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

      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.

      Keywords

      Abbreviations:

      CAD ( coronary artery disease), LV ( left ventricle, ventricular)
      To read this article in full you will need to make a payment
      Subscribe to CHEST
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Mangano DT
        • Goldman L
        Preoperative assessment of patients with known or suspected coronary disease.
        N Engl J Med. 1995; 333: 1750-1756
        • Goldman L
        • Caldera DL
        • Nussbaum SR
        • et al.
        Multifactorial index of cardiac risk in noncardiac surgical procedures.
        N Engl J Med. 1977; 297: 845-850
        • Fleisher LA
        • Eagle KA
        Clinical practice: lowering cardiac risk in noncardiac surgery.
        N Engl J Med. 2001; 345: 1677-1682
        • Detsky AS
        • Abrams HB
        • Mc Laughlin JR
        • et al.
        Predicting cardiac complications in patients undergoing non-cardiac surgery.
        J Gen Intern Med. 1986; 1: 211-219
        • Schein OD
        • Katz J
        • Bass EB
        • et al.
        The value of routine preoperative medical testing before cataract surgery.
        Am J Ophthalmol. 2000; 129: 701
        • Eagle KA
        • Berger PB
        • Calkins H
        • et al.
        ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery: executive summary; a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).
        Anesth Analg. 2002; 94: 1052-1064
        • Geldner G
        • Christ M
        • Wulf H
        Preoperative assessment.
        Lancet. 2004; 363: 400-401
        • Stewart BF
        • Siscovick D
        • Lind BK
        • et al.
        Clinical factors associated with calcific aortic valve disease: Cardiovascular Health Study.
        J Am Coll Cardiol. 1997; 29: 630-634
        • Lindroos M
        • Kupari M
        • Heikkila J
        • et al.
        Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample.
        J Am Coll Cardiol. 1993; 21: 1220-1225
        • Lombard JT
        • Selzer A
        Valvular aortic stenosis: a clinical and hemodynamic profile of patients.
        Ann Intern Med. 1987; 106: 292-298
        • Carabello BA
        Clinical practice: aortic stenosis.
        N Engl J Med. 2002; 346: 677-682
        • Kertai MD
        • Bountioukos M
        • Boersma E
        • et al.
        Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery.
        Am J Med. 2004; 116: 8-13
        • Rohde LE
        • Polanczyk CA
        • Goldman L
        • et al.
        Usefulness of transthoracic echocardiography as a tool for risk stratification of patients undergoing major noncardiac surgery.
        Am J Cardiol. 2001; 87: 505-509
        • O'Keefe Jr., JH
        • Shub C
        • Rettke SR
        Risk of noncardiac surgical procedures in patients with aortic stenosis.
        Mayo Clin Proc. 1989; 64: 400-405
        • Torsher LC
        • Shub C
        • Rettke SR
        • et al.
        Risk of patients with severe aortic stenosis undergoing noncardiac surgery.
        Am J Cardiol. 1998; 81: 448-452
        • Sethi GK
        • Miller DC
        • Souchek J
        • et al.
        Clinical, hemodynamic, and angiographic predictors of operative mortality in patients undergoing single valve replacement: Veterans Administration Cooperative Study on Valvular Heart Disease.
        J Thorac Cardiovasc Surg. 1987; 93: 884-897
        • Mullany CJ
        • Elveback LR
        • Frye RL
        • et al.
        Coronary artery disease and its management: influence on survival in patients undergoing aortic valve replacement.
        J Am Coll Cardiol. 1987; 10: 66-72
        • Levinson JR
        • Akins CW
        • Buckley MJ
        • et al.
        Octogenarians with aortic stenosis: outcome after aortic valve replacement.
        Circulation. 1989; 80: I49-56
        • Carabello BA
        Aortic sclerosis: a window to the coronary arteries?.
        N Engl J Med. 1999; 341: 193-195
        • Otto CM
        • Lind BK
        • Kitzman DW
        • et al.
        Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly.
