Advances in surgical techniques and improved patient outcomes have enabled the application of cardiac surgery in patient populations previously considered ineligible for an intervention of this magnitude. The decision to intervene surgically, as well as the type of intervention best suited to the patient, should be based on an individual risk-benefit analysis. The risks of the procedure, including major morbidities and short- and intermediate-term mortality, must be weighed against the expected benefits with respect to longevity, symptom relief, and improved functional capacity. This chapter reviews the essential information that the cardiologist and surgeon must collect and review to evaluate a patient for cardiac surgery (Table 10-1). This information includes patient and disease characteristics as well as surgical considerations that can be integrated into scoring systems that provide a semi-quantitative risk assessment. With the ever-evolving complexity of patients requiring specialized cardiovascular care, the refinement of surgical techniques, and the emergence of less invasive alternatives for high-risk patients, it has become apparent that there are important limitations to these scores in that they do not adequately account for procedure-specific impediments, major organ system compromise, and patient frailty. In addition, there has been recognition that risk assessment must occur in a framework of shared decision making that ensures that patients and their families have a thorough understanding of the relative risks and benefits of the various treatment options and, most importantly, that their wishes and preferences are respected in the therapeutic plan. There has been increasing recognition that a Heart Team approach that draws on the strength of multidisciplinary participation in decision making may be ideally suited to meet this challenge.
Table 10-1:Risk Assessment Combining STS Risk Estimate, Frailty, Major Organ System Dysfunction, and Procedure-Specific Impediments |Favorite Table|Download (.pdf) Table 10-1: Risk Assessment Combining STS Risk Estimate, Frailty, Major Organ System Dysfunction, and Procedure-Specific Impediments
| ||Low Risk (Must meet ALL Criteria in this column) ||Intermediate risk (any 1 criterion in this column) ||High risk (any 1 Criterion in This column) ||Prohibitive Risk (Any 1 Criterion in This Column) |
|STS PROM* ||<4% ||4–8% ||>8% ||Predicted risk with surgery of death or major morbidity |
| ||AND ||OR ||OR || |
|Frailty† ||None ||1 Index (mild) ||≥2 Indices ||(all-cause) >50% at 1 year |
| ||AND ||OR ||(moderate to severe) OR ||OR |
|Major organ system compromise not to be improved postoperatively‡ ||None ||1 Organ system ||No more than 2 organ system ||≥3 Organ systems |
| ||AND ||OR ||OR ||OR |
|Procedure-specific impediment§ ||None ||Possible procedure-specific impediment ||Possible procedure-specific impediment ||Severe procedure-specific impediment |
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