Aviation Cardiology: Occupational Hazards and Cardiac Surgery Facts for Aircrew and Passengers Undergoing Cardiac Surgery Are Discussed

T. Syburra; R. vonWattenwyl; D. Bron; E. Nicol


Eur Heart J. 2019;40(25):1998-2000. 

In This Article


Aircrew are responsible for safe and reliable aircraft operations. Cardiovascular disease accounts for half of all pilot licenses declined or withdrawn for medical reasons in Western Europe and is the most common causes of sudden incapacitation in flight. Safety considerations are paramount in aviation medicine, and the most dreaded cardiovascular complications are thrombo-embolic events and rhythm disturbances due to their potential for sudden incapacitation.

In aviation, the current consensus risk threshold for an acceptable level of controlled risk of acute incapacitation is 1% per annum (for dual pilot commercial operations), a percentage calculated using engineering principles to ensure the incidence of a fatal air accident is no greater than 1 per 107 h of flying. This is known as the '1% safety rule'.

Aircrew retirement age is increasing and the burden of subclinical, but potentially significant, coronary artery atherosclerosis is unknown in pilots above age 40.

To fly as a pilot after cardiac surgery is possible; however, special attention to perioperative planning between cardiac surgeon and aviation medicine examiner (AME) is mandatory. Choice of procedure is crucial for license renewal. Restrictions are likely to apply, particularly with regards to military aviation and high-performance aircraft, such as used in aerobatics.

Return to flight duties is not considered earlier than 6 months post-operatively and return to flying is only possible after full and satisfactory assessment. High +Gz environments (such as experienced in high-performance jets and aircraft performing aerobatics), sustained Valsalva manoeuvres, and flying roles that demand high cardiac output should all be taken into consideration. The indication for specific surgical procedures needs to also incorporate ethical considerations (such as tissue valve prosthesis under the guideline recommended age).

For aircrew, health-related issues are career critical. To investigate whether aviation decision-making for cardiothoracic surgery was reasonable, we reviewed the current aeronautical and the related surgical literature regarding aircrew and performed an anonymised online survey of cardiac surgeons within the European Association for Cardio-Thoracic Surgery (EACTS).

In Europe, for aircrew, all cardiac surgery cases must be evaluated perioperatively by an AME alongside the operating surgeon and a cardiologist. The results of the questionnaire show that among the EACTS surgeons, there is a significant proportion of cardiac surgeons who are unaware of the specific occupational health regulations that need to be considered and understood when operating on aircrew. Furthermore, the literature review highlighted the fact that many occupational health regulations differ substantially from the clinical guidelines, as edited by the European Society of Cardiology (ESC), often with little obvious explanation or justification for these discrepancies.

In summary, to fly as a pilot after cardiac surgery is possible,[1–3] but special attention to perioperative planning is mandatory, and should be undertaken with the pilot and his AME. The choice of surgical procedure (e.g. full revascularization) or the use of prosthetic material (e.g. stentless prosthesis, mitral valve repair, left atrial appendage (LAA) exclusion) is a crucial consideration for successful license renewal. Restrictions are likely to apply following surgery and pilots should be counselled as such. Unnecessary grounding due to ignorance needs to be avoided at all costs.

The post-operative follow-up needs tight-scheduling and requires collaboration with the cardiologist and the AME. Improving dialogue between the surgical and cardiological societies and the aviation authorities should be mandatory and ensure support and collective agreement for future revisions of the occupational health regulations for flight crew licensing and clinical cardiac surgery guidelines.