Perioperative management of aortic stenosis in patients undergoing non-cardiac surgery

Abstract

Aortic stenosis is one of the most common cardiac valve pathologies in the world and its prevalence increases with age. Although previously associated with increased perioperative mortality, more recent studies suggest that mortality rates may be decreasing. Recent guidelines suggest that major non-cardiac surgery can be performed safely in asymptomatic severe aortic stenosis patients with close hemodynamic monitoring. Among symptomatic patients, the guidelines recommend aortic valve intervention prior to major non-cardiac surgery because of a reduction in the incidence of postoperative heart failure and improved rates of long-term overall survival. This review provides a comprehensive and contemporary review of the perioperative management of patients with severe aortic valve stenosis.

Perioperative Management of Valvular Heart Disease in Patients Undergoing Non-Cardiac Surgery

“…Clinical and echocardiographic evaluation is recommended for all patients with known or suspected VHD who are scheduled for elective intermediate or high-risk NCS [ 8 , 11 ]. Along with a thorough history and physical examination, a non-invasive transthoracic echocardiography (TTE, especially using 3D TTE) or four-dimensional computer tomography (4D CT) examinations are important to study the valve morphology, hemodynamics, left ventricular hypertrophy, systolic and diastolic functions of the left ventricle (LV), and other valvular complications [ 12 ]. Valvular pathologies (whether regurgitation or stenosis) are classified by ESC into three grades (mild, moderate, and severe) according to the severity of lesions.…”

“…In cases of severe VHD, it is very important to identify whether the symptoms are solely related to the underlying VHD (or other cardiovascular diseases) [ 12 ]. A symptomatic severe valvular disease profile, due to its elevated perioperative risk and mortality, in many cases, changes the approach to preoperative management and the timing of NCS.…”

“…Another important consideration prior to major NCS in patients with AS is renal function. Patients with CKD have a higher prevalence of AS, and AS severity correlates with CKD [ 12 , 18 ]. Pre-existing CKD is the most significant risk factor for the development of acute kidney injury (AKI), and the baseline estimated glomerular filtration rate (eGFR) is an important variable in preprocedural risk calculation [ 12 , 19 ].…”

“…Symptomatic severe AS poses a great risk for postoperative cardiac complications such as myocardial infarction and heart failure and is a predictor of 30-day mortality after NCS [ 8 ]. Patients with severe AS are likely to have an increased risk of a major advance cardiac event and intraoperative mortality [ 12 , 20 ]. The mechanism by which this occurs is thought to involve hypotension and tachycardia from anesthetic agents and surgical stress, leading to injurious hemodynamics.…”

High-Degree Heart Block During Noncardiac Surgery Soon After Transcatheter Aortic Valve Replacement: A Case Report

“…A mong patients with severe, symptomatic aortic stenosis (AS), current guidelines recommend aortic valve intervention before major noncardiac surgery because of a reduction in the incidence of postoperative heart failure and improved rates of long-term overall survival. 1 Patients undergoing transcatheter aortic valve replacement (TAVR) to bridge to noncardiac surgery have improved outcomes, 2 but those with preexisting conduction abnormalities are at higher risk for post-TAVR complications which may delay time to their originally intended noncardiac surgery. Patients with preexisting right bundle branch block (RBBB) have higher incidence of postoperative pacemaker insertion (PPI) and all-cause mortality after TAVR compared with patients without RBBB.…”