Chest
Volume 128, Issue 4, October 2005, Pages 2944-2953
Journal home page for Chest

Reviews
Preoperative and Perioperative Care for Patients With Suspected or Established Aortic Stenosis Facing Noncardiac Surgery

https://doi.org/10.1378/chest.128.4.2944Get rights and content

Current medicine has displayed a trend toward less interfering techniques but more invasive surgical approaches in older patients with more comorbidities. In this population, the prevalence of symptomatic cardiac disease including aortic stenosis is increased. More than 25 years have elapsed since severe aortic stenosis was identified as an independent, important risk factor for patients undergoing general anesthesia for noncardiac surgery. Despite impressive advances in anesthesiologic and surgical techniques, morbidity and mortality in patients with severe aortic stenosis remains high. Published study results clearly show that adverse perioperative risk in patients with aortic stenosis depends on the interaction of factors such as the severity of valve disease, concomitant coronary artery disease, and the severity and/or urgency of the surgical procedures. The mainstay of preoperative evaluation remains the obtaining of a comprehensive preoperative medical history and a physical examination, while transthoracic echocardiography is necessary to establish or exclude hemodynamically relevant aortic stenosis in selected patients. Perioperative care is established in patients with asymptomatic aortic stenosis and/or those undergoing low-risk surgery. However, further preoperative testing or aortic valve replacement prior to noncardiac surgery should be discussed individually with the patients awaiting urgent surgical procedures who are at medium or high risk. At this point, decisions should be made in an interdisciplinary manner, including the opinions/wishes of the patient and the patient's family.

Section snippets

Problem Definition: Perioperative Risk Assessment in Noncardiac Surgery

Cardiac complications due to coronary artery disease (CAD) pose the most important risks to patients during noncardiac surgery: about 25% of patients scheduled for noncardiac surgery have coronary risk factors or known CAD,1 and up to 12% of high-risk patients undergoing high-risk vascular surgery will have a perioperative myocardial infarction.2 This contributes to a high morbidity and mortality rate and to a high economic burden due to the required management of those complications.3

Since the

Aortic Valve Disease and Cardiovascular Risk in Noncardiac Surgery

Aortic valve stenosis is the most common valvular heart disease in the elderly.8910 Degeneration of the aortic cusps evolves with age and the population is aging in industrialized countries.11 Large studies report that 2 to 9% of adults who are > 65 years of age are affected by aortic stenosis,89 which has major implications for health-care providers. Additionally, approximately 1 to 2% of the general population is born with a bicuspid aortic valve, which is prone to early degeneration and

Preoperative Risk Assessment in Patients With Aortic Stenosis

The essential issue during preoperative assessment is to estimate the risk/benefit ratio between the risk of noncardiac surgery and the severity of aortic stenosis. However, different definitions of disease severity have been used in published studies, impeding the simple interpretation of those studies. Irrespective of noncardiac surgery, symptomatic patients with severe aortic stenosis, determined according to the definitions published by an American College of Cardiology/American Heart

How to Deal With the Healthy Patient Facing Noncardiac Surgery

The obtaining of a medical history and a physical examination are the cornerstones of the preoperative evaluation of all patients. It is not feasible and not cost-effective to conduct an echocardiographic study in every patient during the preoperative setting.14 Cardiac murmurs are common in asymptomatic patients facing noncardiac surgery. Aortic stenosis can be recognized during the physical examination by the presence of a low-frequency, systolic ejection murmur. Other findings may include

Value of Medical Consultation in Patients With Aortic Stenosis

A medical consultant is often contacted at the request of the surgeon or the primary care physician prior to the consideration of a surgical referral. The goals of a medical consultation are (1) to identify unrecognized comorbid disease and (2) to optimize the preoperative medical condition as a member of the preoperative team. This should include recommendations on prophylaxis for venous thrombembolism and endocarditis, especially in patients with aortic stenosis with or without atrial

Value of Echocardiography in Asymptomatic Patients With Aortic Stenosis

To our knowledge, the clinical value of echocardiography in asymptomatic patients with aortic stenosis facing noncardiac surgery has not been systematically examined. However, the rates of major adverse events in patients with asymptomatic aortic stenosis have been high in older reports,2 while the rates of fatal cardiac complications were considerably lower in newer reports,1415 even when only patients with severe aortic stenosis have been analyzed. Graduation of aortic stenosis was

