Overview of preoperative evaluation and management for cardiac surgery in adults

INTRODUCTION — 

Although cardiac surgical techniques and outcomes have continued to improve, considerable risks for perioperative morbidity and mortality persist. This topic will review unique aspects of preoperative evaluation and management for a cardiac surgical patient.

Many aspects of preoperative assessment of patients undergoing cardiac surgery are similar to those for noncardiac surgery, as discussed in another topic. (See "Preoperative evaluation for noncardiac surgery in adults".)

Some centers have implemented preoperative protocols to enhance recovery after cardiac surgery (ERACS), including elements that begin weeks before surgery (eg, correction of anemia, smoking cessation, nutritional screening, and prehabilitation in selected high-risk patients). These strategies are discussed in a separate topic. (See "Overview of enhanced recovery after cardiothoracic surgery", section on 'Preoperative strategies'.)

HISTORY AND PHYSICAL EXAMINATION

Preanesthetic assessment for cardiac surgery includes reviewing the patient’s history, physical examination, and medical records (eg, indications for the surgical procedure, medical conditions, allergies, previous complications of anesthesia), as for noncardiac surgery. These aspects are discussed in a separate topic. (See "Preoperative evaluation for noncardiac surgery in adults", section on 'Components of the process'.)

Preoperative cardiovascular and other risk factors of particular concern for cardiac surgical patients are discussed below. (See 'Assessment and management of risk factors' below.)

In addition to a routine preoperative history and physical examination (see "Preoperative evaluation for noncardiac surgery in adults", section on 'Anesthesia directed physical examination'), important aspects for patients undergoing cardiac surgery include:

●Venous access evaluation – This includes assessment of the ease and likely adequacy of venous access for both peripheral and central venous catheters. Anticipated difficult venous access may influence selection of the type of intravenous catheter(s). Examples include preoperative placement of a peripherally inserted central catheter (PICC) line or planning for intraoperative insertion of a multilumen catheter.

●Arterial access evaluation – This includes assessment of the adequacy of peripheral arterial pulses to determine the best site(s) for invasive arterial pressure monitoring or possible intra-aortic balloon pump (IABP) placement when indicated. (See "Intra-arterial catheterization for invasive monitoring: Indications, insertion techniques, and interpretation".)

●TEE safety evaluation – Assessment of intraoperative transesophageal echocardiography (TEE) safety includes oropharyngeal evaluation (see next bullet) as well as identification of swallowing problems due to esophageal lesions or problems with neck mobility (eg, due to previous esophageal surgery, dysphagia, or hiatal hernia). This is important because most cardiac procedures and nearly all valve repair or replacement procedures are performed with intraoperative TEE monitoring. Absolute and relative contraindications for placement of a TEE probe are noted in the table (table 1). In all cases, the potential benefit from TEE monitoring must be weighed against the relative risk of injury during placement and manipulation of the probe. (See "Transesophageal echocardiography: Indications, complications, and normal views", section on 'Safety of TEE examination'.)

●Oropharyngeal evaluation – Abnormalities of the oral cavity and teeth are assessed to evaluate risk of infection and risks associated with intubation and intraoperative TEE. Severe periodontal disease and other oropharyngeal abnormalities that are potential sources of bacterial infection should be identified and addressed preoperatively. This is particularly important before any operation involving the implantation of artificial material (eg, prosthetic heart valve, synthetic graft material for aneurysm repair).

●Evaluation of skin integrity - Cellulitis or untreated ulcers are not uncommon due to the high incidence of diabetic vasculopathy in cardiac surgical patients. These are risk factors for systemic infection (eg, endocarditis) and should be brought to the attention of the surgeon.

ASSESSMENT AND MANAGEMENT OF RISK FACTORS — 

Several risk prediction models incorporate patient and procedural characteristics to estimate the overall risk of operative mortality, including the EuroSCORE II [1], the Society of Thoracic Surgeons [STS] risk calculator, and others [2-6]. Risk is more difficult to predict in patients who have multiple severe comorbidities and when uncommon procedures are planned. Models for risk prediction are discussed separately. (See "Operative mortality after coronary artery bypass graft surgery", section on 'Risk prediction algorithms' and "Estimating the risk of valvular procedures".)

Cardiovascular conditions — Major cardiovascular conditions affecting risk include coronary artery disease, ventricular systolic and/or diastolic dysfunction (with or without heart failure), cardiac valve dysfunction (stenosis and/or regurgitation), and atherosclerotic disease of the carotid arteries or proximal aorta. Key cardiovascular conditions associated with perioperative risk are discussed here and below. (See 'Surgical risk factors' below.)

Coronary artery disease — Patients with coronary artery disease (CAD) undergoing cardiac surgery include those with indications for coronary artery bypass grafting (CABG) surgery with or without other procedures such as valve surgery. Factors affecting the risk for perioperative morbidity or mortality include the urgency of surgery and the clinical presentation:

●Low risk – Patients with stable angina without recent myocardial infarction (MI) who undergo elective CABG surgery generally have lower perioperative risk than those requiring urgent or emergency surgery. (See "Revascularization in patients with stable coronary artery disease: Coronary artery bypass graft surgery versus percutaneous coronary intervention".)

●Intermediate risk – Patients with an acute MI who remain hemodynamically stable generally have an intermediate risk of perioperative complications. Among patients with acute MI, elective cardiac surgery is generally deferred. Emergency cardiac surgery in patients with acute MI is reserved for patients who require immediate surgical intervention, such as selected patients with ST-elevation MI who are not candidates for other means of revascularization (percutaneous coronary intervention [PCI] or fibrinolysis) or who have an unsuccessful or complicated PCI requiring emergency revascularization. Choices of method and timing for coronary revascularization after acute MI are discussed separately. (See "Acute ST-elevation myocardial infarction: Selecting a reperfusion strategy" and "Coronary artery bypass graft surgery in patients with acute ST-elevation myocardial infarction", section on 'Timing' and "Non-ST-elevation acute coronary syndromes: Selecting a management strategy".)

●High risk – Hemodynamically unstable patients who undergo emergency CABG are at very high risk for perioperative morbidity and mortality (see 'Emergency surgery' below). Examples include cardiogenic shock due to severe left ventricular (LV) or right ventricular (RV) dysfunction (eg, with acute MI), acute severe mitral regurgitation, or rupture of the LV free wall or interventricular septum [7-10]. (See "Coronary artery bypass graft surgery in patients with acute ST-elevation myocardial infarction", section on 'Indications'.)

