What is the induction plan for anesthesia in a patient with severely reduced Ejection Fraction (EF) and severe aortic stenosis?

From the Guidelines

For a patient with severely reduced ejection fraction (EF) and severe aortic stenosis, the anesthesia induction plan should focus on maintaining hemodynamic stability while ensuring adequate anesthesia, and I recommend a carefully titrated opioid-based induction with etomidate 0.1-0.2 mg/kg IV as the hypnotic agent, fentanyl 3-5 mcg/kg IV (or sufentanil 0.5-1 mcg/kg) given slowly over 3-5 minutes, and rocuronium 0.6 mg/kg IV for muscle relaxation. Avoid propofol due to its vasodilatory effects, as noted in the context of managing patients with severe aortic stenosis and reduced EF, where maintaining systemic vascular resistance is crucial 1. Maintain preload with judicious fluid administration, targeting euvolemia, to ensure adequate coronary perfusion pressure and avoid hypotension, which is particularly important in patients with severe aortic stenosis and reduced EF, as emphasized in guidelines for managing valvular heart disease 1. Ensure invasive monitoring is established before induction, including arterial line and possibly a central venous catheter or pulmonary artery catheter, to closely monitor hemodynamics and guide vasopressor support as needed, in line with recommendations for managing patients with severe valvular heart disease undergoing non-cardiac surgery 1. Have vasopressors immediately available - phenylephrine (50-100 mcg boluses or 0.1-0.5 mcg/kg/min infusion) and ephedrine (5-10 mg boluses) for blood pressure support, and norepinephrine (0.02-0.1 mcg/kg/min) should be prepared for continuous infusion if needed, to maintain systemic vascular resistance and ensure adequate perfusion of vital organs, as suggested by guidelines for managing patients with severe aortic stenosis and reduced EF 1. This approach is designed to maintain the delicate balance required in aortic stenosis: preserving sinus rhythm, maintaining adequate preload, avoiding tachycardia, and supporting systemic vascular resistance, which is critical for optimizing outcomes in patients with severely reduced EF and severe aortic stenosis, as highlighted in recent guidelines for the management of valvular heart disease 1. The severely reduced EF compounds these challenges, making it crucial to avoid negative inotropes and maintain coronary perfusion pressure, and consider having an inotrope like dobutamine (2-10 mcg/kg/min) available for post-induction cardiac support if needed, to support cardiac function and optimize patient outcomes, in accordance with recommendations for managing patients with severe heart failure and valvular disease 1.

Some key considerations in the management of these patients include:

• Maintaining sinus rhythm to ensure optimal cardiac output
• Avoiding tachycardia to prevent decreased diastolic filling time and potential worsening of cardiac function
• Supporting systemic vascular resistance to maintain adequate coronary perfusion pressure
• Judicious use of fluids to maintain euvolemia and avoid hypotension or pulmonary edema
• Close monitoring of hemodynamics to guide vasopressor and inotropic support as needed, as emphasized in guidelines for managing patients with severe valvular heart disease and reduced EF 1.

By following this approach, anesthesia providers can help optimize outcomes for patients with severely reduced EF and severe aortic stenosis undergoing surgery, in line with current guidelines and evidence-based practice 1.

From the Research

Induction Plan for Anesthesia

The patient has severely reduced ejection fraction (EF) and severe aortic stenosis, which requires careful consideration when developing an induction plan for anesthesia.

• The choice of anesthetic agent is crucial, as it can significantly impact hemodynamics.
• A study comparing propofol/fentanyl and etomidate/fentanyl for induction of anesthesia in patients with aortic insufficiency and coronary artery disease found that both combinations decreased arterial pressure, cardiac index, and left ventricular stroke work index 2.
• However, the study also noted that propofol was associated with a greater decrease in systemic vascular resistance and an increase in stroke volume compared to etomidate.

Considerations for Patients with Severe Aortic Stenosis

Patients with severe aortic stenosis and reduced EF are at higher risk for complications during anesthesia induction.

• A study on the approach to patients with aortic stenosis and low EF suggests that operation is still beneficial in most patients, as relief of afterload mismatch can improve ventricular function and provide symptom relief 3.
• Another study found that reduced left ventricular ejection fraction in patients with aortic stenosis is associated with a worse prognosis, and that LVEF deterioration begins before aortic stenosis becomes severe 4.

Anesthetic Management

The anesthetic management of patients with severe aortic stenosis and reduced EF requires careful consideration of the patient's hemodynamic status.

• A study comparing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (AVR) found that TAVI was associated with faster and better recovery of left ventricular function compared to AVR 5.
• The choice of anesthetic agent and technique should be tailored to the individual patient's needs, taking into account their underlying cardiac disease and hemodynamic status.

Key Factors to Consider

When developing an induction plan for anesthesia in a patient with severely reduced EF and severe aortic stenosis, the following key factors should be considered:

• The patient's hemodynamic status, including blood pressure, cardiac output, and systemic vascular resistance
• The choice of anesthetic agent and technique, including the potential impact on hemodynamics
• The patient's underlying cardiac disease, including the severity of aortic stenosis and the presence of any other cardiac conditions
• The potential benefits and risks of different anesthetic techniques, including the use of TAVI or AVR 6, 5.