Echocardiographic Measures in the Diagnosis of Aortic Stenosis

Echocardiography plays a major role in the evaluation of the severity of aortic stenosis and has replaced cardiac catheterization for the assessment of aortic stenosis in many centers. Catheterization is now performed almost only when coronary angiography is required.30 The most common cause of aortic stenosis in older patients is degeneration and calcification, while stenosis of the bicuspid valve is more common in younger adults. Two-dimensional echocardiography is helpful in assessing the

Preoperative Considerations of the Anesthesiologist

Effective communication of the particular valvular lesion and its severity to the anesthesiologist and to the members of the surgical team is necessary to tailor perioperative care. As already stated for cardiovascular adverse events in noncardiac surgery, the type of surgery (Table 1) influences outcome in affected patients with aortic stenosis.6 Therefore, it is of major importance to score the type of surgery and the physical exercise capacity of the patients into three classes, as has been

Management of Anesthesia in Patients With Aortic Stenosis During Noncardiac Surgery

The chronic pressure overload state induced by aortic stenosis results in concentric hypertrophy, subsequently reducing the compliance of the LV. Thus, ventricular filling is more dependent on preload and the functioning of the ventricular filling by the atria. It is not surprising that sinus tachycardia or atrial arrhythmias can worsen LV load, leading to heart failure in patients with aortic stenosis. In addition, concentric hypertrophy results in reduced coronary reserve. Thus, decreases in

Antimicrobial Prophylaxis in Patients With Aortic Stenosis

Antimicrobial prophylaxis for bacterial endocarditis has become standard and routine in most developed countries for patients who are at increased risk for bacterial endocarditis.2125 Although the biological plausibility is very high, no study has definitively demonstrated that prophylactic antibiotics prevent endocarditis after invasive procedures. Patients with aortic stenosis are considered to be at moderate risk for bacterial endocarditis and should therefore be offered antibiotic

Summary

Severe aortic stenosis has been identified as an independent, important risk factor for patients undergoing noncardiac surgery. Some elegant studies have clearly demonstrated that the taking of a medical history and performance of a physical examination are the cornerstones of preoperative risk assessment, while technical tests add further independent information on the perioperative risk only in selected patient groups. Since perioperative risk is increased in patients with severe aortic

References (39)

  • GeertsWH et al.

    Prevention of venous thromboembolism

    Chest

    (2001)
  • MollemaR et al.

    The value of peri-operative consultation on a general surgical ward by the internist

    Neth J Med

    (2000)
  • LeeT et al.

    Impact of inter-physician communication on the effectiveness of medical consultations

    Am J Med

    (1983)
  • LevineMJ et al.

    Palliation of valvular aortic stenosis by balloon valvuloplasty as preoperative preparation for noncardiac surgery

    Am J Cardiol

    (1988)
  • RothRB et al.

    Percutaneous aortic balloon valvuloplasty: its role in the management of patients with aortic stenosis requiring major noncardiac surgery

    J Am Coll Cardiol

    (1989)
  • HayesSN et al.

    Palliative percutaneous aortic balloon valvuloplasty before noncardiac operations and invasive diagnostic procedures

    Mayo Clin Proc

    (1989)
  • ManganoDT et al.

    Preoperative assessment of patients with known or suspected coronary disease

    N Engl J Med

    (1995)
  • GoldmanL et al.

    Multifactorial index of cardiac risk in noncardiac surgical procedures

    N Engl J Med

    (1977)
  • FleisherLA et al.

    Clinical practice: lowering cardiac risk in noncardiac surgery

    N Engl J Med

    (2001)
  • Cited by (62)

    • The 2020 ACC/AHA Guidelines for Management of Patients With Valvular Heart Disease: Highlights and Perioperative Implications

      2022, Journal of Cardiothoracic and Vascular Anesthesia
      Citation Excerpt :

      Epidural or spinal anesthetic interventions should be modified to avoid rapid changes in blood pressure. High-dilution neuraxial local anesthetic agents should be used in combination with opioids.6,33,34 The guidelines stated that it is reasonable to perform elective noncardiac surgery in patients with moderate or greater degree of rheumatic MS with a PASP <50 mmHg (class 2a).

    • Catheterization Laboratory: Structural Heart Disease, Devices, and Transcatheter Aortic Valve Replacement

      2017, Anesthesiology Clinics
      Citation Excerpt :

      The LV receives less preload. Phenylephrine should be considered if pharmacologic intervention is required to increase systemic pressure because it will increase afterload and help to reduce the heart rate via reflexive bradycardia.30 In addition to standard ASA monitors, external defibrillating pads are applied.

    View all citing articles on Scopus

    Dr. Sharkova received a grant from the Deutsche Herzstiftung, Frankfurt, Germany.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

    View full text