In a patient with decompensated heart failure requiring urgent non-cardiac surgery, how much volume optimization do you pursue preoperatively, and at what point does the risk of further surgical delay outweigh the benefit of continued diuresis?

This is an interesting question and a challenging situation for a patient. I think that the ideal scenario would be for the patient to be euvolemic clinically prior to surgery. I am very aggressive with intravenous diuretics. I think that a discussion with the patient, with the surgeon, and with anesthesia is key. The particular surgery is also important. I would see if there are any alternatives to surgery. For example, if a patient presents with cholecystitis or cholangitis, would interventional radiology be able to place a percutaneous cholecystostomy tube? Would the patient be able to have the procedure without general anesthesia (using regional anesthesia or local anesthesia)? If a patient requires surgery for source control for sepsis...

I would recommend preoperative placement of a Swan-Ganz catheter in this situation to guide perioperative management, including intensity of diuresis and use of intravenous inotropic agents and/or vasodilators.

Management of high-risk patients such as this is a reasonable part of cardiology practice. I believe and agree that RHC can be very helpful in perioperative management of these high-risk patients.