Hemodynamic instability from cardiogenic shock or acute mitral regurgitation is often managed with intra-aortic balloon pump (IABP) counterpulsation as a temporizing measure, although impact on outcomes is uncertain [11]. If an IABP is in place, hemodynamic stability and maximal support of LV function and coronary perfusion are achieved by maintaining IABP augmentation at a 1:1 ratio during the preoperative and prebypass periods. (See "Intraaortic balloon pump counterpulsation".)

Other short-term mechanical circulatory assist (support) devices are discussed separately. (See "Short-term mechanical circulatory assist devices".)

Heart failure — Factors affecting the anesthetic care plan (eg, selection of monitoring modalities, hemodynamic goals, preparation of vasoactive infusions) include:

●Cause of heart failure – The cause and severity of lesions causing heart failure (eg, LV or RV systolic dysfunction caused by CAD or cardiomyopathy, diastolic dysfunction, and/or valve dysfunction) is identified.

●Severity of systolic dysfunction – Severity of LV and/or RV systolic dysfunction is assessed. Evaluation and management for patients with advanced heart failure includes consultation to consider potential need for short- or long-term mechanical circulatory support and heart transplantation. (See "Short-term mechanical circulatory assist devices" and "Emergency care of adults with mechanical circulatory support devices" and "Treatment of advanced heart failure with a durable mechanical circulatory support device" and "Heart transplantation in adults: Indications and contraindications".)

LV systolic function is a known predictor of morbidity and mortality in cardiac surgery and is incorporated into most risk prediction models. Although RV functional parameters are not incorporated in commonly used risk models, several retrospective and small prospective studies have demonstrated that RV dysfunction is associated with poor outcomes after cardiac surgery [12,13].

●Concomitant pulmonary hypertension – Pulmonary hypertension, defined as mean pulmonary artery pressure (PAP) >20 mmHg at rest, increases morbidity and mortality risk [13-15], and is included in the Parsonnet and EuroSCORE II risk models (see 'Assessment and management of risk factors' above). Given the various etiologies of pulmonary hypertension (table 2), the severity of pulmonary hypertension may or may not be commensurate with LV dysfunction (eg, marked pulmonary hypertension may be seen in patients with mild or moderate LV dysfunction). (See "Clinical features and diagnosis of pulmonary hypertension of unclear etiology in adults", section on 'Etiologies and terminology'.)

Cardiac valve disease — Preoperative risk evaluation for cardiac valve surgery is discussed separately. (See "Estimating the risk of valvular procedures".)

Significant aortic regurgitation (image 1 and image 2) is of particular importance since ventricular fibrillation occurring at the beginning or near the end of cardiopulmonary bypass (CPB) causes rapid LV distension with impairment of myocardial perfusion and potential for LV injury. Perioperative management details are discussed separately. (See "Management of special populations during cardiac surgery with cardiopulmonary bypass", section on 'Aortic regurgitation'.)

Carotid artery disease — Significant carotid stenosis is a risk factor for perioperative stroke. Preoperative and intraoperative management of patients with significant carotid artery disease is discussed in separate topics. (See "Coronary artery bypass grafting in patients with cerebrovascular disease" and "Management of special populations during cardiac surgery with cardiopulmonary bypass", section on 'Cerebrovascular disease'.)

Noncardiac risk factors — Medical comorbidities are common in cardiac surgical patients. Optimal management is ensured before elective procedures, as noted below. Older age [16-18] and female sex [19,20] are nonmodifiable risk factors that increase the likelihood of morbidity and mortality.

Anemia — Anemia is common in cardiac surgical patients and is associated with increased risk for red blood cell (RBC) transfusion and adverse outcomes. Management includes determining the cause(s) (see "Diagnostic approach to anemia in adults"). Joint guidelines developed by the European Association of Cardio-Thoracic Surgery (EACTS), the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC), and the European Board of Cardiovascular Perfusion (EBCP) [21], the Society of Cardiovascular Anesthesiologists (SCA) and Society of Thoracic Surgeons (STS) [22,23], as well as other professional societies [24-30], have noted that it is often appropriate to postpone elective cardiac surgery to correct reversible causes of preoperative anemia (algorithm 1). Details are discussed in a separate topic. (See "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia and iron deficiency'.)

●Iron deficiency anemia – Anemia due to iron deficiency is particularly common. Also, some degree of iron deficiency may be present in patients with anemia due to other causes (eg, anemia of chronic disease, anemia of inflammation). When iron is administered, sufficient time should be allowed for correction before elective surgery (typically two to four weeks for partial correction and six to eight weeks for full correction). Intravenous (IV) iron is an option if semi-elective cardiac surgery is scheduled in less than four to six weeks, and for patients who cannot tolerate oral iron or do not have a response (eg, due to poor absorption). However, time (at least 10 days) is still required for IV iron to be incorporated into developing RBCs to increase the hemoglobin level [31]. Evidence for the likely benefit of ensuring adequate iron stores in reducing intraoperative transfusions is presented separately. (See "Perioperative blood management: Strategies to minimize transfusions", section on 'Iron deficiency and iron deficiency anemia' and "Treatment of iron deficiency anemia in adults", section on 'Perioperative'.)

●Use of erythropoietin – Selected patients with anemia of chronic disease/anemia of inflammation with hemoglobin <13 g/dL may be treated with erythropoietin (EPO) together with supplemental iron prior to cardiac surgery [22,23,29,30,32,33]. Supplemental iron (even in the absence of baseline iron deficiency) is administered to avoid development of functional iron deficiency that may occur with increased erythropoiesis. In our center, patients with a hemoglobin <13 g/dL who are preparing for cardiac surgery typically receive an EPO-stimulating agent (eg, epoetin alfa 600 units/kg weekly, or 300 units/kg daily) starting three weeks (or as short as 10 days) before surgery. This approach is consistent with guidelines from the European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Cardiothoracic Anaesthesiology (EACTA), and the SCA [22,23,29,30]. Supporting evidence for this practice is presented in another topic. (See "Perioperative blood management: Strategies to minimize transfusions", section on 'Use of erythropoietin'.)

Also, EPO (together with supplemental iron) is often used in patients who do not accept transfusions (eg, Jehovah’s Witnesses) [22]. (See "Approach to the patient who declines blood transfusion", section on 'Erythropoiesis-stimulating agents (ESAs/EPO)'.)

Although increased risk of thromboembolic events has been cited as a concern after administration of EPO, patients receiving postoperative anticoagulation may be protected from this risk, and other complications (eg, hypertension, ischemic events) are uncommon [27,34].

