Perioperative Management

PREOPERATIVE INVESTIGATIONS

All patients undergoing valvular surgery should have a complete workup including clinical examination, chest x-ray, transthoracic echocardiography, and anesthesia consultation. In addition, laboratory tests are used to detect any biological or bacteriological anomalies. In diabetic patients, it is important to assess the effectiveness of blood glucose level control by measurement of hemoglobin A _1c . Patients with aortic root disease require computed tomography (CT) or magnetic resonance imaging. Coronary angiography is recommended in patients beyond the age of 45 or in younger patients with congenital malformations, depressed ventricular function, and/or atherosclerotic risk factors. Right and left heart catheterization should be additional tests ordered for patients with depressed ventricular function and/or congenital malformation. Because of the high risk of systemic embolization, patients with endocarditis should undergo head and abdominal computed tomography to detect asymptomatic focus of embolization or mycotic aneurysm. In the reoperative setting, chest computed tomography might be useful to assess the anatomical relationship between the ascending aorta, the right ventricle, and the posterior table of the sternum. Additional workup may be necessary in the presence of associated organ dysfunction such as respiratory insufficiency, gastrointestinal disorders, cerebrovascular disease, or renal failure. Finally, with the exception of emergency cases, a complete dental clearance should be obtained. Extensive dental extraction, commonly advised in the past, is no longer required provided that all decayed teeth are treated conservatively under proper antibiotic coverage.

Preoperative investigations allow determination of the risk factors for morbidity and mortality in each individual patient using one of the multiple scoring systems available.

The patient should always be carefully informed about his or her disease, the proposed operation in light of the surgeon's experience, and the risk factors linked to the patient's condition and this operation.