Congenital Heart Disease Before Corrective Surgery··················································· 999 (Circ J 2011; 75: 989 – 1009)

Introduction to the Revised Guidelines

As the population ages, more elderly patients are undergo- Class I: Conditions for which there is evidence for and/or ing surgery. An increasing number of patients with heart general agreement that the procedure/treatment is disease are undergoing noncardiac surgery, and guidelines useful. for perioperative cardiovascular evaluation and management Class II: Conditions for which there is conflicting evidence for patients undergoing noncardiac surgery have become nec- regarding the usefulness of a procedure/treatment. essary. The Committee on Preparation for “the Guidelines for Class IIa: Weight of opinion is in favor of usefulness. Perioperative Cardiovascular Evaluation and Management Class IIb: Usefulness is less well established by evidence. for Noncardiac Surgery”, which was established in 2001 at the Class III: Conditions for which there is evidence and general request of the Scientific Committee of the Japanese Circula- agreement that a procedure/treatment is not useful. tion Society, published the first edition of the guidelines in 2002. Five years have passed since the release of the first edition While the ACC/AHA Guidelines for Perioperative Cardio- of the guidelines, during which time surgical treatment has vascular Evaluation for Noncardiac Surgery highlighted the become more common among elderly patients and the diag- perioperative management of patients with ischemic heart nostic and treatment techniques for heart disease have further disease, our guidelines were intended to comprehensively advanced. The guidelines were thus revised to reflect these describe ischemic heart disease and other common heart dis- changes. eases which physicians often encounter during noncardiac In the present edition, we added to and substantially revised surgery, and include risk management during pregnancy and the descriptions about the role of percutaneous coronary in- delivery. In the present guidelines, the evidence and general tervention (PCI), focusing on drug eluting stents (DES), and agreement on the efficacy of diagnostic and treatment pro- aortic stent grafts during the treatment of patients undergoing cedures are classified into Class I to III to help practitioners noncardiac surgery. The descriptions of other cardiovascular use the guidelines efficiently. diseases were also revised to reflect new findings.

Released online March 18, 2011 Mailing address: Scientific Committee of the Japanese Circulation Society, 8th Floor CUBE OIKE Bldg., 599 Bano-cho, Karasuma Aneyakoji, Nakagyo-ku, Kyoto 604-8172, 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 2007 (website: http://www. j-circ.or.jp/guideline/pdf/JCS2008_kyo_d.pdf). Joint Working Groups: The Japanese Circulation Society, The Japanese Coronary Association, The Japanese Association for Thoracic Sur- gery, The Japan Surgical Society, The Japanese Society of Pediatric Cardiology and Cardiac Surgery, The Japanese Society for Cardio- vascular Surgery, The Japanese College of Cardiology, The Japanese Heart Failure Society, The Japanese Society of Anesthesiologists ISSN-1346-9843 doi: 10.1253/circj.CJ-88-0009 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: [email protected]

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However, it is quite difficult to conduct prospective ran- obtained in this area of study described in the present guide- domized clinical studies in patients undergoing surgery, who lines may include many biases, as in the case of the first are often in critical condition, and the data from such studies edition. are also limited in many countries. Please note that the data

I Outline

plications by scoring of relevant factors such as the Cardiac 1. Outline of Diagnosis and Evaluation Risk Index System (CRIS) in Table 2 have been proposed.8

In order to determine treatment strategies of noncardiac sur- (2) Preoperative Evaluation gery and obtain information necessary to ensure safe surgery, In principle, preoperative cardiovascular evaluation should history taking and physical examination should be performed be performed using noninvasive techniques. However, Holter to identify patients in whom the risk for cardiovascular com- ECG and echocardiography are not useful in evaluating the plications is high, and diagnosis and evaluation should then risk of perioperative myocardial infarction. Appropriate tech- be performed. Physicians should at this point also consider niques must be used, even if they are invasive. In addition, the long-term risk of cardiovascular disease as well. In gen- there is little pathological significance to a slight increase in eral, the risk for cardiac complications is high among patients cardiothoracic ratio that results from horizontal position of with a marked decrease in exercise capacity (≤ 4 metabolic the heart due to obesity or other causes, or a single supraven- equivalents [METs]), and careful evaluation of such patients tricular extrasystole, ectopic sinus rhythm, atrial fibrillation, is often necessary. a single unifocal ventricular extrasystole, or first degree atrioventricular block in patients with excellent exercise capacity. (1) Risk Classification Unnecessary examinations should be avoided. Since the inci- The risk factors for cardiac complications during the peri- dence of serious complications of invasive examinations such operative period are classified as shown inTable 1.1–7 Patients as cardiac catheterization and cervical angiography is about with major risk factors require intensive care during the peri- 1%,9,10 such examinations must be reserved for patients in operative period. In some cases, non-urgent noncardiac sur- whom the results of examination will significantly contribute gery must be postponed or cancelled in patients with major to the improvement of prognosis and results of noncardiac risk factors. Systems to predict the incidence of cardiac com- surgery. Table 3 lists the criteria for indication of preopera-

Table 1. Risk Factors for Cardiac Complications During Table 2. Cardiac Risk Index System (CRIS) the Perioperative Period of Noncardiac Surgery Points 1) Major risk factors History Age >70 years 5 • Unstable coronary artery disease Myocardial infarction in previous 10 Myocardial infarction occurring 7 to 30 days before surgery 6 months with clinical signs/symptoms and laboratory findings of myocardial ischemia detectable on noninvasive examina- Aortic stenosis 3 tions, unstable angina, or severe angina (Canadian Class Physical S3 gallop, jugular venous distention, 11 III or IV angina) examination or congestive heart failure • Decompensated congestive heart failure ECG Rhythm other than sinus 7 • Severe arrhythmias >5 PVC/min 7 Advanced atrioventricular block General status and PaO2 <60 mmHg 3 Symptomatic ventricular arrhythmia laboratory findings Supraventricular arrhythmia associated with abnormal ven- PaCO2 >50 mmHg 3 tricular rates Potassium <3 mEq/L 3 • Severe valvular disease BUN >50 mg/dL 3 2) Intermediate risk factors Creatinine >3 mg/dL 3 • Mild angina (Canadian Class I or II angina) Bedridden 3 • History of myocardial infarction with abnormal Q waves Surgery Emergency 4 • History of compensated congestive heart failure or conges- Intrathoracic 3 tive heart failure Intraabdominal 3 • Diabetes mellitus Aortic 3 • Renal failure Incidence of cardiac complications 3) Mild risk factors Class I (0 to 5 points): 1%, Class II (6 to 12 points): 5%, • Advanced age Class III (13 to 25 points): 11%, Class IV (>– 26 points): 22%

• Abnormal ECG (left ventricular hypertrophy, left bundle PVC, premature ventricular contraction; PaO2, partial pressure of branch block, ST-T abnormalities) arterial oxygen; PaCO2, partial pressure of arterial carbon dioxide; • Rhythm other than sinus BUN, blood urea nitrogen. Adapted from N Engl J Med 1977; 297: 845–850,8 with permis- • Decrease in cardiac functional capacity (decrease in exer- sion from Massachusetts Medical Society. cise capacity) • History of stroke • Poorly-controlled hypertension

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Table 3. Guidelines for Coronary Angiography Table 4. Recommendations Regarding PCI and Patient Management Prior to Noncardiac Surgery Class I • Evidence for high risk of adverse outcome based on noninva- 1. Dual antiplatelet therapy using aspirin and thienopyridine sive test results (ticlopidine or clopidogrel) is the most beneficial regimen for preventing in-stent thrombosis. It is recommended that, follow- • Angina unresponsive to adequate medical therapy ing stenting, especially using DES, patients undergo dual anti- • Unstable angina platelet therapy for 12 months. Early discontinuation of this • Equivocal noninvasive test results in patients at high clinical regimen significantly increase the risks of in-stent thrombosis, risk and undergoing high-risk surgery myocardial infarction, and death. Class III 2. Physicians should be aware that dual antiplatelet therapy is required after stenting, and consider avoidance of DES implan- • Low-risk noncardiac surgery with known coronary artery dis- tation in patients who cannot complete 12-months thienopyri- ease and no high-risk results on noninvasive testing dine therapy. Physicians should well consider whether to use • For screening of patients not undergoing appropriate non- DES or not in patients who have or are suspected to have invasive testing* malignant disease. • Asymptomatic after coronary revascularization with excellent 3. For patients who are to undergo PCI and who may require exercise capacity invasive procedures or surgery within 12 months after PCI, physicians should consider use of bare metal stents or balloon • Mild stable angina with good left ventricular function and no angioplasty rather than DES implantation. high-risk noninvasive test results 4. Physicians should fully explain to patients the importance of • Noncandidate for coronary revascularization owing to concom- antiplatelet therapy with thienopyridine, and instruct them to itant medical illness, or severe left ventricular dysfunction consult a physician when they need to discontinue antiplatelet • Undergoing adequate coronary angiography within 5 year* therapy. • Refusal to consider coronary revascularization 5. When invasive procedures are performed in patients with stents Adapted from J Am Coll Cardiol 2002; 39: 542–553,11 with per- on antiplatelet therapy, physicians should be aware that early mission from Elsevier Inc. *Added to this table. discontinuation of antiplatelet therapy after stenting may have serious complications, and should carefully discuss with car- diologists over the optimal treatment strategy. 6. It is preferable that elective surgery with a high risk of bleed- tive coronary angiography.11 It is expected that innovative ing during and after surgery be avoided during the 12-months period after implantation of DES and at least one month after techniques such as multislice computed tomography (CT) implantation of bare metal stents. will change diagnostic strategies in the near future. 7. When patients with DES must discontinue thienopyridine ther- It should be noted that stress ECG, stress myocardial per- apy for surgical procedures, they should continue aspirin ther- fusion imaging, and other techniques commonly considered apy whenever possible, and should resume thienopyridine noninvasive procedures may occasionally cause even death therapy promptly after surgery. When all antiplatelet agents when significant stenosis of the left main coronary trunk or must be discontinued, it is preferable that patients be treated with heparin. However, there is no evidence of prevention of severe aortic valve stenosis is present. in-stent thrombosis by heparin therapy in patients receiving DES or bare metal stents, and heparin therapy is empirically (3) Perioperative Monitoring conducted in many institutions in Japan. Although it is important to promptly detect perioperative car- PCI, percutaneous coronary intervention; DES, drug eluting stents. diac complications in patients undergoing noncardiac surgery, appropriate monitoring should be performed in selected patients in whom cardiac complications are likely to occur for appropriate period of time. Excessive use of invasive moni- ii) Blood Pressure toring must be avoided. Esophageal stethoscopes, peripheral Patients at risk for abrupt hemodynamic changes during non- temperature and percutaneous oxygen saturation monitoring cardiac surgery should be continuously monitored for blood are not specific for cardiac complication. pressure using an arterial line.14 Although blood pressure, when used as a single measure, does not accurately reflect i) ECG hemodynamic condition and cardiovascular events,15 continu- ECG monitoring is best performed for patients with arrhyth- ous blood pressure monitoring during a limited period of time mia or coronary artery disease. Although postoperative myo- is indicated for certain types of patients such as those at high cardial ischemia is a strong predictive factor for perioperative risk of perioperative myocardial infarction. cardiac complications, angina is missing in many cases. Once perioperative myocardial infarction occurs, 30 to 50% of pa- iii) Central Venous Line, Pulmonary Artery tients will die, and long-term survival rate will be decreased. (Swan-Ganz) Catheter ST-segment monitoring is of diagnostic and therapeutic A central venous line is inserted and placed in patients whom value.6,12,13 It is preferable that ECG monitoring should be significant hemodynamic changes can occur during the peri- continued until preoperative drug regimens for cardiac com- operative period for inotropic support and rapid fluid admin- plications have been completely resumed. ECG monitoring istration. However, central venous pressure provides limited before, during, immediately after surgery, and succeeding information about hemodynamic conditions. Monitoring 2 days is a cost-effective strategy. using a pulmonary artery catheter may enable detailed evalua- Arrhythmias during the early postoperative period are often tion of hemodynamics in high-risk patients, though there are caused by factors other than problems of the heart. Since problems associated with its insertion and placement. supraventricular arrhythmia often disappears spontaneously and heart rhythm returns to sinus rhythm after causal factors iv) Transesophageal Echocardiography have been eliminated, cardioversion is not recommended as Although transesophageal echocardiography gives important a routine procedure for patients with it. informations in patients whom monitoring of blood pressures and cardiac output is not sufficient, its usefulness in patients