Frailty — Frailty, an aging-related syndrome of physiological decline, has been identified in 10 to 50 percent of patients who will undergo cardiac surgery and is associated with a higher risk of postoperative morbidity and longer duration of intensive care unit (ICU) and hospital stays [35-37] (see "Frailty"). Frailty may be stratified into none, mild, or severe frailty by the Katz Activities of Daily Living (ADL) score or other frailty scoring systems [38-40] and integrated with the patient’s STS or Euroscore risk estimate, any major organ system compromise not to be improved postoperatively, and surgical procedure-specific impediments. (See "Estimating the risk of valvular procedures", section on 'Integrated approach'.)

Several studies examining the role of prehabilitation in cardiac surgical patients have demonstrated improvements in physical function and quality of life, and reductions in postoperative complications such as atrial fibrillation and ICU and hospital length of stay. [41-43]. The evidence is not entirely consistent due to heterogeneity among studies with respect to patient cohorts, prehabilitation interventions, measurement instruments, and clinical endpoints. A joint consensus statement by the ERAS International Society and the Society of Thoracic Surgeons concluded that prehabilitation may be considered before non-urgent cardiac surgery but rates the supporting evidence as low quality [44,45]. These programs are discussed separately. (See "Overview of prehabilitation for surgical patients", section on 'Frailty' and "Overview of enhanced recovery after cardiothoracic surgery", section on 'Prehabilitation for selected patients'.)

Kidney disease — Patients with pre-existing kidney disease have a higher risk for developing acute kidney injury (AKI) after cardiac surgery. Preoperative strategies to minimize this risk are discussed separately. (See "Management of special populations during cardiac surgery with cardiopulmonary bypass", section on 'Preexisting chronic kidney disease'.)

Current smoking — Patients who are currently smoking are counseled about the benefits of preoperative cessation. (See "Smoking or vaping: Perioperative management".)

Obesity — Obesity confers challenges for anesthetic management due to potential difficulties with airway management and endotracheal intubation, management of ventilation, appropriate dosing of anesthetic drugs, and increased likelihood of positioning injuries, as discussed separately. (See "Anesthesia for the patient with obesity".)

Most centers proceed with cardiac surgery in moderately or severely obese patients if the procedure is indicated, rather than delaying surgery for counseling and attempted weight loss. Although risks for postoperative morbidity and mortality are increased in obese patients, some studies describe an "obesity paradox," in which moderate obesity (body mass index [BMI] 30 to 39 kg/m²) appears to confer reduced risk during cardiac surgery [46-49]. Adequacy of pump flow during CPB is a concern for severely obese patients (BMI >40 kg/m²) [50].

Obstructive sleep apnea — Individuals with obstructive sleep apnea (OSA) are at increased risk of perioperative complications after cardiac surgery, particularly respiratory complications, as illustrated by the following studies:

●A 2017 systematic review included 11 observational studies with a total of 688 cardiac surgical patients with OSA and 1113 without OSA [51]. Major adverse cardiac or cerebrovascular events (MACCE; defined as a composite of all-cause mortality, MI, nonfatal cardiac arrest, revascularization process, pulmonary embolism, deep venous thrombosis, newly documented postoperative atrial fibrillation [AF], stroke, or heart failure) were more frequent among patients with OSA compared to those without OSA (31 versus 10.6 percent; odds ratio [OR], 2.4; 95% CI, 1.38-4.2). Also, postoperative AF was more frequent (31 versus 21 percent; OR, 1.94; 95% CI, 1.13-3.33) and the need for postoperative tracheal intubation and mechanical ventilation was more frequent in patients with OSA compared to those without OSA (13 versus 5.4 percent; OR, 2.67; 95% CI, 1.03-6.89) [51].

●A subsequent observational study that included more than 500,000 patients undergoing CABG surgery identified a diagnosis of OSA in 6.4 percent and noted that this diagnosis was associated with a higher risk for postoperative AF and hospital readmission within 30 days [52].

Preoperative management of OSA is discussed separately. (See "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea".)

Diabetes — Preoperative management of diabetes mellitus is discussed separately. (See "Perioperative management of blood glucose in adults with diabetes mellitus".)

Hypertension — Preoperative management of hypertension is discussed separately. (See "Anesthesia for patients with hypertension" and "Perioperative management of hypertension".)

Pulmonary disease — Preoperative assessment and management to reduce pulmonary complications in patients with elevated pulmonary risk are discussed in separate topics. (See "Evaluation of perioperative pulmonary risk" and "Strategies to reduce postoperative pulmonary complications in adults", section on 'Preoperative strategies'.)

Preoperative anesthetic management of chronic obstructive pulmonary disease (COPD) is discussed separately. (See "Anesthesia for patients with chronic obstructive pulmonary disease", section on 'Preoperative interventions to optimize pulmonary function'.)

Thyroid dysfunction — Although the effects of treatment of hypothyroidism or hyperthyroidism on cardiac surgery outcomes are uncertain, endocrinologic consultation should be considered in patients with suspected thyroid dysfunction or subclinical abnormalities of thyroid stimulating hormone level [53]. These disorders are discussed separately. (See "Cardiovascular effects of hyperthyroidism" and "Clinical manifestations of hypothyroidism", section on 'Cardiovascular system'.)

●Hypothyroidism – Hypothyroidism is associated with adverse outcomes in patients undergoing cardiac surgery although a causal effect has not been established. A meta-analysis of seven observational studies which included 851 patients with subclinical hypothyroidism and 2594 euthyroid patients undergoing nonurgent cardiac surgery noted higher risk for mortality (OR 2.57, 95% CI 1.09-6.04) and kidney complications (OR 2.53, 95% CI 1.74-3.69), as well as longer hospital stays (standardized mean difference, 0.32 days; 95% CI 0.02-0.62) in those with subclinical hypothyroidism compared to euthyroid patients [54]. At a mean follow-up of 49.3 months, subclinical hypothyroidism was associated with higher all-cause mortality (incidence rate ratio, 1.82; 95% CI 1.18-2.83).

●Hyperthyroidism – Cardiovascular effects of hyperthyroidism include sinus tachycardia, systolic hypertension with widened pulse pressure, and increased risk of AF and flutter (see "Cardiovascular effects of hyperthyroidism"). Data are lacking on the effects of hyperthyroidism on cardiac surgery outcomes, but there is concern that hyperthyroidism might increase the risk for developing AF after cardiac surgery. (See "Atrial fibrillation and flutter after cardiac surgery".)

Liver disease — Preoperative evaluation for patients with liver disease is discussed separately. (See "Anesthesia for the patient with liver disease".)

Hematologic disorders — Certain relatively rare hematologic disorders have important physiologic consequences for patients undergoing cardiac surgery with CPB, as discussed in separate topics [55]:

●Cold agglutinin disease – (See "Cardiac surgery with cardiopulmonary bypass in patients with cold agglutinin disease".)