        N Engl J Med. 1999; 341: 142-147
        • Bonow RO
        • Carabello B
        • de Leon AC
        • et al.
        ACC/AHA guidelines for the management of patients with valvular heart disease: executive summary; a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease).
        J Heart Valve Dis. 1998; 7: 672-707
        • Otto CM
        • Burwash IG
        • Legget ME
        • et al.
        Prospective study of asymptomatic valvular aortic stenosis: clinical, echocardiographic, and exercise predictors of outcome.
        Circulation. 1997; 95: 2262-2270
        • Mangano DT
        • Layug EL
        • Wallace A
        • et al.
        Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery: Multicenter Study of Perioperative Ischemia Research Group.
        N Engl J Med. 1996; 335: 1713-1720
        • Geerts WH
        • Heit JA
        • Clagett GP
        • et al.
        Prevention of venous thromboembolism.
        Chest. 2001; 119: 132S-175S
        • Dajani AS
        • Taubert KA
        • Wilson W
        • et al.
        Prevention of bacterial endocarditis: recommendations by the American Heart Association.
        JAMA. 1997; 277: 1794-1801
        • Devereaux PJ
        • Ghali WA
        • Gibson NE
        • et al.
        Physicians' recommendations for patients who undergo noncardiac surgery.
        Clin Invest Med. 2000; 23: 116-123
        • Mollema R
        • Berger P
        • Girbes AR
        The value of peri-operative consultation on a general surgical ward by the internist.
        Neth J Med. 2000; 56: 7-11
        • Macpherson DS
        • Parenti C
        • Nee J
        • et al.
        An internist joins the surgery service: does comanagement make a difference?.
        J Gen Intern Med. 1994; 9: 440-444
        • Lee T
        • Pappius EM
        • Goldman L
        Impact of inter-physician communication on the effectiveness of medical consultations.
        Am J Med. 1983; 74: 106-112
        • Mochizuki Y
        • Pandian NG
        Role of echocardiography in the diagnosis and treatment of patients with aortic stenosis.
        Curr Opin Cardiol. 2003; 18: 327-333
        • Thomas SJ
        • Lowenstein E
        Anesthetic management of the patient with valvular heart disease.
        Int Anesthesiol Clin. 1979; 17: 67-96
        • Goertz AW
        • Lindner KH
        • Schutz W
        • et al.
        Influence of phenylephrine bolus administration on left ventricular filling dynamics in patients with coronary artery disease and patients with valvular aortic stenosis.
        Anesthesiology. 1994; 81: 49-58
        • Goertz AW
        • Lindner KH
        • Seefelder C
        • et al.
        Effect of phenylephrine bolus administration on global left ventricular function in patients with coronary artery disease and patients with valvular aortic stenosis.
        Anesthesiology. 1993; 78: 834-841
        • Sandham JD
        • Hull RD
        • Brant RF
        • et al.
        A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients.
        N Engl J Med. 2003; 348: 5-14
        • Levine MJ
        • Berman AD
        • Safian RD
        • et al.
        Palliation of valvular aortic stenosis by balloon valvuloplasty as preoperative preparation for noncardiac surgery.
        Am J Cardiol. 1988; 62: 1309-1310
        • Roth RB
        • Palacios IF
        • Block PC
        Percutaneous aortic balloon valvuloplasty: its role in the management of patients with aortic stenosis requiring major noncardiac surgery.
        J Am Coll Cardiol. 1989; 13: 1039-1041
        • Hayes SN
        • Holmes Jr., DR
        • Nishimura RA
        • et al.
        Palliative percutaneous aortic balloon valvuloplasty before noncardiac operations and invasive diagnostic procedures.
        Mayo Clin Proc. 1989; 64: 753-757
        • Raymer K
        • Yang H
        Patients with aortic stenosis: cardiac complications in non-cardiac surgery.
        Can J Anaesth. 1998; 45: 855-859
        • Lee TH
        • Marcantonio ER
        • Mangione CM
        • et al.
        Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.
        Circulation. 1999; 100: 1043-1049