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16,17 Table 5. Guidelines for Use of β Nlockers During the undergoing noncardiac surgery has not been established. Perioperative Period of Noncardiac Surgery Transesophageal echocardiography is a somewhat invasive Class I technique, and its use as a continuous monitoring method should be limited to during surgery. 1. β blockers should be continued in patients undergoing surgery who are receiving β blockers to treat angina, symptomatic arrhythmias, hypertension, or other indications. 2. Outline of General Management 2. β blockers should be given to patients undergoing vascular surgery at high cardiac risk owing to the finding of ischemia on preoperative testing. (1) Preoperative Management Class IIa Although the most common strategy for improving cardiac 1. β blockers are probably recommended for patients under- condition before noncardiac surgery is drug treatment, pre- going vascular surgery in whom preoperative assessment operative intensive care or cardiac surgery may be performed identifies coronary heart disease. before noncardiac surgery. Generally, preoperative medica- 2. β blockers are probably recommended for patients in whom tion for cardiovascular disease should be continued during preoperative assessment for vascular surgery identifies high cardiac risk as defined by the presence of multiple clinical and after surgery. risk factors. 3. β blockers are probably recommended for patients in whom i) Cardiac Surgery Before Noncardiac Surgery preoperative assessment identifies coronary heart disease There is much debate concerning whether PCI and coronary or high cardiac risk as defined by the presence of multiple artery bypass grafting (CABG) prior to noncardiac surgery clinical risk factors and who are undergoing intermediate- or can improve the short- and long-term prognosis of patients. high-risk procedures. It is preferable that such cardiac procedures be performed Class IIb only in patients who meet the criteria provided in the ACC/ 1. β blockers may be considered for patients who are under- AHA Guidelines. However, there is much confusion in the going intermediate- or high-risk procedures, including vascular surgery, in whom preoperative assessment identifies clinical setting regarding the indication of PCI, which have intermediate cardiac risk as defined by the presence of a recently been advanced. We therefore provide guidelines for single clinical risk factor. the indication of PCI in patients undergoing noncardiac sur- 2. β blockers may be considered in patients undergoing vas- gery to ensure best practice in the current healthcare envi- cular surgery with low cardiac risk who are not currently on ronment in Japan (Table 4).18 β blockers. Since symptomatic valvular stenosis is often related to peri- Class III operative severe heart failure, patients with valvular stenosis 1. β blockers should not be given to patients undergoing often require balloon valvotomy or valve replacement prior surgery who have absolute contraindications to β blockade. to noncardiac surgery. Since patients with valvular regurgita- Adapted from J Am Coll Cardiol 2006; 47: 2343–2355,19 with tion often maintain stable hemodynamics during the periop- permission from Elsevier Inc. erative period, noncardiac surgery may be prioritized in this patient population. However, it is difficult to maintain hemo-

Table 6. Guidelines for the Prevention of Venous Thromboembolism During the Perioperative Period of Noncardiac Surgery Patient condition and surgical techniques Indications Minor surgery in patients <40 years of age Early ambulation with no risk factors* Moderate-risk surgery in patients >– 40 years ES, LDH (2 hours preoperatively and every 12 hours after), or IPC of the lower extremities of age with no risk factors Major surgery in patients >– 40 years of age LDH (every 8 hours) or LMWH. IPC of the lower extremities if prone to wound bleeding. with risk factors Very high-risk surgery in patients >– 40 years LDH, LMWH, or dextran combined with IPC of the lower extremities. of age with risk factors In selected patients, perioperative warfarin (INR 2.0 to 3.0) may be used. Total hip replacement LMWH (postoperative, subcutaneous, twice daily, fixed dose unmonitored) or warfarin (INR 2.0 to 3.0, started preoperatively or immediately after surgery), or adjusted dose unfractionated heparin (started preoperatively). ES or IPC may provide additional efficacy. Total knee replacement LMWH (postoperative, subcutaneous, twice daily, fixed dose unmonitored) or IPC of the lower extremities. Hip fracture surgery LMWH (preoperative, subcutaneous, fixed dose unmonitored) or warfarin (INR 2.0 to 3.0). IPC of the lower extremities may provide additional benefit. Intracranial neurosurgery IPC of the lower extremities with or without ES. Consider adition of LDH in high-risk patients. Acute spinal cord injury with lower extremity Adjusted dose heparin or LMWH for prophylaxis. Warfarin may also be effective. LDH, ES, paralysis and IPC of the lower extremities may have benefit when used together. Patients with multiple trauma IPC of the lower extremities, warfarin, or LMWH when feasible, serial surveillance with duplex ultrasonography may be useful. In selected very high-risk patients, consider prophylactic infe- rior vena cava filter. *Risk factors for venous thromboembolism: Advanced age, prolonged bed rest or paralysis, history of venous thromboembolism, malignant tumor, major surgery of the abdomen, pelvis, or lower extremities, obesity, varicose veins, congestive heart failure, myocardial infarction, stroke, fractures in the abdomen, pelvis, or lower extremities, hypercoagulability, and high-dose estrogen therapy. ES, graded compression elastic stockings; LDH, low-dose subcutaneous heparin; IPC, intermittent pneumatic compression; LMWH, low molecular weight heparin; INR, international normalized ratio. Adapted from J Am Coll Cardiol 1996; 27: 910–94821, with permission from Elsevier Inc.

Circulation Journal Vol.75, April 2011 JCS Guidelines for Perioperative Cardiovascular Management for Noncardiac Surgery 993 dynamics in patients with left ventricular dysfunction. vi) Malignant Tumors and Cardiac Surgery When cardiac surgery is performed in patients with malignant ii) Hypertension tumor, extracorporeal circulation during cardiac surgery may Untreated or poorly controlled hypertension (diastolic blood decrease immune function and disseminate cancer cells into pressure ≥110 mmHg) should be controlled prior to non- the circulation. In patients with ischemic heart disease, such cardiac surgery, preferably with β blockers, which have been problems may be minimized by selecting off-pump coronary suggested to decrease the incidence of perioperative myocar- bypass surgery. dial infarction. Perioperative treatment with β blockers may decrease the incidence of cardiovascular complications of (2) Management of Anesthesia and Peri- and noncardiac surgery not only in patients with hypertension but Postoperative Management also in those with heart disease or at high risk of perioperative i) Selection of the Methods and Agents of Anesthesia cardiac events (Table 5).19 Patients with hypertension before There are no particular anesthetic methods that yield signifi- surgery are prone to be hypotensive during surgery,19,20 and cant myocardial protection during surgery. The most impor- should be carefully managed to avoid perioperative heart/ tant prognostic factors are complications and surgical tech- renal complications. niques. Although local anesthesia combined with intravenous anesthesia and/or analgesics was previously considered safe, iii) Heart Failure a report pointed out that 30-day mortality was highest for it The presence of dilated or hypertrophic cardiomyopathy is among the anesthetic methods evaluated.22 Epidural anesthe- closely associated with perioperative heart failure. Such pa- sia and spinal anesthesia are used in some cases, but may not tients need close evaluation of hemodynamic condition before be indicated for patients receiving anticoagulants and those noncardiac surgery and medical therapy to be eligible for with poor cardiac function. The effects of narcotics on the car- noncardiac surgery, and must undergo intensive care and diovascular system are stable, but respiratory depression may close monitoring after surgery. Patients with chronic decom- occur. All volatile anesthetics may affect the cardiovascular pensated heart failure, in particular, may benefit from inva- system through a decrease in cardiac contractile force and sive monitoring and intensive care. When noncardiac surgery decrease of afterload. When volatile anesthetics are admin- is indicated children with congenital heart disease and heart istered to patients with heart diseases, hemodynamics should failure, they should be treated with digitalis, diuretics, and be monitored very carefully. Recently, intravenous anesthesia water restriction to control heart failure before surgery. Some with propofol has been established as a standard method of children require treatment with catecholamines and vasodi- anesthesia. Mask anesthesia, when performed by experienced lators. anesthesiologists, is often safer than local anesthesia, during which respiratory and circulatory management is often diffi- iv) Venous Thromboembolism cult. Table 6 shows the guidelines for prevention of venous thromboembolism during the perioperative period of noncardiac ii) Maintenance of Body Temperature During Surgery surgery.21 Hypothermia during surgery is an obvious risk factor for perioperative cardiac events in patients at risk for heart dis- v) Patients After Cardiac Surgery ease. Active warming to maintain body temperature is recom- The risk of perioperative ischemia or reinfarction is expected mended.23 to be low in patients following coronary revascularization when they are asymptomatic. However, patients with residual iii) Perioperative Pain Control ischemia after coronary revascularization require careful man- Most cardiac events in patients undergoing noncardiac sur- agement in a manner similar to that for patients with coro- gery occur during postoperative period. In facilitating early nary disease. ambulation, normalizing blood coagulation, and preventing It is important to adjust anticoagulation therapy in patients postoperative pulmonary embolism, adequate postoperative who have undergone mechanical valve replacement. Since pain control is quite important. Patient-controlled analgesia the incidence of thrombosis is higher in mitral prosthesis than (PCA) is a method with high patient satisfaction, and pain in aortic prosthesis, patients with mitral prosthesis should be scores achieved with PCA are lower than with other analge- managed more carefully. sic methods. For example, epidural or spinal anesthesia with The risk of perioperative cardiac complications is generally narcotics is beneficial in many respects, and physicians low among patients who have undergone corrective surgery should consider use of this method when it is possible. for congenital heart disease. However, patients should be carefully evaluated for remaining defects. Since patients who iv) Perioperative Nitroglycerin have undergone palliative surgery only still have congenital Perioperative nitroglycerin therapy may be beneficial in high- heart disease, careful management is required. risk patients with signs of myocardial ischemia without hypo- Warfarin therapy should be discontinued one week prior to tension who have received nitroglycerin, but is contraindicated such surgery if possible, or 2 days prior to the surgery at the for patients with hypovolemia or signs of hypotension. latest. Warfarin should be replaced with heparin in patients at high risk of thromboembolism. Vitamin K is sometimes (3) Prevention of Cardiac Complications During used to antagonize the effects of warfarin prior to emergency Emergency Surgery surgery. Physicians should be aware that complete normaliza- Patients who require emergency surgery often have conditions tion of coagulation activity may occur in many cases. High- that may affect the heart such as anemia and hypovolemia. risk patients such as those with mechanical valves should Physicians must often start emergency surgery without appro- resume anticoagulation therapy following noncardiac surgery priate evaluation of the risk of surgery and obtaining infor- as soon as the risk of bleeding has disappeared. mation on previous treatment of heart disease. In this situa- tion, patients are likely to develop complications including

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Table 7. Pregnancy and Delivery in Patients With Uncorrected to develop hypothermia during surgery with large-volume Congenital Heart Disease transfusion and/or rapid fluid administration and extensive Atrial septal defect No problem in most cases surgery. It should be noted that rapid transfusion may cause hypocalcemia. Ventricular septal defect No problem in most cases Patent ductus arteriosus No problem in most cases iii) Postoperative Management Congenital aortic stenosis Pressure gradient of <– 50 mmHg Appropriate postoperative management including adjustment (No problem if <25 mmHg) – of fluid volume is important to prevent cardiac overload, Coarctation of the aorta Pressure gradient of <– 20 to 30 mmHg, asymptomatic especially in critically ill patients. Postoperative hyperglyce- mia may cause osmotic diuresis and consequent dehydration. Pulmonary artery stenosis Pressure gradient of <80 mmHg – Following emergency surgery, water and electrolyte balance Tetralogy of Fallot Pregnancy and delivery are danger- ous if are prone to be out of order. If hypokalemia is present, hematocrit is >– 60%; patients are more prone to develop atrial fibrillation and ven- arterial oxygen saturation is tricular extrasystole.25 <– 80%; or Prolonged bed rest after emergency surgery may induce increased right ventricular pres- venous thrombosis and pulmonary embolism. If a venous sure had developed or syncope has occurred. line was placed in femoral vein or leg vein before surgery, it Cyanotic complex cardiac No consensus should be changed to a new position in the upper extremities anomalies after the patient’s condition has stabilized. Eisenmenger syndrome Contraindicated Marfan syndrome No expansion of the ascending aorta iv) Injuries to the Heart or Thoracic Great Vessels Associated With Multiple Trauma Thoracic aorta injury account for many death after blunt trauma, althogh their frequency among total cases is not cardiac complications. Physicians must pay special attention high.26,27 Thoracic aorta injury often occur in the ascending to possible ischemic heart disease, since emergency surgery aorta and the proximal descending aorta. Since patients with is often initiated without performing coronary angiography, ascending aorta injury often fall into catastrophic condition namely, the only method for its definitive evaluation. rapidly, physicians treat patients mainly with injuries of the proximal descending aorta. When chest X-ray reveals a wid- i) Preoperative Management ened mediastinum and a large volume of pleural effusion or Especially in patients with trauma, it is often difficult to ob- when echocardiography reveals pericardial effusion, CT and tain sufficient information before emergency surgery. It is transesophageal echocardiography should be performed to preferable that physicians be aware of the possibility of heart exclude aortic injury prior to noncardiac surgery. disease. Physicians should assess the presence/absence of Priority of treatment in patients with multiple trauma de- known risk factors for heart disease whenever possible. When pends on individual cases. When the aorta is repaired first, arteriosclerotic lesions or other findings known to be asso- blood loss during extracorporeal circulation will be a concern, ciated with heart disease are present, physicians should as- while if noncardiac surgery is performed first, perioperative sume that the patient has heart disease and manage them as aortic rupture may develop. When aortic injury is managed such. A history of “asthma” is a word of caution, and may in conservatively, the patient should be carefully evaluated to fact represent heart failure. find out conditions requiring aggressive surgical treatment. Physicians should carefully examine the ECG for findings CT is the most useful method for objective evaluation in suggestive of myocardial ischemia, and consider coronary such circumstances. artery disease a possible cause of ventricular extrasystole, bradycardia, and/or blocks. When left ventricular hypertrophy is present, the presence of aortic stenosis or cardiomyopathy 3. Pregnancy/Delivery and Heart Disease should be suspected. Chest X-ray should be carefully evaluated for cardio- (1) Pregnancy and Delivery in Patients With Congenital megaly, pulmonary congestion, and aortic calcification. Heart Disease It is quite important to improve general condition before Pregnancy and delivery pose no serious threats in women surgery. Anemia, hypovolemia, poor oxygenation, and periph- who had undergone corrective surgery for simple heart mal- eral hypoperfusion must be treated to the extent possible. formation or tetralogy of Fallot and have New York Heart Association (NYHA) Class II or better cardiac function. How- ii) Intraoperative Management ever, women should be carefully evaluated for remaining The ECG is often the only continuous monitor available dur- defects, since heart failure and/or arrhythmia may develop and ing surgery. Since bleeding and evaporation may exacerbate cyanosis may be exacerbated during pregnancy and deliv- hypovolemia and anemia, patients should be carefully moni- ery.28,29 Table 7 outlines the safety of pregnancy and delivery tored for myocardial ischemia. When ST change, hypotension, for women with uncorrected congenital heart disease.29–32 or frequent arrhythmia occurs, hemodynamics and cardiac Although cases of pregnancy and delivery in women with function should be evaluated using the ECG and transesoph- cyanotic complex cardiac anomalies such as complete trans- ageal echocardiography, and appropriate treatment should position of the great arteries, tricuspid atresia, and univen- be given. When heart failure or arrhythmia occurs, it is essen- tricular heart who have or have not undergone corrective tial to control water balance, electrolyte balance, and ane- surgeries have been reported, the risk of death and compli- mia, if present. Since the incidence of ventricular fibrillation cations including fetus associated with pregnancy is quite increases when the body temperature is 34°C or lower, hypo- high in this population. Live birth is rare among women with thermia should be prevented.24 Patients are especially prone an arterial oxygen saturation ≤85%.33 Among women with