●Sickle cell disease or thalassemia – (See "Management of adults with sickle cell disease or thalassemia during cardiac surgery".)

●Disorders of hemostasis – Perioperative management of patients with inherited or acquired disorders that affect hemostasis is discussed in UpToDate topics for the specific disease. (See "Preoperative assessment of bleeding risk" and "Perioperative blood management: Strategies to minimize transfusions", section on 'Management of specific hemostatic disorders'.)

Surgical risk factors — Surgical factors affecting overall risk for morbidity and mortality include [38,39]:

●Emergency cardiac surgery – Emergency surgery confers a high risk for morbidity and mortality [2,3,56,57]. (See 'Emergency surgery' below and 'Coronary artery disease' above.)

●Chest wall or mediastinal abnormalities – Chest wall malformation, previous (redo) sternotomy, or previous mediastinal radiation confers risks for injury to myocardium, major blood vessels, or previous coronary grafts; thus, additional preoperative imaging and planning is necessary (eg, to identify arterial coronary bypass graft adherent to the chest wall). Preoperative and intraoperative management details are discussed separately. (See "Management of special populations during cardiac surgery with cardiopulmonary bypass", section on 'Previous median sternotomy' and "Estimating the risk of valvular procedures", section on 'Key considerations'.)

●Presence of a tracheostomy – Preoperative planning for anesthetic and airway management in patients with a tracheostomy are discussed separately. (See "Airway management for anesthesia for the patient with a tracheostomy", section on 'Creating a plan for airway management'.)

●Proximal aortic atherosclerosis or calcification – Severe atherosclerosis of the proximal aorta or carotid arteries is a risk factor for perioperative stroke during manipulation of the aorta through various stages of the procedure. (See "Neurologic complications of cardiac surgery".)

Proximal aortic atheromatous or calcific pathology is identified on the preoperative chest radiograph (CXR) or with computed tomography (CT) imaging of the chest (see 'Chest radiograph (CXR) and computed tomography (CT) imaging' below). Atheromatous or calcific debris may be released from aortic plaques during cross-clamping, unclamping, and cannulation of the aorta, graft anastomoses, or by turbulent high-velocity blood flow delivered via the aortic cannula into a diseased aorta. (See "Initiation of cardiopulmonary bypass", section on 'Aortic cannulation' and "Initiation of cardiopulmonary bypass", section on 'Aortic cross-clamping and antegrade cardioplegia administration'.)

Transesophageal echocardiography (TEE) may be used to identify and avoid areas of aortic atheromas or calcification and can mitigate risk of stroke in patients with proximal aortic pathology. (See "Anesthesia for cardiac surgery: General principles", section on 'Components of the initial TEE examination'.)

Also, since aortic manipulation has been associated with increased stroke rates [58], the cardiac surgeon may decide to employ off-pump coronary artery bypass grafting to avoid cannulation, cross-clamping of the atherosclerotic aorta, and the need for CPB. (See "Off-pump and minimally invasive direct coronary artery bypass graft surgery: Clinical use", section on 'Patient selection'.)

●Complexity of the procedure – Complex surgery of longer duration adds additional risk due in part to prolonged duration of aortic cross-clamping and/or total CPB time (eg, combined procedures such as CABG plus cardiac valve surgery [59,60].

●Minimally invasive surgery – The term minimally invasive cardiac surgery refers to an evolving set of techniques and technologies to perform cardiac surgery through a smaller incision as an alternative to median sternotomy. These procedures generally rely on CPB and a still operative field with a non-beating heart, which requires myocardial cardioplegic arrest. Much of the morbidity of cardiac surgery is related to the proinflammatory and anticoagulant effects of CPB, aortic manipulation (cannulation, clamping, and unclamping), and myocardial protection during cardioplegic arrest. Thus, the potential benefit of a minimally invasive approach is limited. (See "Off-pump and minimally invasive direct coronary artery bypass graft surgery: Clinical use".)

Risk assessment for minimally invasive surgery is similar to that for conventional cardiac surgery with special attention to sites of access for CPB. (See "Minimally invasive aortic and mitral valve surgery".)

●Use of CPB – Cardiac surgical procedures that can be accomplished without the use of CPB may confer lower risk for selected patients, as discussed separately. (See "Off-pump and minimally invasive direct coronary artery bypass graft surgery: Clinical use".)

●Procedural volume – Institutional and individual surgeon caseload (ie, experience) may affect the overall risk for mortality [61-63]. (See "Operative mortality after coronary artery bypass graft surgery", section on 'Hospital and surgeon experience'.)

PREOPERATIVE TESTING

Cardiac diagnostic studies — Most patients undergoing cardiac surgery have an established diagnosis. Diagnostic studies (eg, cardiac catheterization with coronary arteriography, right heart catheterization, echocardiography, etc) are reviewed preoperatively.

Electrocardiography — The electrocardiogram (ECG) is examined for dysrhythmias, conduction abnormalities, myocardial ischemia, and proper functioning of pacemakers in patients with these cardiac implantable electronic devices. (See 'Management of cardiac implantable electronic devices' below.)

Echocardiography — Preoperative transthoracic echocardiography is routinely performed for patients scheduled to undergo valve repair or replacement, as well as for the majority of patients scheduled to undergo coronary artery bypass grafting (CABG). An exception may be made in patients scheduled for CABG surgery who have no history of valvular heart disease and in whom left ventricular (LV) function has been quantified by ventriculography during cardiac catheterization or nuclear testing. Key echocardiographic findings of importance to the anesthesiologist are described in the table (table 3).

Diagnostic cardiac catheterization — Coronary angiography is generally performed prior to valve surgery in patients with symptoms of angina, objective evidence of ischemia, decreased LV systolic function, and history of coronary artery disease (CAD) or coronary risk factors (including males >40 years of age and postmenopausal females) [38,39]. For selected patients with low pretest probability of CAD, coronary computed tomography angiography (CCTA) can be an option to exclude the presence of significant obstructive CAD [38]. If epicardial CAD is detected by CCTA, invasive coronary angiography is performed for confirmation and to guide potential revascularization. (See "Cardiac imaging with computed tomography and magnetic resonance in the adult".)

Right heart catheterization data are commonly also available in patients with known or suspected left or right ventricular (RV) dysfunction, pulmonary hypertension, or cardiac valve disease. Key cardiac catheterization findings of importance to the anesthesiologist are described in the table (table 4).

Other preoperative tests

Laboratory tests — Blood tests that are routinely available include a complete blood count (CBC) and a basic metabolic panel (electrolytes, glucose, creatinine, blood urea nitrogen).

●Anemia – The management of anemia noted on the CBC is addressed above and in a separate topic. (See 'Anemia' above and "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia and iron deficiency'.)

