What is a case example of preoperative assessment for aortic stenosis (AS) in a noncardiac surgery patient with asymptomatic valvular heart disease?

Updated: Jul 16, 2021
  • Author: Lindsay A (Finger) Raleigh, MD; Chief Editor: Sheela Pai Cole, MD  more...
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Answer

Answer

A 54-year-old man with a history of BAV and mild AS presents for multilevel laminectomy and decompression for spinal stenosis. The patient reports that he last underwent TTE 5 years ago but states that he has not experienced any symptoms such as dyspnea, chest pain, or angina. The degree of his back pain is such that he is unable to walk up more than one flight of stairs. 

Resolution

This patient has known asymptomatic valvular heart disease and is scheduled to undergo an elective but nonetheless high-risk surgical procedure. Per AHA/ACC guidelines, he should have a preoperative TTE evaluation because his last echocardiogram was more than 1 year ago. [20] If the results of TTE show moderate or severe AS, proceeding with surgery may still be reasonable if advanced hemodynamic monitoring is provided, per the guidelines.

If the patient's AS is severe, consideration can be given to delaying his spine surgery and proceeding with AVR first. This discussion should occur during a consultation with a cardiothoracic surgeon. The patient's age makes him a likely candidate for a mechanical valve; however, this would require lifelong anticoagulation, which might complicate future spine surgery. The risks of AVR should be weighed against the risks of proceeding with this noncardiac surgical procedure.

If the patient proceeds with noncardiac surgery, intraoperative monitoring with a preinduction arterial line should be employed. When he is in the prone position, the ability to perform echocardiography will be limited. Thus, if a decreased ejection fraction or other concerning echocardiographic findings are noted, further advanced monitoring with a pulmonary artery catheter may be considered. This patient is likely to have significant blood loss and postoperative pain. Postoperative monitoring in an ICU or a stepdown unit with telemetry should be considered.


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