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Table 8. Recommendations for Anticoagulation Therapy Table 9. Antibiotic Prophylaxis During Labor and Delivery During Pregnancy in Patients With Mechanical 1. Standard regimen Prosthetic Valves (Ampicillin, gentamicin, and amoxicillin) a) Weeks 1 through 35 • Initial dose Class I 30 minutes before procedure: Ampicillin 2 g plus gentamicin 1. The decision whether to use heparin during the first 1.5 mg/kg (maximal dose 80 mg) IV or IM trimester or to continue oral anticoagulation throughout • Next dose pregnancy should be made after full discussion with the 6 hours after initial dose: Amoxicillin 1.5 g PO (if this is not patient and her partner; if she chooses to change to possible, repeat the initial-dose regimen 8 hours after initial heparin for the first trimester, she should be made aware dose) that heparin is less safe for her, with a higher risk of both 2. Allergic to ampicillin, amoxicillin, or penicillin thrombosis and bleeding, and that any risk to the mother (Vancomycin and gentamicin) also jeopardizes the baby. • Initial dose 2. High-risk women (a history of thromboembolism or an 1 hour before procedure: Vancomycin 1 g IV (over >– 1 hour) older-generation mechanical prosthesis in the mitral plus gentamicin 1.5 mg/kg (maximal dose 80 mg) IV or IM position) who choose not to take warfarin during the first trimester should receive continuous unfractionated • Next dose (if necessary) heparin intravenously in a dose to prolong the mid-inter- 8 hours after initial dose: Repeat the initial-dose regimen val (6 hours after dosing) aPTT to 2 to 3 times control. 3. Low-risk patients (Amoxicillin) Transition to warfarin can occur thereafter. • Initial dose Class IIa 1 hour before procedure: Amoxicillin 3 g PO In patients receiving warfarin, INR should be maintained • Next dose between 2.0 and 3.0 with the lowest possible dose of warfa- 6 hours after initial dose: Amoxicillin 1.5 g PO rin, and low-dose aspirin should be added. IV, intravenous injection; IM, intramuscular injection; PO, oral Class IIb administration. Women at low risk (no history of thromboembolism, newer Adapted from Elkayam U, Pregnancy and cardiovascular disease. low-profile prosthesis) may be managed with adjusted-dose In: Braunwald E, editor. Heart disease. A textbook of cardiovas- subcutaneous heparin (17,500 to 20,000 U BID) to prolong cular medicine, 5th edn. W.B. Saunders Company, 1997; 1843– the mid-interval (6 hours after dosing) aPTT to 2 to 3 times 186430; with permission from Elsevier Inc. control. b) After the 36th week Class IIa cause hypovolemia and result in suboptimal uteroplacental 1. Warfarin should be stopped no later than week 36 and 30,38 heparin substituted in anticipation of labor. circulation. Percutaneous mitral valvuloplasty may be 2. If labor begins during treatment with warfarin, a Caesar- indicated for severe mitral stenosis before pregnancy. When ian section should be performed. heart failure not responding to medical therapy develops 3. In the absence of significant bleeding, heparin can be during pregnancy, physicians should consider percutaneous resumed 4 to 6 hours after delivery and warfarin begun mitral valvuloplasty.30 Pregnancy and delivery in women with orally. acquired aortic stenosis should be treated similarly to that aPTT, activated partial thromboplastin time; INR, international in those with congenital aortic stenosis. Mitral insufficiency normalized ratio; U, unit; BID, twice a day. and aortic insufficiency may often be treated with medical Adapted from J Am Coll Cardiol 1998; 32: 1486–158839, with per- therapy when patient’s condition is not severe. Angiotensin mission from Elsevier Inc. converting enzyme (ACE) inhibitors must be avoided during pregnancy, since these drugs will affect the development of the fetus. Surgery before pregnancy should be considered complete transposition of the great arteries who have under- when women with severe valvular disease wish to become gone the atrial switch operation, special care should be taken pregnant. for those with decrease in function of the anatomical right ventricle, those complicated with atrioventricular valve regur- (3) Pregnancy and Delivery in Patients With Mechanical gitation, and those complicated with sinus dysfunction. Data Prosthetic Valves are limited on pregnancy and delivery in women following Table 8 shows the recommendations for anticoagulation ther- the Fontan procedure. apy in pregnant women with mechanical prosthetic valves.39 In women with Ebstein’s malformation, the type and inci- Both warfarin and heparin may pose the risk of bleeding and dence of complications such as right heart failure, para- thrombosis in the mother and the fetus. Warfarin, which doxical embolism, and infectious endocarditis depend on the passes through the placenta, increases the incidences of spon- severity of tricuspid insufficiency, presence/absence of exist- taneous abortion, premature birth, and stillbirth, and causes ing right heart failure, and severity of cyanosis.34 Although fetal malformation in 0 to 20% of mothers receiving warfarin the presence of cyanosis increases the incidence of compli- (the average incidence in the four most recent reports is cations of pregnancy and delivery,35 a number of successful 1.6%). The risk of fetal malformation is especially high when pregnancies and deliveries in women with Ebstein’s malfor- warfarin is administered during weeks 6 to 12 of gestation.38 mation have been reported.36 Although heparin therapy is considered safe, since it does not pass through the placenta, long-term heparin therapy may (2) Pregnancy and Delivery in Women With Valvular cause such as noninfective abscess, osteoporosis, thrombo- Disease cytopenia, and bleeding.39 It has been reported that thrombo- Pregnant women with mild or moderate mitral stenosis may embolism occurs in 4 to 14% of patients receiving adequate receive diuretics and β blockers to prevent and treat con- anticoagulation therapy with heparin.40–42 gestive heart failure and tachycardia,37 respectively. Diuretics Bioprosthetic valves are believed to be a good option for should be used carefully, since excessive use of them may women who wish to become pregnant, since anticoagulation

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Table 10. Effects of Cardiovascular Drugs During Pregnancy Drug Potential fetal adverse effects Safety Warfarin Fetal bleeding in utero, embryopathy, CNS abnormalities Unsafe Heparin None reported Probably safe Digoxin Low birth weight Safe Quinidine Toxic dose may induce premature labor and cause damage to fetal eighth cranial nerve Safe Procainamide None reported Not established Disopyramide May initiate uterine contractions Not established Lidocaine In high blood levels and fetal acidosis may cause CNS depression Safe Fetal bradycardia, intraurine growth retardation, low Apgar score, neonatal hypoglycemia, Mexiletine Not established neonatal bradycardia, neonatal hypothyroidism Flecainide One reported fetal death Not established Amiodarone Intraurine growth retardation, prematurity, hypothyroidism Unsafe Calcium blockers Fetal distress due to maternal hypotension Not established Intraurine growth retardation, apnea at birth, bradycardia, hypoglycemia, hyperbilirubinemia β blockers Safe β2 blockers may initiate uterine contractions Hydralazine None reported Safe Sodium nitroprusside Potential thiocyanate toxicity with high dose, fetal mortality with nitroprusside in animal studies Potentially unsafe Organic nitrates Fetal bradycardia Not established Skull ossification defect, intraurine growth retardation, premature deliveries, low birth weight, oligo- ACE inhibitors Unsafe hydramnios, neonatal renal failure, anemia and death, limb contractures, patent ductus arteriosus Diuretics Impairment of uterine blood flow, thrombocytopenia, jaundice, hyponatremia, bradycardia Potentially unsafe CNS, central nervous system; ACE, angiotensin converting enzyme. Adapted from J Am Coll Cardiol 1998; 32: 1486–158839, with permission from Elsevier Inc. therapy is not necessary in patients with such valves unless be low, and it is not generally recommended that patients in they have a history of atrial fibrillation or thromboembo- this population receive antibiotic prophylaxis. However, anti- lism. However, it is known that bioprosthetic valves deterio- biotic prophylaxis during delivery is performed in patients rate more rapidly in young patients, and reports have noted with prosthetic valves, those with a history of endocarditis, that deterioration of bioprosthetic valves is further promoted those following corrective surgery of congenital heart mal- during pregnancy.38,42,43 Physicians should adequately explain formation (depending on condition), those following shunt to patients the fact that they may have to undergo reopera- surgery, and those with mitral prolapse or insufficiency.30 tion earlier as a result of pregnancy. Table 9 shows common methods of antibiotic prophylaxis.30

(4) Prevention of Infection During Pregnancy and (5) Effects of Cardiovascular Drugs During Pregnancy Delivery in Patients With Heart Disease Table 10 presents the current findings on cardiovascular The incidence of infective endocarditis after uncomplicated drugs commonly used during pregnancy.30,39,44 vaginal delivery in women with heart disease is believed to

II Descriptions

1. Ischemic Heart Disease (2) Severity Evaluation and Risk The severity of myocardial ischemia is correlated with angio- graphic findings such as the number of affected vessels, level (1) Diagnosis of stenosis, and presence/absence of stenosis in the left main Physicians should interview patients for subjective symptoms, trunk, as well as the severity of angina. Evaluation of cardiac personal and family history of ischemic heart disease, and function and degree of mitral regurgitation is quite important the presence/absence of coronary risk factors and conditions for appropriate perioperative management of patients under- frequently associated with ischemic heart disease. It should going noncardiac surgery. be noted that patients with diabetes and elderly patients often do not complain of significant symptoms of angina. It is (3) Special Management important to check for exertional angina as well as atypical The indications for coronary revascularization as a part of angina due to coronary spasm. It is common for the chest management of patients undergoing noncardiac surgery are X-ray to reveal few findings typical of ischemic heart disease, basically identical to those in patients in general. However, and ECG at rest in the absence of anginal attacks is normal. transcatheter intervention on PCI is especially preferred to Definitive diagnosis of ischemic heart disease can be made bypass surgery in patients whose noncardiac disease has a with coronary angiography. Figure 1 shows a flow chart for poor prognosis and those in poor general condition including considering indications for coronary angiography according bleeding tendency. to risk of noncardiac surgery.21 There are several issues for patients whom CABG is indicated. Off-pump CABG and minimally invasive direct coro-

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Step 1 Noncardiac surgery Emergency surgery Surgery Elective surgery Step 2 History of coronary ≤ 5 years previously Asymptomatic revascularization PCI: No restenosis on confirmatory angiography at month 6 Surgery CABG: Arterial grafts only Surgery Recurrence of symptoms Unsuccessful cases, incomplete revascularization ≥ 5 years after revascularization CABG: Venous grafts used Step 3 Coronary angiography Contrast imaging; Good results & Surgery ≤ 2 years previously no changes in clinical symptoms

Contrast imaging; Poor results or changes in clinical symptoms No imaging study

Risk of ischemic heart disease

Step 4 Step 5 Step 6 High Intermediate Low Acute myocardial infarction Mild angina (CCS I or II) Abnormal ECG without ≤ 30 days after onset Clinical symptom of ischemic heart disease abnormal Q waves Unstable angina History of myocardial infarction with Severe angina (CCS III or IV) abnormal Q waves Decompensated heart failure Compensated heart failure History of heart failure Step 6 Step 7 Coronary angiography Exercise capacity Exercise capacity

Decreased (< 4 METs) > 4 METs Decreased (< 4 METs) > 4 METs

Coronary angiography Risk of noncardiac surgery (Table 1)

High/intermediate Low High Intermediate/low

Coronary angiography Surgery Coronary angiography Surgery

Figure 1. Flow chart of preoperative cardiac evaluation including coronary angiography. PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; CCS, Canadian Cardiovascular Society; METs, metabolic equivalents. *Evaluation may include echocardiography, myocardial imaging, exercise stress testing, other than exercise stress testing, and Holter ECG. Consider cost-effectiveness of each testing.

nary artery bypass (MIDCAB) have been gaining popularity45 In patients undergoing PCI prior to noncardiac surgery, it although no consensus exists about the effects of extracor- has been recommended that conventional PCI without stent- poreal circulation on malignant tumors. It is also important ing be performed about 1 to 2 weeks prior to noncardiac whether coronary revascularization and noncardiac surgery surgery. However, PCI using stents, especially DES, requires should be performed simultaneously or as two-stage surgery. potent anticoagulation therapy for a longer period of time, Physicians should determine the schedule of surgeries care- which may pose risks during noncardiac surgery and signifi- fully considering surgical invasiveness, posture during sur- cantly affect the timing of noncardiac surgery. The use of gery, risk of surgical site contamination, and urgency of non- DES should be considered only in selected cases (Table 4).18 cardiac surgery. If two-stage surgery is a choice, patency of bypass grafts and perioperative drug treatment will be major (4) Intraaortic Balloon Pumping concerns in patients undergoing CABG first, while preven- Although intraaortic balloon pumping (IABP) may increase tion of perioperative myocardial infarction will be important coronary blood flow, support cardiac function, and decrease in patients undergoing noncardiac surgery first. afterload, the efficacy of perioperative IABP use in patients