●Abnormalities in tests of coagulation and platelet count and function – Tests of coagulation (prothrombin time, activated partial thromboplastin time, international normalized ratio) and platelet count and function are reserved for patients receiving anticoagulant or antiplatelet agents preoperatively. Their routine use for the prediction of perioperative bleeding is not recommended.

Abnormalities due to administration of anticoagulant or antiplatelet agents may necessitate a delay for elective surgery or correction for urgent surgery, as discussed in separate topics. (See "Preoperative assessment of bleeding risk" and 'Medications affecting hemostasis' below and 'Emergency surgery' below.)

●Hyperglycemia – Adequate glycemic control in the perioperative period is associated with reduced mortality, reduced morbidity (including wound infections and reduced hospital length of stay [LOS]), and improved long-term outcomes [64]. Routine assessment of HbA1c is recommended as it sometimes unmasks previously undiagnosed diabetes mellitus [65]. The benefits of screening for diabetes and optimizing glycemic control preoperatively before elective surgery may not be feasible for emergency procedures. (See 'Emergency surgery' below.)

A blood glucose range between 110 and 180 mg/dL (6.1 to 10 mmol/L) is generally targeted throughout the perioperative period, as discussed further separately. (See "Perioperative management of blood glucose in adults with diabetes mellitus" and "Glycemic control in critically ill adult and pediatric patients".)

Other major laboratory abnormalities detected during the preoperative assessment should prompt evaluation and management similar to patients undergoing noncardiac surgery. (See "Preoperative testing for noncardiac surgery".)

Pretransfusion testing — Typically, at least two units of packed red blood cells (RBCs) are crossmatched prior to a cardiac surgical procedure since significant blood loss is possible in any operation involving the heart and major blood vessels. The anesthesiologist should ensure that these RBC units will be available and determine whether there are issues that may affect the availability of additional crossmatched units (eg, unusual blood type or antibodies). (See "Pretransfusion testing for red blood cell transfusion".)

Chest radiograph (CXR) and computed tomography (CT) imaging — Examination of the standard preoperative CXR often provides critical information before cardiac surgery (eg, abnormal heart size, presence of pulmonary edema or pleural effusions indicating heart failure, or severe calcification of the thoracic aorta).

Scar adherence of the RV heart chambers or ascending aorta to the posterior table of the sternum may cause life-threatening hemorrhage due to unintentional right atrial, RV, or aortic injury during sternotomy. For redo patients, many centers now obtain routine chest CT scans to assess risk for vascular injury during sternotomy [66]. If necessary, alternative cannulation approaches (eg, axillary or femoral) are planned prior to sternal incision. (See "Management of special populations during cardiac surgery with cardiopulmonary bypass", section on 'Previous median sternotomy'.)

Pulmonary function tests — Pulmonary function tests (PFTs) and arterial blood gases (ABGs) are not needed in the majority of patients and should not be routinely obtained preoperatively. These tests are reserved for patients with unexplained dyspnea, poor exercise tolerance or cough, in which PFTs may aid in the diagnosis (and potential optimization) of a pulmonary condition rather than in risk stratification. (See "Evaluation of perioperative pulmonary risk", section on 'Preoperative risk assessment'.)

Moderate or severe airway obstruction, as well as reduced DLCO, on preoperative PFTs confers higher short- and long-term mortality risk in cardiac surgical patients [67,68]. Aside from risk estimation, results of PFTs aid in determining optimal perioperative management strategies (eg, use of inhaled bronchodilators, management of mechanical ventilation, and planning for the possibility of prolonged postoperative respiratory support). (See "Anesthesia for patients with chronic obstructive pulmonary disease", section on 'Perioperative medication management'.)

MANAGEMENT OF PREOPERATIVE MEDICATIONS — 

Premedication in the immediate preoperative period is discussed separately. (See "Anesthesia for cardiac surgery: General principles", section on 'Premedication'.)

Cardiovascular medications — Similar to noncardiac surgery, doses of chronically administered cardiovascular medications, particularly beta blockers and statins, are administered on the morning of surgery. Evidence is presented in separate topics:

●Beta blockers - (See "Coronary artery bypass surgery: Perioperative medical management", section on 'Beta blockers' and "Management of cardiac risk for noncardiac surgery", section on 'Patients taking beta blockers'.)

Decisions regarding starting beta blocker therapy to reduce the risk of atrial fibrillation after cardiac surgery are discussed separately. (See "Atrial fibrillation and flutter after cardiac surgery", section on 'Prevention of atrial fibrillation'.)

●Statins - (See "Coronary artery bypass surgery: Perioperative medical management", section on 'Statins' and "Management of cardiac risk for noncardiac surgery", section on 'Statins'.)

●Antihypertensive medications - Chronically administered oral antihypertensive medications should generally be continued up to the time of surgery, as discussed separately. (See "Perioperative management of hypertension", section on 'Preoperative antihypertensive medication management'.)

●Renin-angiotensin-aldosterone system inhibitors – These medications (including angiotensin-converting enzyme [ACE] inhibitors, angiotensin II receptor blockers [ARBs], and aldosterone antagonists) are generally continued during the perioperative period. Evidence on the role of perioperative ACE inhibitor therapy is discussed separately. (See "Coronary artery bypass surgery: Perioperative medical management", section on 'Angiotensin converting enzyme inhibitors'.)

●Other medications - Decisions regarding perioperative continuation of other cardiovascular medications (eg, calcium channel blockers, alpha 2 agonists, non-statin hypolipidemic agents, digoxin, diuretics) are similar to those for noncardiac surgery, as discussed separately. (See "Perioperative medication management", section on 'Cardiovascular medications'.)

Medications affecting hemostasis — Management of preoperative medications that affect hemostasis is important to minimize bleeding risk during cardiac surgery.

Antiplatelet agents — Chronic administration of dual antiplatelet therapy with aspirin and P2Y₁₂ antagonists is common in patients presenting for cardiac surgery, particularly those with coronary artery disease.

●Aspirin – For most patients who are already taking aspirin, aspirin is continued through the day of (and following) coronary artery bypass graft surgery (CABG). The dosing schedule and supporting evidence is presented in a separate topic. (See "Coronary artery bypass surgery: Perioperative medical management", section on 'Aspirin'.)

●P2Y₁₂ antagonists – For patients who are taking a P2Y₁₂ inhibitor (eg, clopidogrel, ticagrelor), the agent is discontinued ≥5 days prior to elective CABG surgery to reduce risks for perioperative bleeding, transfusions, and associated adverse outcomes (table 5). Evidence supporting this practice is presented in a separate topic. (See "Coronary artery bypass surgery: Perioperative medical management", section on 'Platelet P2Y12 receptor blocker therapy'.)

