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

<b>Background:</b> Improvements in cancer detection and treatment have led to a growing population of cancer survivors who subsequently develop cardiovascular (CV) disease requiring cardiac surgery. <b>Methods:</b> 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. <b>Results:</b> 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. <b>Conclusions:</b> 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.