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Severity of aortic stenosis, physical findings, ECG, chest X-ray

Symptomatic Asymptomatic Echocardiography, cardiac catheterization, Echocardiography coronary angiography

Moderate to severe Mild Moderate to severe Mild

Pressure gradient ≥ 50 mmHg Pressure gradient < 50 mmHg Pressure gradient ≥ 50 mmHg Pressure gradient < 50 mmHg Valve orifice area ≤ 1.0 cm2 Valve orifice area > 1.0 cm2 Valve orifice area ≤ 1.0 cm2 Valve orifice area > 1.0 cm2

Determine according to cardiac function as evaluated with echocardiography and Perform aortic valve replacement first degree of invasion of noncardiac surgery Perform noncardiac surgery first

Figure 2. Treatment strategies for noncardiac surgery in patients with aortic stenosis.

undergoing noncardiac surgery has not been established. cant, and diagnosis and investigation of them are required. It IABP support may be continued before and throughout sur- is quite rare for functional murmurs with a grade ≥ III to IV gery. A trocar may be placed in the femoral artery before sur- on the Levine scale to be heard, but the loudness of murmurs gery to ensure prompt insertion of IABP, or emergency IABP depends on body size and does not accurately reflect the may be initiated during or after surgery. It should be noted severity of valvular disease. that certain body positions hinder the use of IABP. (1) Valvular Diseases and Noncardiac Surgery (5) Precautions Regarding Anesthesia and Perioperative i) Aortic Stenosis Management in Patients Undergoing Noncardiac Severe aortic stenosis is one of the most important risk fac- Surgery tors for cardiac complications during noncardiac surgery.46 Anesthesia should be induced with fentanyl, which causes It is preferable that noncardiac surgery be avoided or aortic fewer hypotension, and benzodiazepines such as midazolam valve replacement be performed prior to noncardiac surgery and diazepam, and should be maintained with neuroleptanal- in patients with symptomatic aortic stenosis with a left ven- gesia (NLA). Combined use with epidural anesthesia has been tricular-aortic pressure gradient of ≥50 mmHg, syncope, angi- reported to be useful. When coronary vasodilators are used, nal pain, and/or left heart failure (Figure 2).47 physicians should be aware of the characteristics of drugs, i.e. low incidence of hypotension (Nitrol and nicorandil), ii) Mitral Insufficiency short duration of action after withdrawal (nitroglycerin), and No specific measures are required during noncardiac surgery in inhibition of spasm and slowing of heart rate (diltiazem), patients with mild or moderate mitral regurgitation and with- and should select appropriate drugs according to patient’s con- out signs/symptoms of heart failure. However, antibiotic pro- dition. Small doses of dopamine may be useful to treat hypo- phylaxis is needed to prevent infectious endocarditis. Mitral tension during surgery. Patients with severe coronary spasm valve surgery such as valvuloplasty and prosthetic valve re- should be treated with adequate doses of calcium blockers, placement should be performed first in patients with grade undergo measures to prevent hypothermia and respiratory ≥ III mitral regurgitation and signs/symptoms of heart failure. alkalosis, and have their blood pressure adequately controlled. It should be noted that mitral insufficiency often cause a seem- During noncardiac surgery in patients with frequent ven- ingly favorable left ventricular ejection fraction. Perioperative tricular extrasystoles, physicians should infuse lidocaine con- antibiotic therapy is required to prevent infections not only in tinuously, monitor and maintain serum potassium level, and patients with clinically significant mitral valve prolapse but also keep an external defibrillator ready for use. “Precautions for in asymptomatic patients in whom echocardiography reveals anesthesia in cardiac surgery” should be followed. findings of mitral regurgitation or thickened valve leaflets.48

iii) Tricuspid Insufficiency 2. Valvular Heart Disease Since patients with severe tricuspid insufficiency may exhibit significant hepatic congestion possibly resulting in hepatic When cardiac murmur is heard prior to noncardiac surgery, disorders such as hepatic cirrhosis, modification of treatment physicians must identify the cause of the murmur, consider strategies is often required if high-risk noncardiac surgery is whether the murmur reflects a serious condition or not, to be performed. whether further assessment is needed to investigate its severity, and whether prevention of infectious endocarditis is required. iv) Aortic Insufficiency Diastolic murmurs are almost always pathologically signifi- In patients with aortic regurgitation of grade II or less, noncar-

Circulation Journal Vol.75, April 2011 JCS Guidelines for Perioperative Cardiovascular Management for Noncardiac Surgery 999 diac surgery may be performed before cardiac surgery when plasty is believed to reduce the risks of such surgery, and appropriate measures including the prevention of infectious therefore to be beneficial.52 However, mitral valve replace- endocarditis are taken. In patients with aortic regurgitation ment is required in patients with atrial fibrillation, those with of grade III or higher and those with clinical symptoms, phy- left atrial thrombus, and patients with very severe valve sicians should be aware that the risk of noncardiac surgery lesions.53 Balloon valvuloplasty for aortic stenosis is not is, depending on the type of surgery performed, often sig- recommended. Since only limited data are available to this nificantly high when performed prior to surgical treatment procedure, and the risk in elderly patients is quite high. of aortic regurgitation. Fatal arrhythmia may occur in this patient population, and perioperative management is difficult. (3) Management of Patients With Valvular Disease Although the risk of noncardiac surgery varies according to During Noncardiac Surgery the type of procedure, it is preferable that surgical treatment In patients with valve regurgitation, low peripheral vascular of aortic valves be performed first before left heart function resistance is important. Hypertension is harmful, vasodilators has significantly exacerbated.49–51 should be used if necessary. On the other hand, patients with severe valve stenosis are often unable to accommodate hemo- v) Mitral Stenosis dynamic changes due to fluid overload. Volume overload Most noncardiac surgical procedures may be performed in pa- induces congestive heart failure, while excessive dehydration tients with mitral stenosis with a valve orifice area of≥ 1.5 cm2. may cause circulatory collapse. Water balance should be However, heart rate should be controlled during the peri- managed strictly, especially in patients with aortic and mitral operative period, since tachycardia may induce serious pul- stenoses regardless of the severity of valve lesions. Since monary congestion. It is preferable that patients with severe arrhythmia often occurs in patients with valvular diseases, mitral stenosis undergo percutaneous transcatheter balloon appropriate antiarrhythmic therapy and heart rate control mitral commissurotomy, or surgical commissurotomy or play key roles during the perioperative period. mitral valve replacement before undergoing high-risk non- 47 cardiac surgery. 3. Treatment of Congenital Heart Disease vi) Prosthetic Valves Before Corrective Surgery In order to prevent infectious endocarditis during the perioperative period, antibiotics should be administered to patients The mortality after noncardiac surgery in neonates and in- with prosthetic valves from the day before noncardiac surgery fants with congenital heart disease is about twice that in until laboratory data, such as leukocyte count and C-reactive those without it, and it has been reported that the presence of protein (CRP), normalize, for example, 7 days after surgery. congenital heart disease significantly increases the risk of Anticoagulation therapy should be adjusted according to mortality even after minor noncardiac surgery.54 individual patient condition, considering the effects of anticoagulants that have been decreased in dose and the effects (1) Neonates and Infants of heparin initiated during the perioperative period. Although The prevalence of heart disease in neonates is 13.2 to 43% patients with prosthetic valves used do discontinue anti- among those with esophageal atresia, 9 to 12.1% among those coagulation therapy for about 3 days prior to less invasive with anal atresia, 13.9 to 45.5% in those with exomphalos, procedures (such as dental treatment and surface biopsy), it is 17.9 to 33% in those with duodenal atresia, and 10.5 to 12.5% becoming a common practice that anticoagulation therapy is in those with diaphragmatic hernia.55–63 Children born with continued for less invasive procedures such as dental treat- conditions requiring surgical treatment immediately after ment. Perioperative heparin therapy is recommended for birth should be evaluated with echocardiography. patients in whom the risk of bleeding is high when receiving Although the methods of surgical correction of anal atresia oral anticoagulants and the risk of thromboembolism is also and intestinal atresia/stenosis are well established, the mor- high in the absence of anticoagulant (e.g., patients with a tality rates of neonates and infants with large exomphalos and mitral valve prosthesis are to undergo major surgery). When- diaphragmatic hernia are still high. In such infants, it is quite ever possible, anticoagulation therapy should be discon- difficult to perform surgical correction of heart disease during tinued one week before surgery, and heparin therapy should early infancy. In children with esophageal atresia and heart be initiated when prothrombin time and international normal- disease, correction of esophageal atresia is often performed ized ratio (PT-INR) decreases below the therapeutic range. first. However, no consensus has been reached regarding the Although the optimal dose differs among individuals, heparin timing of heart surgery (before or after correction of esopha- should be administered by continuous intravenous infusion geal atresia) or the strategy of treatment for esophageal atre- at a dose of about 5,000 to 15,000 units/day until the day of sia (one- or two-stage corrective surgery). surgery. Following surgery, the absence of postoperative In neonates with congenital heart diseases that increase pul- bleeding must be confirmed, and administration of antico- monary blood flow, surgical correction of noncardiac disease agulants at regular doses should be resumed when patients may be performed during the first several days of life, during can take drugs orally. When that is impossible, heparin should the period when pulmonary vascular resistance remains high, be administered as mentioned above until treatment with oral while in neonates with congenital heart diseases that decrease anticoagulants can be resumed. pulmonary blood flow, noncardiac surgery may be performed when cyanosis has improved by treatment with prostaglandin (2) Treatment of Valvular Disease Before Noncardiac (PG) E1 (0.05 to 0.1 μg/kg/min) to a stable hemodynamic con- Surgery dition.55 No consensus exists regarding treatment strategy or Cardiac surgery is the only option available for patients with the order of cardiac and noncardiac surgeries in patients with severe valve insufficiency. When patients with severe mitral complex heart disease who exhibit cyanosis and increased stenosis need emergency noncardiac surgery such as repair for pulmonary blood flow. serious gastrointestinal bleeding, catheter balloon valvulo- Many types of congenital heart diseases can be diagnosed

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Table 11. Cardiac Risk Factors in Adult Patients With Table 12. Severity of Residual Problems Following Corrective Congenital Heart Disease Surgery 1) Major risk factors: Fatal cardiac complications may occur. Pulmonary hypertension (pulmonary arterial systolic pressure) Cardiac repair may be indicated first in some conditions. Mild 30 to 50 mmHg * Eisenmenger syndrome Moderate 50 to 70 mmHg * Significant persistent lesions/complications following repar- Severe >70 mmHg ative surgery – Pulmonary artery stenosis or extracardiac conduit stenosis * Decompensated heart failure Right ventricular Pressure gradient * Severe hypoxemia (untreated cyanotic heart disease, follow- pressure (extracardiac conduit ing palliative surgery) (pulmonary artery stenosis) * Severe arrhythmia stenosis) Recommended management: Patients should be admitted to Mild 50 to 70 mmHg 30 to 60 mmHg the intensive care unit (ICU) for perioperative management by Moderate 70 to 100 mmHg 60 to 90 mmHg specialists. Discontinuation or postponement of non-urgent noncardiac surgery is preferable. If corrective treatment (includ- Severe >– 100 mmHg >– 90 mmHg ing catheter techniques, and/or pacemaker placement) is indi- Persistent left-to-right shunt cated for heart disease, it should be treated first. Pulmonary to systemic flow ratio (Qp/Qs) 2) Intermediate risk factors: Factors that increase the risk of Mild <1.5 perioperative cardiac complications. Patient’s condition should be carefully evaluated. Moderate 1.5 to 2.0 * Moderate persistent lesions/complications following repara- Severe >– 2.0 tive surgery * Compensated heart failure * Following palliative surgery (hypoxemia is present) noncardiac surgery is planned, patients should be evaluated Recommended management: Patients should be evaluated for cardiovascular abnormality in detail. If the results are poor, using necessary and sufficient intraoperative monitoring, and cardiac surgery or catheter intervention prior to noncardiac should be considered for treatment in the ICU during periop- surgery may be considered. erative period whenever necessary. 3) Mild risk factors: Cardiovascular abnormalities that have (2) Cardiac Risk Factors During the Perioperative not themselves been demonstrated to increase the risk Period of perioperative cardiac complications. Table 11 lists common risk factors in adult patients with * Congenital heart disease not requiring repair congenital heart disease.21 * Patients after cardiac repair in whom continued treatment is not required (3) Examinations Used in Preoperative Evaluation of Risk Factors All patients with congenital heart disease require preoperative with echocardiography, and cardiac catheterization and/or evaluation with 12-lead ECG, chest X-ray, and echocardiogra- angiography is rarely required. phy. While arterial blood gas analysis, pulmonary ventilation/ perfusion scintigraphy, and Holter ECG may be necessary in (2) Young Children some cases, exercise stress testing and cardiac catheterization Baum et al reported that, in children ≥1 year of age, the mortal- are indicated for only a small number of patients. ity after noncardiac surgery was slightly higher in those with cardiac disease,54 though the difference was not significant. (4) Criteria for Severity of Persistent Heart Lesions Pulmonary hypertension (PH) and severe cyanosis and so on Table 12 presents the criteria for severity of heart lesions re- are considered as risk factors for mortality after noncardiac maining after corrective surgery for congenital heart disease.64 surgery, though no evidence has been obtained for this. Clini- cal experience has suggested that children following palliative (5) Problems Following Corrective Surgery surgeries such as shunt surgery and the Glenn procedure can Following corrective surgery for acyanotic congenital heart tolerate noncardiac surgery well. When anesthetic procedures disease, patients may experience embolism secondary to atrial requiring mechanical ventilation are performed, prompt extuba- arrhythmia/fibrillation; congestive heart failure due to a tion may be preferable for ensuring favorable hemodynamics. residual shunt; severe PH; mitral insufficiency/stenosis or left ventricular outflow obstruction following correction of atrioventricular septal defect; and restenosis of repaired aortic 4. Adults With Congenital Heart Disease coarctation, among other conditions. Patients born with cyanotic complex cardiac anomaly may (1) Cardiovascular Evaluation Prior to Noncardiac often require reoperation at a later age even if they are treated Surgery with corrective surgery. Depending on the procedure of the Patients with congenital heart disease planned to undergo non- corrective surgery, patients may exhibit characteristic hemo- cardiac surgery should be evaluated for history of cardiac sur- dynamic changes for which special management may be gery and the procedures used, presence/absence and type of needed during noncardiac surgery. Patients with the condi- persistent heart lesions, complications and sequelae of heart tions listed in Table 12,64 valvular regurgitation, or serious disease, clinical course after heart surgery, and current condi- arrhythmia must be treated especially carefully. Patients with tion. following conditions need special care: for patients after atrial In patients planned to undergo low-risk noncardiac surgery switch operation, vena cava obstruction, pulmonary venous as defined in the ACC/AHA Guidelines,21 routine preopera- stenosis, right ventricular dysfunction which acts as systemic tive evaluation is sufficient. When high- or intermediate-risk ventricle. For patients after atrial switch operation, pulmonary