Management of these antiplatelet agents before and during urgent or emergency surgery is addressed below. (See 'Emergency surgery' below.)

Warfarin and direct oral anticoagulants — For most patients, parenteral or enteral anticoagulant agents (eg, heparins, vitamin K antagonists, direct thrombin inhibitors such as dabigatran, factor Xa inhibitors such as rivaroxaban, apixaban, or edoxaban) are stopped prior to elective cardiac surgery. Discontinuation should be early enough to allow sufficient time for resolution of anticoagulant effects before elective cardiac surgery. For example, warfarin is typically discontinued five days before elective surgery. The table notes the recommended duration for cessation for direct oral anticoagulants (DOACs) and factor Xa inhibitors (table 6) [69]. However, there is individual variability in the resolution of anticoagulant effects, which may take longer in some patients due to factors such as renal insufficiency. Routine laboratory testing can reliably detect residual anticoagulant effect for warfarin (ie, prothrombin time [PT] and international normalized ratio [INR]), but validated and easily accessible tests are not available for all DOACs (table 7). Further discussion regarding perioperative management of these agents is available in a separate topic. (See "Perioperative management of patients receiving anticoagulants".)

Perioperative management of anticoagulation for patients with prosthetic heart valves is discussed separately. (See "Anticoagulation for prosthetic heart valves: Management of bleeding and invasive procedures", section on 'Planning for invasive procedures'.)

MANAGEMENT OF CARDIAC IMPLANTABLE ELECTRONIC DEVICES — 

Patients undergoing cardiac surgery often have a previously inserted pacemaker (with single or dual chamber leads, or leadless) and/or implantable cardioverter defibrillator (ICD) device. The location of the pulse generator for any subcutaneous cardiac implantable electronic device (CIED) should be noted. Details regarding perioperative management of ICDs and pacemakers are discussed separately. (See "Perioperative management of patients with a pacemaker or implantable cardioverter-defibrillator".)

SPECIAL SITUATIONS

Surgical repair for congenital heart disease — Anesthetic management of adult cardiac surgical patients undergoing initial repair or additional surgical procedures for congenital heart lesions is discussed in separate topics. (See "Anesthesia for surgical repair of congenital heart defects in adults: General management" and "Anesthesia for surgical repair of congenital heart defects in adults: Management of specific lesions and reoperation".)

Dialysis-dependent end-state kidney disease (ESKD) — Preoperative management of anemia that accompanies ESKD may include iron replacement and/or erythropoietin (EPO) several weeks before surgery. Details of therapy should be discussed with the patient's primary nephrologist. (See "Treatment of anemia in patients on dialysis", section on 'Treatment'.)

Physical examination should identify the functional arteriovenous fistula or other dialysis access site, as this impacts decisions regarding which artery to cannulate for invasive arterial pressure monitoring. Dialysis access sites must be carefully protected and padded during final patient positioning to preserve functionality.

Patients with dialysis-dependent ESKD typically undergo routine scheduled dialysis the day prior to elective scheduled cardiac surgery. Management of dialysis-dependent patients in the immediate preoperative period involves particular attention to the presence of hyperkalemia, metabolic acidosis, volume overload, or bleeding diathesis, and is discussed in detail elsewhere. (See "Anesthesia for dialysis patients", section on 'Preanesthetic management' and "Medical management of the dialysis patient undergoing surgery".)

A hemoconcentrator is typically added to the cardiopulmonary bypass (CPB) circuit and used to perform ultrafiltration, zero-balance ultrafiltration, or hemodialysis in order to correct hypervolemia, hyperkalemia, metabolic acidosis, and azotemia during CPB, as explained in another topic [70]. (See "Management of special populations during cardiac surgery with cardiopulmonary bypass", section on 'Dialysis-dependent end-stage kidney disease'.)

Role of palliative care — Planning for postoperative management may include a palliative care consultation in selected high-risk cardiac surgical patients to improve end-of-life experiences for the individual and their family [71]. The aim of these consultations is to communicate goals of care for a potentially difficult or prolonged recovery, and to provide symptomatic and psychosocial support in the postoperative period. (See "Benefits, services, and models of subspecialty palliative care".)

One retrospective study that included more than 95,000 patients undergoing high-risk cardiothoracic, vascular, or other major surgery noted that families of patients who had died during the postoperative period were more likely to rate overall care in the final month of life as excellent after a palliative care consultation, compared with families who did not have this consultation (odds ratio [OR] 1.47, 95% CI 1.14-1.88) [72]. However, fewer than six percent of the families of deceased patients had received such consultation in the preoperative period, and only 30 percent had received a palliative care consultation at any point during the perioperative period.

Emergency surgery — Patients requiring emergency surgery have a high risk for morbidity and mortality [2,3,56,57]. In this setting, the anesthesiologist may have limited time to question the patient directly and/or review the medical record but must nevertheless perform a rapid preoperative evaluation.

●General considerations

•Assess the cardiac pathophysiology and understand the emergency nature of the proposed procedure, as well as any preoperative interventions (eg, attempted fibrinolysis [thrombolysis]). Review the patient's chart, as time allows.

•Establish intravenous access adequate for fluid resuscitation and transfusions if not already available, as well as intra-arterial access for continuous monitoring of arterial blood pressure. Other monitors (eg, central venous access and transesophageal echocardiography [TEE]) are typically inserted after induction of anesthesia.

•Check recent laboratory values.

•Check availability of blood products. It is prudent to have a sufficient number of red blood cell (RBC) units typed and crossmatched to address any existing anemia and anticipated surgical blood loss (see 'Pretransfusion testing' above). If massive transfusion is a possibility, preoperative communication with the cardiac surgeon regarding estimates of potential blood loss and subsequent communication with the blood bank are essential.

In some emergency situations (eg, rapid bleeding due to aortic dissection), there might not be time to perform full compatibility testing. Decisions regarding transfusion in such settings depend on assessment of the risks and benefits of immediate transfusion versus full blood compatibility testing. Importantly, "emergency release" blood, typically group O, is always available for immediate lifesaving transfusion. (See "Pretransfusion testing for red blood cell transfusion", section on 'Emergency release blood for life-threatening anemia or bleeding'.)

•Speak briefly to the patient, family members, and/or care team members (eg, cardiologist, cardiac surgeon, intensivist, intensive care nurse) to determine and confirm:

-Allergies

-Fasting status

-Relevant past medical and surgical history

-Problems with prior anesthetics

-Recently administered medications (eg, chronically administered antiplatelet and/or anticoagulant agents) (see 'Medications affecting hemostasis' above)

●Emergency reversal of medication affecting hemostasis – Management of the ongoing effects of chronically or acutely administered medications affecting hemostasis may be necessary in patients undergoing urgent or emergency cardiac surgery.

