5
Table 3. Valvular Heart Disease, CIEDs and Pulmonary
Vascular Disease (cont'd)
Recommendations COR LOE
Aortic and Mitral Regurgitation
Elevated-risk elective noncardiac surgery with appropriate
intraoperative and postoperative hemodynamic monitoring
is reasonable in adults with asymptomatic severe MR.
IIa C
Elevated-risk elective noncardiac surgery with appropriate
intraoperative and postoperative hemodynamic monitoring
is reasonable in adults with asymptomatic severe AR and a
normal LVEF.
IIa C
CIEDs
Before elective surgery in a patient with a CIED, the
surgical/procedure team and clinician following the CIED
should communicate in advance to plan perioperative
management of the CIED.
I C
Patients with ICDs who have preoperative reprogramming
to inactivate tachytherapy should be on a cardiac monitor
continuously during the entire period of inactivation, and
external defibrillation equipment should be available.
Systems should be in place to ensure that ICDs are
reprogrammed to active therapy before discontinuation of
cardiac monitoring and discharge from the facility.
I C
Pulmonary Vascular Disease
Chronic pulmonary vascular targeted therapy (i.e.,
phosphodiesterase type 5 inhibitors, soluble guanylate
cyclase stimulators, endothelin receptor antagonists, and
prostanoids) should be continued unless contraindicated or
not tolerated in patients with pulmonary hypertension who
are undergoing noncardiac surgery.
I C
Unless the risks of delay outweigh the potential benefits,
preoperative evaluation by a pulmonary hypertension
specialist before noncardiac surgery can be beneficial for
patients with pulmonary hypertension, particularly for
those with features of increased perioperative risk.
a
IIa C
a
Features of increased perioperative risk in patients with pulmonary hypertension include:
1) diagnosis of Group 1 pulmonary hypertension (i.e., pulmonary arterial hypertension),
2) other forms of pulmonary hypertension associated with high pulmonary pressures
(pulmonary artery systolic pressures >70 mm Hg ) and/or moderate or greater right ventricular
dilatation and/or dysfunction and/or pulmonary vascular resistance >3 Wood units, and
3) World Health Organization/New York Heart Association class III or IV symptoms attributable
to pulmonary hypertension.