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Table 13. AHA Recommendations on Prophylactic Regimens Table 14. Indications for Surgical Treatment (Including for the Prevention of Infectious Endocarditis Interventions) of Aortic Aneurysms 1. Dental/upper respiratory tract procedures Indications for surgical treatment of true aortic aneurysm (1) Standard Class I: Amoxicillin 3 g PO (1 hour before procedure) + amoxicillin • Ruptured aortic aneurysm 1.5 g PO (6 hours after) • Ascending aortic aneurysm associated with severe compli- (2) High-risk patients cations (aortic insufficiency associated with heart failure, or Ampicillin 2 g + gentamicin 1.5 mg/kg IV or IM (30 minutes cardiac tamponade) before procedure) + amoxicillin 1.5 g PO (6 hours after) • Sinus of Valsalva aneurysm associated with intracardiac (3) Allergic to amoxicillin/penicillin shunt (ruptured sinus of Valsalva aneurysm) Erythromycin 1 g PO (2 hours before procedure) + erythromycin 0.5 g PO (6 hours after) • True TAA >– 6 cm of maximal diameter or Class IIa: Clindamycin 300 mg PO (1 hour before procedure) + clinda- • True TAA >– 5 cm in diameter in patients with Marfan syn- mycin 150 mg PO (6 hours after) drome 2. Gastrointestinal/genitourinary procedures • True TAA 5 to 6 cm in diameter (1) Standard • Saccular aortic aneurysm Ampicillin 2 g + gentamicin 1.5 mg/kg IV or IM (30 minutes before procedure), amoxicillin 1.5 g PO (6 hours after) • True TAA associated with rapid expansion in diameter (>5 mm/6 months) (2) Allergic to ampicillin/amoxicillin/penicillin Vancomycin 1 g IV + gentamicin 1.5 mg/kg IV or IM (1 hour Class IIb: before procedure); may be repeated 8 hours after. • True TAA 4 to 5 cm in diameter (3) Low-risk patients Indications for surgical treatment of false aortic aneurysm Amoxicillin 3 g PO (1 hour before procedure) + amoxicillin Class I: All diagnosed false aortic aneurysms not associated 1.5 g PO (6 hours after) with other organ injuries PO, oral administration; IV, intravenous injection; IM, intramuscu- Class IIb: False aortic aneurysm associated with other organ lar injection. injuries Adapted from JAMA 1990; 264: 2919–292248, with permission from American Medical Association. Indications for surgical treatment of dissecting aortic aneurysm Class I: • Type A acute dissection with patent false lumen (type I, II artery stenosis. Patients who had undergone Fontan operation dissecting, type III retrograde) are prone to heart failure. About 10 years after the Fontan oper- • Aortic dissection with severe complications which surgery ation, patients are prone to develop supraventricular arrhyth- may improve or prevent progression of ruptured false lumen, mias, thromboembolism, protein-losing gastroenteropathy, redissection, cardiac tamponade, circulatory disorder asso- hepatic congestion, hepatic dysfunction, decrease in cardiac ciated with loss of consciousness and paralysis, aortic function, or other abnormal conditions, and thus require care- insufficiency associated with heart failure, myocardial infarction, blood flow disturbance in the visceral organs or ful management. the extremities • Aortic dissection associated with aortic expansion (>6 cm (6) Problems With Uncorrected Congenital Heart Disease of maximal diameter) No special perioperative management is required for non- • Chronic dissection associated with rapid aortic expansion cardiac surgery in patients with congenital heart disease not in diameter (>5 mm/6 months) indicated for surgery such as small atrial or ventricular septal Class IIa: defect and acyanotic tetralogy of Fallot. Many patients with • Aortic dissection not responding to blood pressure control large uncorrected left-to-right shunt exhibit Eisenmenger syn- and pain drug control drome, and the risk of noncardiac surgery is quite high in • Aortic dissection associated with Marfan syndrome these patients. Patients with cyanosis must be carefully man- Class IIb: aged for hypoxemia, polycythemia, prevention of visceral • Type A acute dissection with occluded false lumen disorder, brain abscess, and infectious endocarditis. • Aortic dissection 5 to 6 cm of maximal diameter (7) Important Aspects of Perioperative Management TAA, thoracic aortic aneurysm. Perioperative management of patients with a history of congenital heart disease who are undergoing noncardiac surgery is performed mainly to prevent heart failure, hypoxemia, and racic aortic aneurysm (TAA). arrhythmias. Selective pulmonary vasorelaxants are effective Most patients with true aortic aneurysm, other than those in patients with right ventricular failure. It is important to pre- with ruptured aortic aneurysm or impending aneurysm rup- vent infectious endocarditis, air embolism, and brain abscess ture, are asymptomatic.65,66 When aortic aneurysm is sus- in patients with cyanotic heart disease. Table 13 lists the pected on chest X-ray or other examinations, contrast CT or AHA’s recommendations on antibiotic treatment for the pre- magnetic resonance imaging (MRI) should be performed to vention of infectious endocarditis.48 confirm the diagnosis.67,68 Avoidance of angiography is increasingly common now. False aortic aneurysm developes mainly after injury, but 5. Aortic Diseases is often overlooked during the period immediately after its development. Since the risk of rupture is high, patients diag- (1) Diagnosis and Evaluation of Thoracic Aortic nosed with false aortic aneurysm should be transferred as Aneurysm During Noncardiac Surgery soon as possible to institutions where appropriate treatment Table 14 lists the indications for surgical treatment of tho- is available.

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Class I • Malignant tumors (advanced cancer, Perform aortic surgery • Ruptured TAA cancer requiring highly first or simultaneously • False aortic aneurysm (excluding those invasive surgery) surrounded by significant adhesion) • Cholelithiasis • Type A acute aortic dissection with patent false • Cerebral aneurysm lumen • Aortic dissection with severe complications which • Gastrointestinal bleeding surgery may improve or prevent disease Simultaneous surgery progression • Strangulation ileus

• Malignant tumors (advanced cancer, cancer requiring highly Perform aortic surgery Class I invasive surgery) later or simultaneously • Ascending aortic aneurysm associated with severe • Gastrointestinal bleeding complications • Strangulation ileus • True TAA ≥ 6 cm in diameter • Cerebral aneurysm • Aortic dissection with expansion > 6 cm of maximal diameter • Malignant tumors (slowly • Chronic dissection with rapid expansion of the progressive cancer, Perform aortic surgery aorta in diameter (> 5 mm / 6 months) cancer requiring less first or simultaneously invasive surgery) • Cholelithiasis

• Malignant tumors (advanced cancer, Class IIa cancer requiring highly Perform aortic surgery • True TAA ≥ 5 cm in diameter in patients with invasive surgery) later or simultaneously Marfan syndrome • Gastrointestinal bleeding • True TAA 5 to 6 cm in diameter • Strangulation ileus • Saccular aortic aneurysm • Cerebral aneurysm • True TAA with rapid expansion of the aorta in diameter (> 5 mm /6 months) • Malignant tumors (slowly • Aortic dissection not responding to blood pressure progressive cancer, control and pain drug control cancer requiring less Perform aortic surgery • Aortic dissection due to Marfan syndrome invasive surgery) first or simultaneously • Cholelithiasis

• Malignant tumors (advanced cancer, cancer requiring highly Perform aortic surgery invasive surgery) later Class IIb • Gastrointestinal bleeding • True TAA 4 to 5 cm in diameter • Strangulation ileus • False aortic aneurysm associated with other organ • Cerebral aneurysm injury • Acute aortic dissection with occluded false lumen • Malignant tumors (slowly • Aortic dissection 5 to 6 cm of maximal diameter progressive cancer, cancer requiring less Perform aortic surgery invasive surgery) first or simultaneously • Cholelithiasis

Figure 3. Guidelines for priority of aortic surgery and noncardiac surgery. TAA, thoracic aortic aneurysm.

Patients suspected to have acute aortic dissection should (2) Management of Aortic Aneurysm During undergo contrast CT to confirm the diagnosis under strict Noncardiac Surgery blood pressure control. Treatment of type A acute aortic dis- During noncardiac surgery, patients with aortic aneurysms section should be prioritized even when noncardiac surgery should be carefully observed for ischemic heart disease and is planned. Antihypertensive therapy is the treatment of first severe hypertension, that frequently co-exist. Although there choice for patients with type B acute aortic dissection. have been few reports about aortic aneurysm rupture during the perioperative period of noncardiac surgery, perioperative blood pressure control has been reported to be effective in preventing rupture of aortic aneurysms.69–71 When hyper-

Circulation Journal Vol.75, April 2011 JCS Guidelines for Perioperative Cardiovascular Management for Noncardiac Surgery 1003 tension is mild or moderate and no abnormal findings related disease should be carefully managed during the periopera- to hypertension are observed, noncardiac surgery may not be tive period of patients undergoing aortic aneurysm surgery. postponed. However, patients with severe hypertension require IABP support is often not feasible in this patient population. careful blood pressure control throughout the perioperative Since hemodynamics during the perioperative period are often period. In patients who cannot take drugs orally and who are unstable due to hypertension and systemic arteriosclerosis, going to undergo emergency surgery, intravenous infusion management of ischemic heart disease is more important dur- of antihypertensives is recommended.72 ing aortic surgery than other types of surgery. Patients with aortic disease requiring elective, nonurgent (3) Priority of Surgeries and Simultaneous Surgery surgery and symptomatic or severe coronary artery disease Abdominal aortic aneurysms (AAA) ≥6 cm in diameter should should undergo coronary surgery first, coronary surgery and be treated surgically before noncardiac surgery even when aortic aneurysm surgery simultaneously, or coronary inter- the latter involves surgery of malignant disease, or should be vention first. DES, which require long-term treatment with treated concomitantly during noncardiac surgery in the case potent antiplatelet drugs, are not feasible in patients planned of abdominal surgery.73,74 to undergo aortic aneurysm surgery after coronary stenting. Figure 3 shows the guidelines for priority of noncardiac When simultaneous surgery is selected, hybrid treatment, surgery and TAA surgery. Priority depends on the pathologi- namely, off-pump coronary bypass surgery and transcatheter cal conditions of aortic aneurysms and noncardiac diseases. coronary intervention should be considered. Patients with Further investigation of optimal management of aortic aneu- aneurysms in the descending aorta or thoracoabdominal aorta rysms in patients receiving noncardiac surgery is needed. may simultaneously undergo aortic surgery and bypass surgery to the left anterior descending artery and/or the circum- (4) Stent Grafting flex coronary artery. Although stent grafting for aortic aneurysm is not a standard treatment procedure in Japan, and is only available in limited ii) Valvular Heart Disease institutions, it may be used for the treatment of aortic aneu- When aortic surgery and valve surgery can be performed rysms depending on the anatomical and structural character- through the same incision, simultaneous surgery is feasible istics of lesions. It has been found that stent grafting improves provided that cardiac function is normal. Although no con- the short- and long-term prognosis of patients with relatively sensus has been reached regarding the optimal surgical treat- low risk of surgical complications who are likely to tolerate ment of aortic lesions and valvular lesions which cannot be conventional artificial vascular graft implantation with thora- treated through the same incision, it is important to consider cotomy or laparotomy, while it does not substantially improve stent grafting as an option. the prognosis of high-risk patients.75 Further clinical data and analyses are needed to determine the efficacy and safety of this technique. However, if outcome does not differ between 6. Peripheral Arterial Disease endovascular stent grafting and surgical grafting, stent graft- (Abdomen, Neck, and Lower Extremities) ing is worth considering because it is useful, less invasive option to treat aortic aneurysms in patients undergoing elec- Table 15 shows guidelines for evaluation and management tive noncardiac surgery to ensure a favorable clinical course of patients who have AAA, carotid artery stenosis, or arte- during the perioperative period of noncardiac surgery. riosclerosis obliterans (ASO) of the lower extremities and are to undergo noncardiac surgery under general anesthesia (5) Rare Heart Diseases (cases of emergency surgery for noncardiac diseases are i) Aortitis Syndrome (Takayasu Disease) excluded). Since peripheral arterial disease may develop as a Surgical treatment is required in 13% of patients with aor- result of arteriosclerosis, patients diagnosed with a vascular titis syndrome. To ensure the safety of noncardiac surgery, lesion must be examined for other vascular lesions. patients should be carefully observed for hypertension due to renal artery stenosis and heart failure associated with aortic (1) Abdominal Aortic Aneurysms regurgitation. Patients with active inflammation as suggested When patients with AAA undergo noncardiac surgery, they by a high CRP level should be treated with corticosteroids to should be carefully observed for rupture of aortic aneurysm, control inflammation and corticosteroid therapy should be embolism due to mural thrombi, and blood coagulation disor- reduced before noncardiac surgery when it is not urgently der during the perioperative period. It is believed that noncar- required. diac surgery before aneurysm surgery does not significantly increase the incidence of rupture. The indication for AAA ii) Marfan Syndrome surgery should be determined primarily without considering The outcome of cardiovascular surgery in patients with possible effects of noncardiac surgery, and the order of non- Marfan syndrome is excellent.76,77 When appropriate cardio- cardiac surgery and AAA surgery should be based on the vascular evaluation does not reveal abnormal findings, patients prognosis of AAA and noncardiac disease. Physicians should with Marfan syndrome may usually undergo conventional avoid performing gastrointestinal tract surgery and AAA sur- noncardiac surgery. gery simultaneously since vascular grafts may be contami- nated during surgery. (6) Management of Aortic Aneurysms in Patients In cases of spindle-shaped aneurysms ≥6 cm in diameter, With Other Heart Diseases which are known to have a high risk of rupture, and of sac- i) Ischemic Heart Disease cular aneurysms, symptomatic aneurysms, and infectious It has been reported that coronary lesions are observed in aneurysms regardless of the diameter, AAA surgery should one-eights of patients with aortic dissection and one-thirds be performed before noncardiac surgery or simultaneously of patients with true aortic aneurysm. Ischemic heart disease with it. Although it has been reported that peripheral arterial is more common among patients with AAA.72 Ischemic heart embolism develops in 3 to 29% of patients with AAA,78–80

