7 Pre-operative cardiac interventions in non-cardiac surgery

Pre-operative cardiac interventions may be performed before a planned non-cardiac surgical procedure in order to optimize the patient's status and to reduce peri-operative morbidity and mortality (MM). The interventional procedures in patients with coronary artery disease are coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty, in patients with severe aortic stenosis, aortic valve replacement or aortic balloon valvuloplasty. These procedures can only be recommended if surgery without intervention would result in a higher peri-operative MM than the direct approach. Several aspects make the decision process difficult: lack of prospective randomized trials, specific indications for specific procedures, small cohorts of clinical studies, changing management in surgery, anaesthesiology and cardiology, and the influence on short- and long-term outcome. Excellent decision analysis models and guidelines of task forces, however, may help the clinician to obtain sufficient support for his or her pre-operative strategies. Finally, the local experience of the surgical, anaesthesiological and cardiological team has to be taken into consideration before the decision is made, if the individual patient is to benefit from the pre-operative interventional procedure.