Table 1: Open in new tab Risk factors...

Co-morbidities

Definition/criteria

Diagnostic modalities

Porcelain aorta or severely atherosclerotic aorta

Heavy circumferential calcification or severe atheromatous plaques of the entire ascending aorta extending to the arch such that aortic cross-clamping is not feasible

Non-contrast axial CT at levels:

Sinotubular junction
Tubular ascending aorta between the sinotubular junction and the innominate artery
Innominate artery
Entire transverse arch

Frailty

Slowness, weakness, exhaustion, wasting and malnutrition, poor endurance and inactivity, loss of independence Criteria:

5 m walking time^a
Grip strength^a
BMI <20 kg/m² and/or weight loss 5 kg/year
Serum albumin <3.5 g/dl
Cognitive impairment or dementia

Medical history
Physical examination
Physical performance measures
Cognitive assessments
Laboratory tests

Severe liver disease/cirrhosis

Any of the following:

Child-Pugh class C
MELD score ≥10
Portal-caval, spleno-renal, or transjugular intrahepatic portal shunt
Biopsy proven cirrhosis with portal hypertension or hepatocellular dysfunction

Medical history
Physical examination
Laboratory tests
Child-Pugh classification
MELD score
Liver biopsy

Hostile chest

Any of the following or other reasons that make redo operation through sternotomy or right anterior thoracotomy prohibitively hazardous:

Abnormal chest wall anatomy due to severe kyphoscoliosis or other skeletal abnormalities (including thoracoplasty, Potts' disease)
Complications from prior surgery
Evidence of severe radiation damage (e.g. skin burns, bone destruction, muscle loss, lung fibrosis, or oesophageal stricture)
History of multiple recurrent pleural effusions causing internal adhesions

Medical history
Physical examination
Chest X-ray
CT scan

IMA or other critical conduit(s) crossing midline and/or adherent to posterior table of sternum

A patent IMA graft that is adherent to the sternum such that injuring it during re-operation is likely A patient may be considered at extreme risk if any of the following are present:

The conduit(s) are radiographically indistinguishable from the posterior table of the sternum
The conduit(s) are radiographically distinguishable from the posterior table of the sternum but lie within 2–3 mm of the posterior table

Axial CT scan images illustrating the graft crossing the midline so that the distance from sternum to graft can be measured
Angiogram from the lateral and PA projections and/or a CPR or VR (volume rendering) 3D reconstructed CT scan image showing relationships between the graft and the sternum

Severe pulmonary hypertension
Severe right ventricular dysfunction

Primary or secondary pulmonary hypertension with PA systolic pressures greater than two-thirds of systemic pressure
Criteria as defined by the guidelines (e.g. TAPSE <15 mm, RV end-systolic area >20 cm², etc.)^b

Echocardiography, right and left-heart-catheterization documenting PA and systemic pressures
Documentation of secondary causes of pulmonary hypertension

Co-morbidities

Definition/criteria

Diagnostic modalities

Porcelain aorta or severely atherosclerotic aorta

Heavy circumferential calcification or severe atheromatous plaques of the entire ascending aorta extending to the arch such that aortic cross-clamping is not feasible

Non-contrast axial CT at levels:

Sinotubular junction
Tubular ascending aorta between the sinotubular junction and the innominate artery
Innominate artery
Entire transverse arch

Frailty

Slowness, weakness, exhaustion, wasting and malnutrition, poor endurance and inactivity, loss of independence Criteria:

5 m walking time^a
Grip strength^a
BMI <20 kg/m² and/or weight loss 5 kg/year
Serum albumin <3.5 g/dl
Cognitive impairment or dementia

Medical history
Physical examination
Physical performance measures
Cognitive assessments
Laboratory tests

Severe liver disease/cirrhosis

Any of the following:

Child-Pugh class C
MELD score ≥10
Portal-caval, spleno-renal, or transjugular intrahepatic portal shunt
Biopsy proven cirrhosis with portal hypertension or hepatocellular dysfunction

Medical history
Physical examination
Laboratory tests
Child-Pugh classification
MELD score
Liver biopsy

Hostile chest

Any of the following or other reasons that make redo operation through sternotomy or right anterior thoracotomy prohibitively hazardous:

Abnormal chest wall anatomy due to severe kyphoscoliosis or other skeletal abnormalities (including thoracoplasty, Potts' disease)
Complications from prior surgery
Evidence of severe radiation damage (e.g. skin burns, bone destruction, muscle loss, lung fibrosis, or oesophageal stricture)
History of multiple recurrent pleural effusions causing internal adhesions

Medical history
Physical examination
Chest X-ray
CT scan

IMA or other critical conduit(s) crossing midline and/or adherent to posterior table of sternum

A patent IMA graft that is adherent to the sternum such that injuring it during re-operation is likely A patient may be considered at extreme risk if any of the following are present:

The conduit(s) are radiographically indistinguishable from the posterior table of the sternum
The conduit(s) are radiographically distinguishable from the posterior table of the sternum but lie within 2–3 mm of the posterior table

Axial CT scan images illustrating the graft crossing the midline so that the distance from sternum to graft can be measured
Angiogram from the lateral and PA projections and/or a CPR or VR (volume rendering) 3D reconstructed CT scan image showing relationships between the graft and the sternum

Severe pulmonary hypertension
Severe right ventricular dysfunction

Primary or secondary pulmonary hypertension with PA systolic pressures greater than two-thirds of systemic pressure
Criteria as defined by the guidelines (e.g. TAPSE <15 mm, RV end-systolic area >20 cm², etc.)^b

Echocardiography, right and left-heart-catheterization documenting PA and systemic pressures
Documentation of secondary causes of pulmonary hypertension

Table 1:

Open in new tab

Risk factors not captured by traditional risk scores

Co-morbidities	Definition/criteria	Diagnostic modalities
Porcelain aorta or severely atherosclerotic aorta	Heavy circumferential calcification or severe atheromatous plaques of the entire ascending aorta extending to the arch such that aortic cross-clamping is not feasible	Non-contrast axial CT at levels: Sinotubular junction Tubular ascending aorta between the sinotubular junction and the innominate artery Innominate artery Entire transverse arch
Frailty	Slowness, weakness, exhaustion, wasting and malnutrition, poor endurance and inactivity, loss of independence Criteria: 5 m walking time^a Grip strength^a BMI <20 kg/m² and/or weight loss 5 kg/year Serum albumin <3.5 g/dl Cognitive impairment or dementia	Medical history Physical examination Physical performance measures Cognitive assessments Laboratory tests
Severe liver disease/cirrhosis	Any of the following: Child-Pugh class C MELD score ≥10 Portal-caval, spleno-renal, or transjugular intrahepatic portal shunt Biopsy proven cirrhosis with portal hypertension or hepatocellular dysfunction	Medical history Physical examination Laboratory tests Child-Pugh classification MELD score Liver biopsy
Hostile chest	Any of the following or other reasons that make redo operation through sternotomy or right anterior thoracotomy prohibitively hazardous: Abnormal chest wall anatomy due to severe kyphoscoliosis or other skeletal abnormalities (including thoracoplasty, Potts' disease) Complications from prior surgery Evidence of severe radiation damage (e.g. skin burns, bone destruction, muscle loss, lung fibrosis, or oesophageal stricture) History of multiple recurrent pleural effusions causing internal adhesions	Medical history Physical examination Chest X-ray CT scan
IMA or other critical conduit(s) crossing midline and/or adherent to posterior table of sternum	A patent IMA graft that is adherent to the sternum such that injuring it during re-operation is likely A patient may be considered at extreme risk if any of the following are present: The conduit(s) are radiographically indistinguishable from the posterior table of the sternum The conduit(s) are radiographically distinguishable from the posterior table of the sternum but lie within 2–3 mm of the posterior table	Axial CT scan images illustrating the graft crossing the midline so that the distance from sternum to graft can be measured Angiogram from the lateral and PA projections and/or a CPR or VR (volume rendering) 3D reconstructed CT scan image showing relationships between the graft and the sternum
Severe pulmonary hypertension Severe right ventricular dysfunction	Primary or secondary pulmonary hypertension with PA systolic pressures greater than two-thirds of systemic pressure Criteria as defined by the guidelines (e.g. TAPSE <15 mm, RV end-systolic area >20 cm², etc.)^b	Echocardiography, right and left-heart-catheterization documenting PA and systemic pressures Documentation of secondary causes of pulmonary hypertension

Co-morbidities	Definition/criteria	Diagnostic modalities
Porcelain aorta or severely atherosclerotic aorta	Heavy circumferential calcification or severe atheromatous plaques of the entire ascending aorta extending to the arch such that aortic cross-clamping is not feasible	Non-contrast axial CT at levels: Sinotubular junction Tubular ascending aorta between the sinotubular junction and the innominate artery Innominate artery Entire transverse arch
Frailty	Slowness, weakness, exhaustion, wasting and malnutrition, poor endurance and inactivity, loss of independence Criteria: 5 m walking time^a Grip strength^a BMI <20 kg/m² and/or weight loss 5 kg/year Serum albumin <3.5 g/dl Cognitive impairment or dementia	Medical history Physical examination Physical performance measures Cognitive assessments Laboratory tests
Severe liver disease/cirrhosis	Any of the following: Child-Pugh class C MELD score ≥10 Portal-caval, spleno-renal, or transjugular intrahepatic portal shunt Biopsy proven cirrhosis with portal hypertension or hepatocellular dysfunction	Medical history Physical examination Laboratory tests Child-Pugh classification MELD score Liver biopsy
Hostile chest	Any of the following or other reasons that make redo operation through sternotomy or right anterior thoracotomy prohibitively hazardous: Abnormal chest wall anatomy due to severe kyphoscoliosis or other skeletal abnormalities (including thoracoplasty, Potts' disease) Complications from prior surgery Evidence of severe radiation damage (e.g. skin burns, bone destruction, muscle loss, lung fibrosis, or oesophageal stricture) History of multiple recurrent pleural effusions causing internal adhesions	Medical history Physical examination Chest X-ray CT scan
IMA or other critical conduit(s) crossing midline and/or adherent to posterior table of sternum	A patent IMA graft that is adherent to the sternum such that injuring it during re-operation is likely A patient may be considered at extreme risk if any of the following are present: The conduit(s) are radiographically indistinguishable from the posterior table of the sternum The conduit(s) are radiographically distinguishable from the posterior table of the sternum but lie within 2–3 mm of the posterior table	Axial CT scan images illustrating the graft crossing the midline so that the distance from sternum to graft can be measured Angiogram from the lateral and PA projections and/or a CPR or VR (volume rendering) 3D reconstructed CT scan image showing relationships between the graft and the sternum
Severe pulmonary hypertension Severe right ventricular dysfunction	Primary or secondary pulmonary hypertension with PA systolic pressures greater than two-thirds of systemic pressure Criteria as defined by the guidelines (e.g. TAPSE <15 mm, RV end-systolic area >20 cm², etc.)^b	Echocardiography, right and left-heart-catheterization documenting PA and systemic pressures Documentation of secondary causes of pulmonary hypertension

CT: computed tomography; MELD: Model for End-Stage Liver Disease; INR: international normalized ratio; IMA: internal mammary artery; PA: pulmonary artery.

^aVariable with respect to age and gender without validated scientific thresholds.

^bRudski et al. [71].

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