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Table 15. Guidelines for Noncardiac Surgery in Patients With Peripheral Vascular Disease Peripheral vascular Evaluation Treatment disease Class I Class II Class III AAA Perform aortic surgery • Ruptured aneurysm • Spindle-shaped aneurysm • Slowly expanding spindle- first (or simultaneously • Symptomatic aneurysm 5 to 6 cm of maximal diam- shaped aneurysm <– 5 cm of in some noncardiac dis- • Spindle-shaped aneurysm eter maximal diameter eases) >– 6 cm of maximal diameter • Saccular aneurysm • Aneurysm with bleeding • Rapidly expanding aneu- tendency rysm • Infectious aneurysm • Aneurysm causing embolism Extracranial stenosis Perform carotid surgery • Symptomatic carotid steno- • Symptomatic carotid steno- • Symptomatic carotid steno- of carotid artery first (or simultaneously sis >– 70% sis 50 to 69% sis <– 49% in some noncardiac dis- • Asymptomatic carotid eases) stenosis ASO of the lower Treat ASO of the lower • Severe limb ischemia • Intermittent claudication extremities extremities first (or simultaneously in some noncardiac diseases) AAA, abdominal aortic aneurysm; ASO, arteriosclerosis obliterans. prediction of embolism is difficult. Patients with ecchymoses tremities is an important problem during the perioperative and prolonged hemostasis should be suspected to have con- period of noncardiac surgery. Careful monitoring should be sumption coagulopathy associated with aneurysms. The inci- performed, particularly in patients with severe chronic leg dence of coagulopathy tends to be high in patients with large ischemia whose blood pressure is of ≤50 to 70 mmHg in the aneurysms, and it is difficult to control blood coagulation foot joint and ≤30 to 50 mmHg in the toes.83 When acute ASO unless the aneurysm is surgically treated. of the lower extremity develops, amputation of the lower Patients with the following anatomical characteristics may extremities may be required, or reperfusion injury followed undergo stent grafting for the treatment of AAA, and may by multi-organ failure may occur. thus undergo noncardiac surgery earlier than those undergoing conventional aneurysm surgery. 7. Pulmonary Artery Disease 1) A 20 to 22 Fr catheter sheath may be inserted. 2) Infrarenal abdominal aorta (central landing zone) is 19 to Primary pulmonary artery disease that can coexist in paients 26 mm in diameter and ≥15 mm in length. undergoing noncardiac surgery are mainly idiopathic PH, 3) Infrarenal abdominal aorta with an angle of ≤60° relative familial PH, and chronic pulmonary thromboembolism, and to long axis of aneurysm. these entities are discussed here.84 When the following find- 4) Common iliac artery (distal landing zone) is 8 to 16 mm ings are noted in patients planned to undergo noncardiac sur- in diameter and ≥10 mm in length. gery, they should be suspected to have PH and carefully 5) Absence of bilateral common iliac aneurysms. evaluated for it.

(2) Carotid Artery Stenosis Clinical findings: Exertional dyspnea, leg edema, facial The carotid artery should be checked in patients with a history edema of cerebral infarction and those suspected to be experiencing Auscultation: Pulmonary diastolic murmur and apical a transient ischemic attack (TIA). Patients with carotid artery holosystolic murmur stenosis are at risk for cerebral infarction during the peri- Chest X-ray: Left second arc protrusion and decrease operative period of noncardiac surgery. Since the risk of in peripheral vessel shadow, left fourth cerebral infarction is high in males, patients with a history of arc protrusion cerebral infarction rather than TIA, patients with cerebral ECG: Findings of right ventricular overload hemisphere signs and symptoms rather than amaurosis, carotid (S1Q3T3 and S1S2S3 patterns in typical surgery should be considered.81,82 No benefit of carotid sur- cases) gery has been observed in patients with mild stenosis with or Echocardiography: Right ventricular enlargement, paradoxi- without symptoms. Carotid endovascular treatment may be cal motion of the interventricular septum considered in patients with symptomatic severe carotid artery stenosis, those in whom the surgical approach to the carotid Pulmonary artery disease is strongly suspected when rest- artery is difficult, those with a high risks associated with sur- ing mean pulmonary arterial pressure in catheterization is gery, those with carotid artery stenosis after radiotherapy, ≥25 mmHg, and hypocapnia with hypoxemia are observed on and those with carotid artery restenosis after surgery. When arterial blood gas analysis, while no significant pulmonary noncardiac surgery is performed without treating carotid parenchyma diseases or airway disorders are observed on artery stenosis, patients should be managed carefully to pre- respiratory function testing. Prior to noncardiac surgery, phy- vent dehydration and hypotension and thus prevent cerebral sicians should consider that the natural history of moderate infarction. or severe PH is quite poor. No systematic criteria are available to evaluate the risk of (3) Arteriosclerosis Obliterans of the Lower Extremity perioperative complications in noncardiac surgery in patients Acute exacerbation of hemodynamics of the lower ex- with PH. Since patients with PH tend to have hypoxemia and

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Suspected cardiomyopathy Cardiac dilatation: Cardiothoracic ratio ≥ 60% Under treatment for heart failure Arrhythmia, pacemaker History of NYHA Class III or worse condition

Echocardiography

EF ≤ 20% 20% < EF < 40% EF ≥ 40%

Myocardial scintigraphy Myocardial scintigraphy Coronary angiography Coronary angiography

Severe Moderate Mild

Figure 4. Flow chart of evaluation for cardiomyopathy. NYHA, New York Heart Association; EF, ejection fraction.

right heart failure, careful monitoring (ECG, arterial line Low cardiac output in patients with dilated cardiomyopa- placement, and pulse oximetry) should be performed from thy is treated by decreasing afterload with vasodilators and the induction of anesthesia through the postoperative period. increasing cardiac contractile force with catecholamines and Although pulmonary arterial catheterization provides impor- PDE III inhibitors, while such treatment is contraindicated in tant information, it is difficult to place the catheter at an patients with hypertrophic cardiomyopathy and should be appropriate position, and lung injuries due to puncture and performed with care in patients with restrictive cardiomy- vessel injuries due to balloon dilatation may cause serious opathy. Physicians should attempt to optimize intravascular outcomes. Transesophageal echocardiography is very useful volume to increase cardiac output regardless of the type of for monitoring the right ventricular function. cardiomyopathy. However, since the range of the target intra- The effects of decreasing pulmonary vascular resistance vascular volume is narrow, a pulmonary artery catheter should during the perioperative period of noncardiac surgery with be placed to monitor hemodynamics carefully during the peri- inhaled nitric oxide, dipyridamole, phosphodiesterase (PDE) operative period, in which intravascular volume may change III inhibitors, PGI2, calcium blockers, and intravenous nitro- significantly, and diuretics should be administered whenever glycerin have been reported. Endothelin-1 receptor antagonist necessary. are effective but not appropriate during the perioperative Patients who had received warfarin to prevent embolism period, since only oral forms of them are available. should be switched from warfarin to continuous infusion of heparin at least two days before surgery, and should discontinue heparin therapy about 3 hours before surgery. It is 8. Idiopathic Cardiomyopathy preferable that warfarin therapy be promptly resumed when the risk of postoperative bleeding has decreased, and that Cardiomyopathy is defined as “heart muscle disease associ- patients who cannot take drugs orally be administered hepa- ated with cardiac dysfunction”, and is classified into dilated rin continuously. Adequate pain control is necessary, since cardiomyopathy, hypertrophic cardiomyopathy, restrictive car- postoperative pain increases afterload by increasing sympa- diomyopathy, arrhythmogenic right ventricular cardiomyopa- thetic activity. thy, and other unclassifiable cardiomyopathy. “Heart muscle disease with known etiology or clearly related to systemic disease” is defined as specific cardiomyopathy, and is not 9. Arrhythmias included into the above classification.85,86 Although new classification have recently been proposed, this classification is still In addition to myocardial infarction, arrhythmias and conduc- common in Japan and useful in the clinical setting. Figure 4 tion disorders are quite common perioperative cardiac com- shows a flow chart of preoperative examinations for cardio- plications of noncardiac surgery. Arrhythmia may not occur myopathy. as a single disorder. It is important to check for all possible In management during the perioperative period of non- heart diseases associated with arrhythmia when examining cardiac surgery, arrhythmia and low cardiac output require patients with perioperative arrhythmia. special attention in patients with any type of cardiomyopathy. Extra vigilance is needed in patients with severe ventricular (1) Perioperative Arrhythmia and Its Treatment arrhythmia, which may cause sudden death. Patients often i) Preoperative Arrhythmia have been treated with antiarrhythmic drugs and may receive When arrhythmia occurs in patients planned to undergo non- continuous intravenous lidocaine infusion during the peri- cardiac surgery, physicians should check for the presence/ operative period as needed, and many cases of arrhythmia are absence of an underlying disease causing the arrhythmia and intractable. It is important to maintain normal sinus rhythm consider how to manage the patient should arrhythmia worsen by adjusting electrolyte levels. If such treatment is impossi- during the perioperative period. The following types of organic ble, heart rate should be controlled while in atrial fibrillation. heart disease may play roles in preoperative arrhythmia.

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Table 16. The Causes of Arrhythmias That May Occur During ventricular pacing using transvenous leads inserted from the the Perioperative Period internal jugular vein, transesophageal pacing, or external Myocardial ischemia pacing using chest patch electrodes. Hypovolemia ← bleeding iii) Arrhythmias That May Occur After Surgery Hypoxemia ← pneumothorax, bleeding in pleural cavity, atelecta sis, respiratory tract bleeding, etc. The incidence of cardiac complications is highest during the first several days after surgery.88 Arrhythmias that may occur Coronary embolism (e.g., air embolism) after surgery include those immediately after recovery from Coronary spasm (hyperventilation, hypercalcemia) anesthesia, fatal arrhythmias due to pulmonary embolism, Cardiac overload which is prone to occur during the first several days after Atrial overload → atrial extrasystole, ventricular overload → surgery, and atrial fibrillation, the incidence of which is high ventricular extrasystole during the first week after surgery. Overhydration (transurethral resection of prostate, burns, etc.) Atrial fibrillation is clinically significant, since thrombus Pulmonary embolism (including air embolism, fat embolism) → may develop in the left atrium and cause arterial embolism. right heart overload Transesophageal echocardiography is useful arterial to ex- Mitral regurgitation, aortic regurgitation → left heart overload clude possible arterial thrombus. Patients with atrial fibrilla- Neurogenic arrhythmia (e.g., vagal impulse) tion may exhibit severe bradycardia requiring temporary Electrolyte imbalance such as hypokalemia, hypocalcemia pacing. Since severe and prolonged bradycardia may reflect Hypothermia the presence of latent conduction disorder, physicians should consider prompt implantation of permanent pacemakers.