•Antiplatelet agents – Bleeding risk is increased if patients recently received P2Y₁₂ antagonists (eg, due to unstable angina or after unsuccessful percutaneous coronary intervention) [73,74]. Intraoperative administration of platelets (eg, 1 apheresis unit or 6 units of pooled platelets) may be necessary to overcome the effects of recently administered antiplatelet agents in patients with unacceptable microvascular bleeding, although supportive data are limited [74,75]. For patients who have received antiplatelet agents, preoperative communication with the blood bank is necessary to ensure platelet availability.

•Anticoagulant agents – If discontinuation of anticoagulant agents is not possible (eg, emergency coronary artery bypass grafting [CABG] surgery in a patient chronically receiving anticoagulant agents), then urgent anticoagulant reversal may be necessary if there are no contraindications [69,76]. For warfarin, a 4-factor prothrombin complex concentrate (PCC) product is the preferred treatment for emergency reversal of anticoagulation with a vitamin K antagonist, rather than reversal with fresh frozen plasma (table 8 and table 9) [77]. Also, concomitant vitamin K is administered together with the PCC since any PCC has a limited duration of action. The direct oral anticoagulants (DOACs) that inhibit thrombin or factor Xa have shorter half-lives than warfarin; nevertheless, reversal strategies for DOACs may be necessary for urgent and emergency procedures (table 10 and table 11).

Details regarding management of these agents for urgent or emergency cardiac surgical procedures are available in separate topics:

-(See "Perioperative management of patients receiving anticoagulants", section on 'Urgent/emergency invasive procedure'.)

-(See "Management of warfarin-associated bleeding or supratherapeutic INR".)

-(See "Management of bleeding in patients receiving direct oral anticoagulants".)

Management of anticoagulants in patients with prosthetic heart valves is discussed separately. (See "Anticoagulation for prosthetic heart valves: Management of bleeding and invasive procedures", section on 'Procedures with more than minimal risk of bleeding'.)

•Fibrinolytic agents – In patients undergoing emergency CABG surgery after receiving fibrinolytic (thrombolytic) agents during failed attempts to manage acute ST elevation myocardial infarction (MI), it may be necessary to increase fibrinogen levels with administration of fibrinogen concentrates or transfusion of cryoprecipitate or plasma, in addition to administering an antifibrinolytic agent (eg, aminocaproic acid or tranexamic acid). Discussions regarding preoperative management of emergency surgery in such patients are available elsewhere:

-(See "Anticoagulation and blood management strategies during cardiac surgery with cardiopulmonary bypass", section on 'Antifibrinolytic administration'.)

-(See "Achieving hemostasis after cardiac surgery with cardiopulmonary bypass", section on 'Transfusion of other blood components' and "Achieving hemostasis after cardiac surgery with cardiopulmonary bypass".)

●Emergency management of an implantable cardioverter defibrillator device (ICD) or pacemaker

•For patients with an ICD, the device should ideally be reprogrammed to suspend antitachyarrhythmia therapy before surgical incision. In emergencies, a sterile magnet (or a magnet encased in a sterile sheath) may be used in the surgical field to disable the antitachycardia function. Since pacing function will be lost during electromagnetic interference (EMI), short electrocautery bursts must be used to prevent hypotension in patients who are pacing-dependent.

•For patients with a pacemaker, the device should ideally be reprogrammed to an asynchronous mode (VOO or DOO) before surgical incision. In emergency situations and when the patient is pacemaker dependent, a sterile magnet placed over the pacemaker will disable all sensing, producing an asynchronous VOO or DOO mode.

Details are discussed in a separate topic. (See "Perioperative management of patients with a pacemaker or implantable cardioverter-defibrillator", section on 'Emergency surgery'.)

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Perioperative cardiovascular evaluation and management" and "Society guideline links: Preoperative medical evaluation and risk assessment".)

SUMMARY AND RECOMMENDATIONS

●Physical examination – A routine preoperative physical examination is performed (see "Preoperative evaluation for noncardiac surgery in adults", section on 'Anesthesia directed physical examination').

Important aspects include (see 'History and physical examination' above):

•Sites for peripheral and central venous catheters.

•Peripheral pulses to determine sites for invasive arterial pressure monitoring.

•Presence of a tracheostomy, as discussed separately. (See "Airway management for anesthesia for the patient with a tracheostomy", section on 'Creating a plan for airway management'.)

•Esophageal lesions or problems with neck mobility that may preclude use of intraoperative transesophageal echocardiography (TEE), as discussed separately. (See "Transesophageal echocardiography: Indications, complications, and normal views", section on 'Safety of TEE examination'.)

•Evidence of severe periodontal disease or cellulitis as potential sources of bacterial infection.

●Cardiovascular risk factors

•Myocardial ischemia – Patients requiring coronary revascularization may have low, intermediate, or high risk, with factors affecting the timing of the procedure and likelihood of morbidity or mortality. (See 'Coronary artery disease' above.)

•Heart failure – The anesthetic care plan (eg, selection of monitoring modalities, preparation of vasoactive infusions) is influenced by etiology and severity of left or right ventricular dysfunction and whether concomitant pulmonary arterial hypertension is present. (See 'Heart failure' above.)

•Valve disease – Preoperative considerations for cardiac valve disease are discussed separately. (See "Anesthesia for cardiac valve surgery".)

•Carotid artery disease – Significant carotid stenosis as a risk factor for perioperative stroke is discussed separately. (See "Coronary artery bypass grafting in patients with cerebrovascular disease" and "Management of special populations during cardiac surgery with cardiopulmonary bypass", section on 'Cerebrovascular disease'.)

●Noncardiac risk factors – Preoperative management of common medical comorbidities is discussed in separate topics:

•Anemia – Anemia is common and is associated with increased risk for red blood cell (RBC) transfusion and adverse outcomes. Elective cardiac surgery is postponed to diagnose causes and correct anemia when feasible, including iron replacement and, in selected cases, administration of erythropoietin (algorithm 1), as discussed separately. (See "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia and iron deficiency'.)

•Frailty – (See "Overview of prehabilitation for surgical patients", section on 'Frailty' and "Overview of enhanced recovery after cardiothoracic surgery", section on 'Prehabilitation for selected patients'.)

•Kidney disease – (See "Management of special populations during cardiac surgery with cardiopulmonary bypass", section on 'Preexisting chronic kidney disease'.)

•Current smoking – (See "Smoking or vaping: Perioperative management".)

•Obesity – (See "Anesthesia for the patient with obesity".)

