CARDIAC INSUFFICIENCY AND

SURGERY
KIGGWE TIMOTHY
DEPT. OF SURGERY
2021/MMed/048/PS
• Cardiac insufficiency – also known as Heart failure, occurs when the
heart cannot pump strongly enough to make sufficient blood reach
the entire body.

• Left-sided heart failure: Ischemic heart disease(especially myocardial

infarction), Hypertension, Aortic and mitral valvular disease,
Myocardial diseases, such as cardiomyopathies and myocarditis

• Right-sided heart failure: Left-sided heart failure is the most common

cause of right-sided heart failure, Left-sided lesions (such as mitral
stenosis), Pulmonary hypertension often caused by chronic lung
disease (cor pulmonale), Various types of cardiomyopathy and diffuse
myocarditis, Tricuspid or pulmonary valvular disease.
• In HF, the failing heart can no longer efficiently pump the blood
delivered to it by the venous circulation. The result is an increased
end-diastolic ventricular volume, leading to increased end-diastolic
pressures and, finally, elevated venous pressures.

• Thus, inadequate cardiac output—called forward failure—is almost

always accompanied by increased congestion of the venous
circulation— that is, backward failure.

• The cardiovascular system attempts to compensate for reduced

myocardial contractility or increased hemodynamic burden through
several homeostatic mechanisms.
The Frank-Starling mechanism.
• Increased end-diastolic filling volumes dilate the heart and cause
increased cardiac myofiber stretching; these lengthened fibers
contract more forcibly, thereby increasing cardiac output.
• If the dilated ventricle is able to maintain cardiac output by this
means, the patient is said to be in compensated heart failure.
• However, ventricular dilation comes at the expense of increased wall
tension and amplifies the oxygen requirements of an already-
compromised myocardium.
• With time, the failing muscle is no longer able to propel sufficient
blood to meet the needs of the body, and the patient develops
decompensated heart failure.
• Activation of neurohumoral systems:
• Release of the neurotransmitter norepinephrine by the autonomic
nervous system increases heart rate and augments myocardial
contractility and vascular resistance.

• Activation of the renin-angiotensin-aldosterone system spurs water

and salt retention (augmenting circulatory volume) and increases
vascular tone.

• Release of atrial natriuretic peptide acts to balance the renin-

angiotensin-aldosterone system through diuresis and vascular smooth
muscle relaxation.
• Myocardial structural changes, including augmented muscle mass.

• Cardiac myocytes cannot proliferate, yet can adapt to increased

workloads by assembling increased numbers of sarcomeres, a change
that is accompanied by myocyte enlargement (hypertrophy).

• In pressure overload states (e.g., hypertension or valvular stenosis),

new sarcomeres tend to be added parallel to the long axis of the
myocytes, adjacent to existing sarcomeres. The growing muscle fiber
diameter thus results in concentric hypertrophy—the ventricular wall
thickness increases without an increase in the size of the chamber.
• In volume overload states (e.g., valvular regurgitation or shunts), the
new sarcomeres are added in series with existing sarcomeres, so that
the muscle fiber length increases. Consequently, the ventricle tends
to dilate, and the resulting wall thickness can be increased, normal, or
decreased; thus, heart weight— rather than wall thickness—is the
best measure of hypertrophy in volume-overloaded hearts.
Determinants of risk of any cardiac patient
undergoing a non-cardiac surgery
• Urgency of the Surgery
• Complexity of the procedure
• Extent of the medical comorbidities
• Extent and severity of the underlying heart disease
• Patients with compensated heart failure pose less of a challenge
compared to those with decompensated heart failure

• Evidence points to the benefits B-blockers and ACE inhibitors in heart

failure patients with improved surgical outcomes with perioperative
use. (BMJ)

• Accurate assessment of patient’s clinical status and the risk of the

proposed surgery are fundamental components of the preoperative
evaluation and are essential in making recommendations for
intraoperative monitoring
New York Association functional class
• Class I: Patient has no limitation of regular physical activities

• Class II: Mild limitation of physical activities; comfortable at rest; normal

physical activity results in dyspnoea, fatigue or angina

• Class III: Major limitation of physical activities; comfortable at rest, minimal

physical activity results in dyspnoea, fatigue or angina

• Class IV: Inability to perform any physical activity without symptoms;

symptoms are present at rest and are worsened with any activity
• In summary, accurate assessment of a patient’s clinical status and the
risk of the proposed surgery are critical elements in the preoperative
evaluation of heart failure patients.