(2) Perioperative Management of Patients Using • Sick sinus syndrome, atrioventricular block (particularly Implantable Pacemakers and Implantable Mobitz type II, Grade 3) → Coronary heart disease Cardioverter Defibrillators • Ventricular extrasystole (multifocal, sequential) → Coro- In patients with implantable pacemakers and implantable car- nary heart disease, previous myocardial infarction dioverter defibrillators (ICD), electromagnetic interference • Ventricular extrasystole → Cardiomyopathy, left ventricu- and infection are the most important complications of non- lar hypertrophy/dilatation (valvular disease) cardiac surgery. • Atrial fibrillation → Left ventricular diastolic dysfunction, The use of electric knives may interfere with pacemakers, valvular disease which will then not function properly. Unipolar devices are more susceptible to interference than bipolar devices. Physi- There are reports suggesting that detailed monitoring and cians should be aware of the risk of electromagnetic inter- specific treatment are unnecessary in patients with preopera- ference when the surgical site is in close proximity to the tive ventricular extrasystole when myocardial infarction or pacemaker or leads. Physicians should also be familiar with other heart disease is absent.87 However, since arrhythmia the possible effects of use of electric knives at a surgical site may worsen during the perioperative period in patients with distant from the pacemaker. Use of bipolar electric knives is ischemic heart disease, appropriate examination should be in all cases the safest procedure, though such devices may performed to exclude possible diseases and uncover undiag- make surgical procedures more complicated than unipolar nosed diseases. devices. Pacing mode must be adjusted during surgery if For patients who have been diagnosed with arrhythmia and surgical site is close near to the pacemaker and require fre- are taking antiarrhythmic drugs, physicians should consult quent use of electric knives to stop bleeding. In patients who with anesthesiologists to determine whether antiarrhythmic depend on a pacemaker to maintain heart rate, AOO, VOO, drugs should be given intravenously or be suspended during or DOO mode may be used during surgery. In patients in the perioperative period. Many believe that β blockers used their own rhythm with the pacemaker in sense mode, the before surgery should be continued during the perioperative pacemaker is not used or is used with a low pacing rate dur- period.19 In patients receiving anticoagulation therapy to con- ing surgery. trol atrial fibrillation, physicians should consider the benefits In patients using an ICD, electromagnetic interference by and risks of bleeding with anticoagulation therapy in deter- electric knives may trigger the device, which may deliver a mining a strategy of treatment for the perioperative period. shock during surgery. In such patients, external patch electrodes should be placed on the chest wall to prepare for ii) Arrhythmias That May Occur During Surgery prompt electrocardioversion, and the ICD should be turned Table 16 lists conditions that may cause arrhythmias during off during surgery. After surgery, the ICD should promptly be the perioperative period. Although arrhythmias existing be- turned on. Continuous administration of antiarrhythmic drugs fore surgery and underlying heart disease affect the type and should be considered in patients susceptible to ventricular incidence of arrhythmias during surgery, myocardial ischemia, tachycardia. In any case, physicians and medical engineers overload on the heart, hypokalemia, and hypomagnesemia with expertise in adjusting programs of implantable pace- during surgery may induce arrhythmia. Anesthetics, surgical makers and ICD should support the surgery. procedures, and bleeding control also affect the incidence of In patients undergoing gastrointestinal surgery and patients arrhythmia during surgery. Since cardiac arrest may occur at with traumatic open wounds, bacteremia may develop. If the time of reperfusion during surgical treatment of intestinal leads exposed to venous blood become infected, the pace- ischemia or lower extremity ischemia, appropriate measures maker may need to be removed. In patients with implantable such as exsanguination of venous blood may be required. pacemakers and ICD, antibiotic treatment should be initiated Intraoperative bradycardia may be improved for a short during surgery to minimize the occurrence of pacemaker in- period of time with atropine sulfate andβ agonists. However, fection. when bradycardia is prolonged or severe, patients may need

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813 – 818. References 19. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, 1. Detsky AS, Abrams HB, McLaughlin JR, Drucker DJ, Sasson Z, Fleischmann KE, et al. ACC/AHA 2006 guideline update on peri- Johnston N, et al. Predicting cardiac complications in patients under- operative cardiovascular evaluation for noncardiac surgery: Focused going non-cardiac surgery. J Gen Intern Med 1986; 1: 211 – 219. update on perioperative beta-blocker therapy: A report of the Ameri- 2. Ashton CM, Petersen NJ, Wray NP, Kiefe CI, Dunn JK, Wu L, et al. can College of Cardiology/American Heart Association Task Force The incidence of perioperative myocardial infarction in men under- on Practice Guidelines (Writing Committee to Update the 2002 going noncardiac surgery. Ann Intern Med 1993; 118: 504 – 510. Guidelines on Perioperative Cardiovascular Evaluation for Noncar- 3. Hollenberg M, Mangano DT, Browner WS, London MJ, Tubau JF, diac Surgery) developed in collaboration with the American Society Tateo IM. Predictors of postoperative myocardial ischemia in pa- of Echocardiography, American Society of Nuclear Cardiology, tients undergoing noncardiac surgery: The Study of Perioperative Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Ischemia Research Group. JAMA 1992; 268: 205 – 209. Society for Cardiovascular Angiography and Interventions, and 4. Hubbard BL, Gibbons RJ, Lapeyre AC 3rd, Zinsmeister AR, Society for Vascular Medicine and Biology. J Am Coll Cardiol Clements IP. Identification of severe coronary artery disease using 2006; 47: 2343 – 2355. simple clinical parameters. Arch Intern Med 1992; 152: 309 – 312. 20. Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on 5. Lette J, Waters D, Bernier H, Champagne P, Lassonde J, Picard M, mortality and cardiovascular morbidity after noncardiac surgery: et al. Preoperative and long-term cardiac risk assessment: Predictive Multicenter Study of Perioperative Ischemia Research Group. N Engl value of 23 clinical descriptors, 7 multivariate scoring systems, and J Med 1996; 335: 1713 – 1720. quantitative dipyridamole imaging in 360 patients. Ann Surg 1992; 21. Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, 216: 192 – 204. Hertzer NR, et al. Guidelines for perioperative cardiovascular eval- 6. Mangano DT, Browner WS, Hollenberg M, London MJ, Tubau JF, uation for noncardiac surgery: Report of the American College of Tateo IM. Association of perioperative myocardial ischemia with Cardiology/American Heart Association Task Force on Practice cardiac morbidity and mortality in men undergoing noncardiac sur- Guidelines (Committee on Perioperative Cardiovascular Evaluation gery: The Study of Perioperative Ischemia Research Group. N Engl for Noncardiac Surgery). J Am Coll Cardiol 1996; 27: 910 – 948. J Med 1990; 323: 1781 – 1788. 22. Cohen MM, Duncan PG, Tate RB. Does anesthesia contribute to 7. Michel LA, Jamart J, Bradpiece HA, Malt RA. Prediction of risk in operative mortality? JAMA 1988; 260: 2859 – 2863. noncardiac operations after cardiac operations. J Thorac Cardiovasc 23. Frank SM, Fleisher LA, Breslow MJ, Higgins MS, Olson KF, Kelly Surg 1990; 100: 595 – 605. S, et al. Perioperative maintenance of normothermia reduces the in- 8. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, cidence of morbid cardiac events: A randomized clinical trial. JAMA Murray B, et al. Multifactorial index of cardiac risk in noncardiac 1997; 277: 1127 – 1134. surgical procedures. N Engl J Med 1977; 297: 845 – 850. 24. Kakinohana M, Odo Y, Sugahara K. Total intravenous anesthesia by 9. Wyman RM, Safian RD, Portway V, Skillman JJ, McKay RG, Baim propofol, fentanyl and ketamine for five cases of acute superior mes- DS. Current complications of diagnostic and therapeutic cardiac enteric artery occlusion. Masui 2001; 50: 273 – 277 (in Japanese). catheterization. J Am Coll Cardiol 1988; 12: 1400 – 1406. 25. Wahr JA, Parks R, Boisvert D, Comunale M, Fabian J, Ramsay J, 10. Waugh JR, Sacharias N. Arteriographic complications in the DSA et al. Preoperative serum potassium levels and perioperative out- era. Radiology 1992; 182: 243 – 246. comes in cardiac surgery patients: Multicenter Study of Periopera- 11. Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, tive Ischemia Research Group. JAMA 1999; 281: 2203 – 2210. Fleischmann KE, et al; American College of Cardiology; American 26. Yasuhara H, Naka S, Kuroda T, Wada N. Blunt thoracic and Heart Association. ACC/AHA guideline update for perioperative car- abdominal vascular trauma and organ injury caused by road traffic diovascular evaluation for noncardiac surgery–executive summary: A accident. Eur J Vasc Endovasc Surg 2000; 20: 517 – 522. report of the American College of Cardiology/American Heart As- 27. Williams JS, Graff JA, Uku JM, Steinig JP. Aortic injury in vehicu- sociation Task Force on Practice Guidelines (Committee to Update lar trauma. Ann Thorac Surg 1994; 57: 726 – 730. the 1996 Guidelines on Perioperative Cardiovascular Evaluation for 28. Nakazawa M. Management of adult patients who have undergone Noncardiac Surgery). J Am Coll Cardiol 2002; 39: 542 – 553. surgical treatment of cardiac anormaly. In: Kawashima Y, Hosoda S, 12. Fleisher LA, Nelson AH, Rosenbaum SH. Postoperative myocar- Sasayama S, editors. Advanced Medicine Series 12 Heart Diseases– dial ischemia: Etiology of cardiac morbidity or manifestation of Current Medical Practice for Heart Diseases. Tokyo: Sentan Iryo underlying disease? J Clin Anesth 1995; 7: 97 – 102. Gijutsu Kenkyusho, 2001; 206 – 214 (in Japanese). 13. Landesberg G, Erel J, Anner H, Eidelman LA, Weinmann E, Luria 29. Khairy P, Ouyang DW, Fernandes SM, Lee-Parritz A, Economy KE, MH, et al. Perioperative myocardial ischemia in carotid endarter- Landzberg MJ. Pregnancy outcomes in women with congenital heart ectomy under cervical plexus block and prophylactic nitroglycerin disease. Circulation 2006; 113: 517 – 524. infusion. J Cardiothorac Vasc Anesth 1993; 7: 259 – 265. 30. Elkayam U. Pregnancy and cardiovascular disease. In: Braunwald E, 14. Charlson ME, MacKenzie CR, Gold JP, Ales KL, Topkins M, editor. Heart disease. A textbook of cardiovascular medicine, 5th Shires GT. Intraoperative blood pressure: What patterns identify edn. Philadelphia: W.B. Saunders Company, 1997; 1843 – 1864. patients at risk for postoperative complications? Ann Surg 1990; 31. Presbitero P, Rabajoli F, Somerville J. Pregnancy in patients with 212: 567 – 580. congenital heart disease. Schweiz Med Wochenschr 1995; 125: 311 – 15. Mangano DT, Hollenberg M, Fegert G, Meyer ML, London MJ, 315. Tubau JF, et al. Perioperative myocardial ischemia in patients under- 32. Akagi T, Yamakawa R, Kato H. Pregnancy and childbirth after going noncardiac surgery–I: Incidence and severity during the 4 day surgical treatment of congenital heart disease. Heart Nursing 1998; perioperative period. The Study of Perioperative Ischemia (SPI) 11: 823 – 827 (in Japanese). Research Group. J Am Coll Cardiol 1991; 17: 843 – 850. 33. Presbitero P, Somerville J, Stone S, Aruta E, Spiegelhalter D, 16. Eisenberg MJ, London MJ, Leung JM, Browner WS, Hollenberg M, Rabajoli F. Pregnancy in cyanotic congenital heart disease: Out- Tubau JF, et al. Monitoring for myocardial ischemia during noncar- come of mother and fetus. Circulation 1994; 89: 2673 – 2676. diac surgery: A technology assessment of transesophageal echocar- 34. Elkayam U, Cobb T, Gleicher N. Congenital heart disease in preg- diography and 12-lead electrocardiography: The Study of Perioper- nancy. In: Elkayam U, Gleicher N, editors. Cardiac problem in preg- ative Ischemia Research Group. JAMA 1992; 268: 210 – 216. nancy. Diagnosis and management of maternal and fetal disease, 17. London MJ, Tubau JF, Wong MG, Layug E, Hollenberg M, Krupski 2nd edn. New York: Alan R. Liss, Inc., 1900; 73 – 98. WC, et al. The “natural history” of segmental wall motion abnor- 35. Whittemore R, Hobbins J, Engle M. Pregnancy and its outcomes in malities in patients undergoing noncardiac surgery: S.P.I. Research women with and without surgical treatment in congenital heart dis- Group. Anesthesiology 1990; 73: 644 – 655. ease. Am J Cradiol 1982; 50: 641 – 651. 18. Grines CL, Bonow RO, Casey DE Jr, Gardner TJ, Lockhart PB, 36. Connoly HM, Warnes CA. Ebstein’s anomaly: Outcome of preg- Moliterno DJ, et al; American Heart Association; American Col- nancy. J Am Coll Cardiol 1994; 23: 1194 – 1198. lege of Cardiology; Society for Cardiovascular Angiography and 37. Weiss BM, Zemp L, Seifert B, Hess OM. Outcome of pulmonary Interventions; American College of Surgeons; American Dental vascular disease in pregnancy: A systemic overview from 1978 Association; American College of Physicians. Prevention of pre- through 1996. J Am Coll Cardiol 1998; 31: 1650 – 1657. mature discontinuation of dual antiplatelet therapy in patients with 38. Hung L, Rahimtoola SH. Prosthetic hearts valves and pregnancy. coronary artery stents: A science advisory from the American Heart Circulation 2003; 107: 1240 – 1246. Association, American College of Cardiology, Society for Car- 39. ACC/AHA guidelines for the management of patients with valvu- diovascular Angiography and Interventions, American College of lar heart disease. J Am Coll Cardiol 1998; 32: 1486 – 1588. Surgeons, and American Dental Association, with representation 40. Oakley CM. Anticoagulants in pregnancy. Br Heart J 1995; 74: from the American College of Physicians. Circulation 2007; 115: 107 – 111.

