# Cardiac Surgery in Cancer Patients: Clinical Dilemmas and Decision-Making Challenges

## TL;DR

This paper reviews the challenges of performing cardiac surgery on cancer patients, emphasizing the need for personalized decisions considering both heart and cancer health.

## Contribution

The paper provides a comprehensive review of clinical dilemmas in cardiac surgery for cancer patients and highlights gaps in current risk assessment tools.

## Key findings

- Cancer patients undergoing cardiac surgery face heightened risks due to factors like hypercoagulability and frailty.
- Conventional surgical risk scores fail to account for cancer-specific variables like tumor biology and prognosis.
- Transcatheter and minimally invasive approaches are increasingly used in high-risk cancer patients.

## Abstract

Advances in cancer therapy have improved survival, resulting in a growing number of patients who develop cardiovascular disease requiring surgical intervention. Cardiac surgery in patients with active or prior cancer presents complex clinical dilemmas, as clinicians must balance cardiac urgency, oncologic prognosis, treatment-related toxicity, frailty, and quality-of-life considerations. This review synthesizes current evidence on the epidemiology, perioperative risks, timing, and outcomes of cardiac surgery in oncology populations. We highlight the limitations of existing surgical risk scores, discuss the role of transcatheter and minimally invasive alternatives, and emphasize the central importance of multidisciplinary decision-making. An individualized, patient-centered approach is essential to ensure that cardiac interventions are both clinically meaningful and aligned with oncologic goals.

Background: Improvements in cancer detection and treatment have led to a growing population of cancer survivors who subsequently develop cardiovascular (CV) disease requiring cardiac surgery. Methods: This narrative review synthesizes contemporary evidence from observational studies, registries, meta-analyses, and international guidelines addressing cardiac surgery in patients with active or prior cancer. Results: Cancer patients undergoing cardiac surgery face heightened risks related to hypercoagulability, bleeding, immunosuppression, frailty, and prior exposure to chemotherapy or radiotherapy. Conventional surgical risk scores inadequately capture cancer-specific factors such as tumor biology, prognosis, treatment trajectory, and frailty, often underestimating operative risk. Timing of surgery must balance CV urgency against oncologic priorities, with urgent cardiac conditions necessitating prompt intervention irrespective of cancer status, while stable disease allows individualized sequencing. Transcatheter and minimally invasive approaches increasingly play a key role, particularly in patients with limited life expectancy, hostile thoracic anatomy, or high surgical risk. Outcomes are heterogeneous and largely driven by cancer stage and prognosis rather than cardiac pathology alone. Conclusions: Cardiac surgery can be lifesaving and restore eligibility for definitive oncologic therapy in carefully selected patients, particularly those with early-stage or potentially curable malignancies. In advanced cancer, the benefits of invasive intervention must be weighed against perioperative burden, quality of life impact, and overall prognosis. Multidisciplinary, patient-centered decision-making within specialized cardio-oncology teams is essential. Future priorities include the development of cancer-specific risk prediction models, prospective surgical registries, and greater integration of quality-of-life outcomes into clinical decision-making.