•Obstructive sleep apnea – (See "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea".)

•Diabetes – (See "Perioperative management of blood glucose in adults with diabetes mellitus".)

•Hypertension – (See "Anesthesia for patients with hypertension" and "Perioperative management of hypertension".)

•Pulmonary disease – (See "Evaluation of perioperative pulmonary risk" and "Strategies to reduce postoperative pulmonary complications in adults" and "Anesthesia for patients with chronic obstructive pulmonary disease", section on 'Preoperative interventions to optimize pulmonary function'.)

•Thyroid dysfunction - (See "Cardiovascular effects of hyperthyroidism" and "Clinical manifestations of hypothyroidism", section on 'Cardiovascular system'.)

•Liver disease - (See "Anesthesia for the patient with liver disease".)

•Hematologic disorders - Selected uncommon hematologic disorders have important consequences during cardiopulmonary bypass (CPB), as discussed separately:

-Cold agglutinin disease – (See "Cardiac surgery with cardiopulmonary bypass in patients with cold agglutinin disease".)

-Sickle cell disease or thalassemia - (See "Management of adults with sickle cell disease or thalassemia during cardiac surgery".)

-Disorders of hemostasis – (See "Preoperative assessment of bleeding risk" and "Perioperative blood management: Strategies to minimize transfusions", section on 'Management of specific hemostatic disorders'.)

●Surgical risk factors

•Emergency cardiac surgery – (See 'Emergency surgery' above.)

•Chest wall or mediastinal abnormalities – (See "Management of special populations during cardiac surgery with cardiopulmonary bypass", section on 'Previous median sternotomy'.)

•Presence of a tracheostomy – (See "Airway management for anesthesia for the patient with a tracheostomy", section on 'Creating a plan for airway management'.)

•Proximal aortic atherosclerosis or calcification – (See "Neurologic complications of cardiac surgery".)

•Use of CPB – (See "Off-pump and minimally invasive direct coronary artery bypass graft surgery: Clinical use".)

•Complex procedures of long duration

•Procedural volume of the institution and individual surgeon

●Preoperative test results

•Cardiac diagnostic studies – The electrocardiogram, echocardiography (table 3), and diagnostic cardiac catheterization (table 4) are assessed. (See 'Cardiac diagnostic studies' above.)

•Laboratory tests – Standard laboratory tests are assessed for anemia, coagulation abnormalities, platelet count or function, or hyperglycemia. (See 'Laboratory tests' above.)

•Pretransfusion testing – At least two units of packed RBCs are typically crossmatched and available, and issues affecting the availability of additional units (eg, unusual blood type or antibodies) are addressed. (See 'Pretransfusion testing' above.)

•Chest radiograph (CXR) and computed tomography (CT) imaging – A standard CXR and, for patients requiring redo sternotomy, chest CT imaging provides critical information. (See 'Chest radiograph (CXR) and computed tomography (CT) imaging' above.)

•Pulmonary function tests (PFTs) – Individual patient factors guide decisions to obtain PFTs. (See "Evaluation of perioperative pulmonary risk", section on 'Preoperative risk assessment'.)

●Management of preoperative medications

•Cardiovascular medications – Doses of chronically administered cardiovascular medications, particularly beta blockers and statins, are administered on the morning of surgery, as discussed in separate topics:

-(See "Management of cardiac risk for noncardiac surgery", section on 'Patients taking beta blockers'.)

-(See "Management of cardiac risk for noncardiac surgery", section on 'Statins'.)

-(See "Coronary artery bypass surgery: Perioperative medical management", section on 'Beta blockers'.)

-(See "Coronary artery bypass surgery: Perioperative medical management", section on 'Statins'.)

•Medications affecting hemostasis – Management of antiplatelet and anticoagulant agents for elective procedures and in patients with prosthetic heart valves is discussed in the tables and in separate topics (table 5 and table 6 and table 7):

-(See "Coronary artery bypass surgery: Perioperative medical management", section on 'Aspirin'.)

-(See "Coronary artery bypass surgery: Perioperative medical management", section on 'Platelet P2Y12 receptor blocker therapy'.)

-(See "Perioperative management of patients receiving anticoagulants".)

-(See "Anticoagulation for prosthetic heart valves: Management of bleeding and invasive procedures", section on 'Planning for invasive procedures'.)

●Management of implantable cardioverter defibrillator devices (ICD) or pacemaker – These devices are reprogrammed to an asynchronous mode, as discussed separately. (See "Perioperative management of patients with a pacemaker or implantable cardioverter-defibrillator".)

●Special situations

•Patients with congenital heart lesions - Anesthetic management for initial repair or additional surgical procedures for congenital heart lesions is discussed in separate topics. (See "Anesthesia for surgical repair of congenital heart defects in adults: General management" and "Anesthesia for surgical repair of congenital heart defects in adults: Management of specific lesions and reoperation".)

•Patients on dialysis – Preoperative management of dialysis-dependent patients is discussed in separate topics. (See "Anesthesia for dialysis patients", section on 'Preanesthetic management' and "Management of special populations during cardiac surgery with cardiopulmonary bypass", section on 'Dialysis-dependent end-stage kidney disease'.)

•Role of palliative care – Palliative care consultations are useful in selected high-risk patients to improve end-of-life patient and family experiences. (See 'Role of palliative care' above.)

•Emergency surgery – Considerations for emergency surgery include (see 'Emergency surgery' above):

-Establish intravenous and intra-arterial access.

-Determine cardiac pathophysiology, allergies, fasting status, relevant past medical and surgical history, and recently administered medications.

-Check recent laboratory results and availability of blood products.

-Plan for emergency reversal of recently administered anticoagulant agents, as discussed in the tables (table 8 and table 9 and table 10 and table 11), and in separate topics:

(See "Perioperative management of patients receiving anticoagulants", section on 'Urgent/emergency invasive procedure'.)

(See "Management of warfarin-associated bleeding or supratherapeutic INR".)

(See "Management of bleeding in patients receiving direct oral anticoagulants".)

-If P2Y₁₂ antagonists were recently administered, ensure availability of platelets (eg, 1 apheresis unit or 6 units of pooled platelets).

-If fibrinolytic agents were administered, fibrinogen levels may be increased by transfusing cryoprecipitate, plasma, or fibrinogen concentrates, as well as administering an antifibrinolytic agent, as discussed separately:

(See "Anticoagulation and blood management strategies during cardiac surgery with cardiopulmonary bypass", section on 'Antifibrinolytic administration'.)

(See "Achieving hemostasis after cardiac surgery with cardiopulmonary bypass", section on 'Transfusion of other blood components' and "Achieving hemostasis after cardiac surgery with cardiopulmonary bypass".)