Circulation Journal Vol.75, April 2011 1008 JCS Joint Working Group

41. Elkayam U. Anticoagulation in pregnant women with prosthetic surgical treatment of congenital heart diseases: A report of a study heart valves: A double jeopardy. J Am Coll Cardiol 1996; 27: on “Evaluation of postoperative conditions of congenital heart dis- 1704 – 1706. eases and establishment of criteria for postoperative management” 42. Sbarouni E, Oakley CM. Outcome of pregnancy in women with by the MHW-Sponsored Cardiovascular Disease Study Group. valve prostheses. Br Heart J 1994; 71: 196 – 201. Pediatric Cardiology and Cardiac Surgery 1994; 9: 589 – 599 (in 43. Elkayam U, Bitar F. Valvular heart disease and pregnancy: Part II: Japanese). Prosthetic valves. J Am Coll Cardiol 2005; 46: 403 – 410. 65. Pitt MP, Bonser RS. The natural history of thoracic aortic aneurysm 44. Akagi T, Kato H. Pregnancy and childbirth: General introduction. disease: An overview. J Card Surg 1997; 12(2 Suppl): 270 – 278. In: Monma K, editor. Guideline-based clinical practice for patients 66. Tabayashi K, Suzuki Y, Niibori N, Ito Y, Sekino Y, Togo T, et al. with congenital heart disease. Tokyo: CHUGAI-IGAKUSHA, 2001; Treatment of aneurysms of the aortic arch. Kyobu Geka 1991; 44: 25 – 28 (in Japanese). 531 – 536 (in Japanese). 45. Guidelines for the Diagnosis and Treatment of Cardiovascular Dis- 67. Takamiya M, Kuribayashi S, Hamada S, Iino M. Recent progress eases (2004–2005 JCS joint working groups report). Guidelines for of diagnostic imaging for aortic dissection. Nippon Geka Gakkai the clinical application of bypass grafts and the surgical techniques. Zasshi 1996; 97: 884 – 889 (in Japanese). Circ J 2006; 70(Suppl IV): 1477 – 1553 (in Japanese). 68. Prince MR. Gadolinium-enhanced MR aortography. Radiology 46. Varadarajan P, Kapoor N, Bansal RC, Pai RG. Clinical profile and 1994; 191: 155 – 164. natural history of 453 nonsurgically managed patients with severe 69. Landesberg G, Mosseri M, Wolf YG, Bocher M, Basevitch A, aortic stenosis. Ann Thorac Surg 2006; 82: 2111 – 2115. Rudis E, et al. Preoperative thallium scanning, selective coronary 47. Bonow RO, Carabello B, de Leon AC Jr, Edmunds LH Jr, Fedderly revascularization and long-term survival after major vascular sur- BJ, Freed MD, et al. Guidelines for the management of patients gery. Circulation 2003; 108: 177 – 183. with valvular heart disease: Executive summary: A report of Ameri- 70. Breen P, Lee JW, Pomposelli F, Park KW. Timing of high-risk vas- can College of Cardiology/American Heart Association Task Force cular surgery following coronary artery bypass surgery: A 10-year on Practice Guideline (Committee on Management of Patients with experience from an academic medical centre. Anaesthesia 2004; Valvular Heart Disease). Circulation 1998; 98: 1949 – 1984. 59: 422 – 427. 48. Dajani AS, Bisno AL, Chung KJ, Durack DT, Freed M, Gerber 71. The fifth report of the Joint National Committee on Detection, Eval- MA, et al. Prevention of bacterial endocarditis: Recommendations uation, and Treatment of High Blood Pressure (JNCV). Arch Intern by the American Heart Association. JAMA 1990; 264:2919 – 2922. Med 1993; 153: 154 – 183. 49. Henry WL, Bonow RO, Borer JS, Ware JH, Kent KM, Redwood 72. Islamogˇlu F, Atay Y, Can L, Kara E, Ozbaran M, Yüksel M, et al. DR, et al. Observation on the optimum timing for operative inter- Diagnosis and treatment of concomitant aortic and coronary dis- vention for aortic regurgitation. I: Evaluation of the results of aortic ease: A retrospective study and brief review. Tex Heart Inst J 1999; valve replacement in symptomatic patients. Circulation 1980; 61: 26: 182 – 188. 471 – 483. 73. Hafez KS, El Fettouh HA, Novick AC, Ouriel K. Management 50. Carabello BA, Usher BW, Hendrix GH, Assey ME, Crawford FA, of synchronous renal neoplasm and abdominal aortic aneurysm. Leman RB. Predictors of outcome for aortic valve replacement in J Vasc Surg 2000; 32: 1102 – 1110. patients with aortic regurgitation and left ventricular dysfunc- 74. Morris HL, da Silva AF. Co-existing abdominal aortic aneurysm tion: A change in the measuring stick. J Am Coll Cardiol 1987; 10: and intra-abdominal malignancy: Reflections on the order of treat- 991 – 997. ment. Br J Surg 1998; 85: 1185 – 1190. 51. Hirota Y, Kusukawa J, Shimizu G, Kaku K, Kita Y, Saito T, et al. 75. EVAR trail participants. Endovascular aneurysm repair and out- Optimal timing valve replacement in chronic aortic regurgitation: come in patients unfit for open repair of abdominal aortic aneurysm Analysis based on the myocardial contractility and postoperative (EVAR trail 2): Randomised controlled trial. Lancet 2005; 365: prognosis. J Cardiol 1988; 18: 747 – 756. 2187 – 2192. 52. Hayes SN, Holmes DR Jr, Nishimura RA, Reeder GS. Palliative 76. Coselli JS, LeMaire SA, Buket S. Marfan syndrome: The variability percutaneous aortic balloon valvuloplasty before noncardiac opera- and outcome of operative management. J Vasc Surg 1995; 21: 432 – tions and invasive diagnostic procedures. Mayo Clin Proc 1989; 64: 443. 753 – 757. 77. Groenink M, Lohuis TA, Tijssen JG, Naeff MS, Hennekam RC, 53. Stein PD, Alpert JS, Copeland J, Dalen JE, Goldman S, Turpie AGG. van der Wall EE, et al. Survival and complication free survival in Antithrombotic therapy in patients with mechanical and biological Marfan’s syndrome: Implications of current guidelines. Heart 1999; prosthetic heart valves. Chest 1992; 102(Suppl): 445S – 455S. 82: 499 – 504. 54. Baum VC, Barton DM, Gutgesell HP. Influence of congenital heart 78. Lord JW Jr, Rossi G, Daliana M, Drago JR, Schwartz AM. Unsus- disease on mortality after noncardiac surgery in hospitalized chil- pected abdominal aortic aneurysms as the cause of peripheral arte- dren. Pediatrics 2000; 105: 332 – 335. rial occlusive disease. Ann Surg 1973; 177: 767 – 771. 55. Yamagugchi M. Postoperative management of pediatric surgical dis- 79. Nemir P Jr, Micozzi MS. Combined aneurysmal and occlusive orders associated with cardiovascular anomalies in neonate and early arterial disease. Circulation 1977; 56(Suppl 2): 169 – 170. infancy. Jap J Pediat Surg 1984; 16: 1337 – 1345 (in Japanese). 80. Baxter BT, McGee GS, Flinn WR, McCarthy WJ, Pearce WH, Yao 56. Mee RBB, Beasley SW, Auldist AW, Myers NA. Influence of con- JS. Distal embolization as a presenting symptom of aortic aneu- genital heart disease on management of oesophageal atresia. Pediatr rysms. Am J Surg 1990; 160: 197 – 201. Surg Int 1992; 7: 90 – 93. 81. Beneficial effect of carotid endarterectomy in symptomatic patients 57. Satoh Y, Iwaya F, Igari T, Satokawa H, Takase S, Hoshino S, et al. with high-grade carotid stenosis. North American Symptomatic Two cases of congenital cardiac anomaly associated with esophageal Carotid Endarterectomy Trial Collaborators. N Engl J Med 1991; atresia. Kyobu Geka 1992; 45: 424 – 427 (in Japanese). 325: 445 – 453. 58. Spitz L, Kiely E, Brereton RJ, Drake D. Management of esophageal 82. Randomised trial of endarterectomy for recently symptomatic carotid atresia. World J Surg 1993; 17: 296 – 300. stenosis: Final results of the MRC European Carotid Surgery Trial 59. Hirobe S, Hayashi A, Kamagata S, Fuchimoto Y, Shimono R, (ECST). Lancet 1998; 351: 1379 – 1387. Kodera A, et al. Management of esophageal atresia associated with 83. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes congenital heart disease. Jpn J Pediatr Surg 2000; 32: 921 – 927 FG. Inter-Society Consensus for the Management of Peripheral Arte- (in Japanese). rial Disease (TASC II). J Vasc Surg 2007; 45(Suppl S): S5 – S67. 60. Kimble RM, Harding J, Kolbe A. Additional congenital anomalies 84. Rubin LJ; American College of Chest Physicians. Diagnosis and in babies with gut atresia or stenosis: When to investigate, and which management of pulmonary hypertension: ACCP evidence-based investigation. Pediatr Surg Int 1997; 12: 565 – 570. clinical practice guideline. Chest 2004; 126(1 Suppl): 7S – 10S. 61. Rescorla FJ, Grosfeld JL. Intestinal atresia and stenosis: Analysis 85. Richardson P, McKenna W, Bristow M, Maisch B, Mautner B, of survival in 120 cases. Surgery 1985; 98: 668 – 676. O’Connell J, et al. Report of the 1995 World Health Organization/ 62. Grosfeld JL, Rescorla FJ. Duodenal atresia and stenosis: Reassess- International Society and Federation of Cardiology Task Force on ment of treatment and outcome based on antenatal diagnosis, patho- the Definition and Classification of cardiomyopathies. Circulation logic variance, and long-term follow-up. World J Surg 1993; 17: 1996, 93: 841 – 842. 301 – 309. 86. Kawai H, Yokoyama M. Dilated cardiomyopathy: Diagnostic crite- 63. Taguchi T, Uesugi T, Nagata K, Masumoto K, Suita S. Cardiac ria/clinical findings/chest X-ray, phonocardiogram, electrocardiog- anomalies associated with congenital diaphragmatic hernia. Jpn J raphy/echocardiography, Doppler method. In: Matsumori A, editor. Pediatr Surg 2006; 38: 163 – 169 (in Japanese). Cardiomyopathy. Tokyo: MEDICAL VIEW CO. LTD, 2000; 106 – 64. Momma K, Kamiya T, Imai Y, Nagashima M, Matsuda H, Shirotani 113 (in Japanese). H, et al. Guidelines for standard management of patients following 87. O’Kelly B, Browner WS, Massie B, Tubau J, Ngo L, Mangano DT.

Circulation Journal Vol.75, April 2011 JCS Guidelines for Perioperative Cardiovascular Management for Noncardiac Surgery 1009

Ventricular arrhythmias in patients undergoing noncardiac surgery: Collaborators: The Study of Perioperative Ischemia Research Group. JAMA 1992; • Isamu Koyama, Department of Surgery, Saitama Medical University 268: 217 – 221. International Medical Center 88. Gibson SC, Payne CJ, Byrne DS, Berry C, Dargie HJ, Kingsmore • Mikihiko Kudo, Department of Cardiovascular Surgery, Keio Univer- DB. B-type natriuretic peptide predicts cardiac morbidity and mor- sity School of Medicine tality after major surgery. Br J Surg 2007; 94: 903 – 909. • Goro Matsumiya, Department of Cardiovascular Surgery, Chiba Uni- versity Graduate School of Medicine • Tetsuro Morota, Department of Cardiothoracic Surgery, Graduate Appendix School of Medicine, The University of Tokyo Chair: • Kazumasa Orihashi, Department of Surgery, Hiroshima University • Shunei Kyo, Department of Therapeutic Strategy for Heart Failure, Graduate School of Biomedical Sciences Graduate School of Medicine, The University of Tokyo • Hideki Oshima, Department of Cardiothoracic Surgery, Nagoya Uni- versity, Graduate School of Medicine Members: • Yoshikatsu Saiki, Department of Cardiovascular Surgery, Tohoku • Kazuhito Imanaka, Department of Cardiovascular Surgery, Saitama University Graduate School of Medicine Medical Center, Saitama Medical University • Satoshi Saito, Department of Cardiovascular Surgery, Tokyo Women’s • Hiromi Kurosawa, Sapia Tower Clinic Medical University • Munetaka Masuda, Department of Cardiovascular Surgery, Yokohama • Yoshimasa Sakamoto, Department of Cardiac Surgery, Jikei Univer- City University sity School of Medicine • Tetsuro Miyata, Department of Vascular Surgery, Graduate School of Medicine, The University of Tokyo Independent Assessment Committee: • Kiyozo Morita, Department of Cardiovascular Surgery, Jikei Univer- • Takao Imazeki, Department of Cardiovascular Surgery, Koshigaya sity School of Medicine Hospital, Dokkyo University School of Medicine • Minoru Nomura, Department of Anesthesiology, Tokyo Women’s • Kohei Kawazoe, St. Luke’s International Hospital Heart Center Medical University • Masakazu Kuro, Department of Anesthesiology, National Cerebral • Yoshiki Sawa, Division of Cardiovascular Surgery, Department of and Cardiovascular Center Surgery, Osaka University Graduate School of Medicine • Masunori Matsuzaki, Division of Cardiology, Department of Medicine • Taijirou Sueda, Department of Surgery, Hiroshima University Gradu- and Clinical Science, Yamaguchi University Graduate School of ate School of Biomedical Sciences Medicine • Koichi Tabayashi, Tohoku Kosei Nenkin Hospital • Ryozo Nagai, Department of Cardiovascular Medicine, Graduate • Shinichi Takamoto, Mitsui Memorial Hospital School of Medicine, The University of Tokyo • Yuichi Ueda, Department of Cardiothoracic Surgery, Nagoya Univer- • Fumio Yamamoto, Department of Cardiovascular Surgery, Akita Uni- sity, Graduate School of Medicine versity School of Medicine • Ryohei Yozu, Department of Cardiovascular Surgery, Keio Univer- (The affiliations of the members are as of September 2010) sity School of Medicine

Circulation Journal Vol.75, April 2011