What preoperative evaluation and management are recommended for a patient with atrial fibrillation (AF), hypertension (HTN), heart failure with preserved ejection fraction (HFpEF), history of mitral clip placement, severe tricuspid regurgitation (TR), hypothyroidism, and chronic kidney disease (CKD) stage 3a undergoing right anterior hip replacement using robotic assistance?

From the Guidelines

For a patient with atrial fibrillation, hypertension, HFpEF, history of mitral clip, severe tricuspid regurgitation, hypothyroidism, and CKD stage 3a undergoing robotic right anterior hip replacement, a comprehensive preoperative evaluation and management strategy is crucial to minimize perioperative risk. This should include a recent echocardiogram (within 3-6 months) to assess cardiac function, especially given the mitral clip and tricuspid regurgitation, as recommended by the latest guidelines 1.

Preoperative Evaluation

• Cardiology consultation is recommended to optimize heart failure management and anticoagulation strategy.
• Anticoagulation for atrial fibrillation should be managed carefully, typically discontinuing direct oral anticoagulants 48-72 hours before surgery or warfarin 5 days preoperatively with bridging therapy using low molecular weight heparin if CHA₂DS₂-VASc score is high.
• Rate control medications should be continued perioperatively, including beta-blockers like metoprolol, as they reduce myocardial oxygen consumption by reducing contractile force and heart rate, thus providing cardioprotection 1.
• Antihypertensive medications should generally be continued until the morning of surgery, except ACE inhibitors and ARBs which may be held 24 hours before surgery to avoid intraoperative hypotension.
• Thyroid function tests should be checked to ensure the patient is euthyroid, as hypothyroidism can affect anesthetic requirements and cardiovascular stability.
• Renal function assessment with recent creatinine, BUN, and electrolytes is crucial given the CKD, with medication doses adjusted accordingly.

Anesthetic Considerations

• Anesthesiology consultation should address the cardiac risk factors and determine the optimal anesthetic approach, considering the patient's complex medical history and the nature of the surgical procedure.
• The choice of anesthetic technique should aim to minimize the risk of perioperative cardiac complications, considering factors such as the need for invasive monitoring, the potential for significant blood loss, and the impact of anesthesia on cardiac function.

Management of Cardiovascular Risk Factors

• Smoking cessation and control of CV risk factors are always recommended in patients with heart failure, as it is associated with reduced postoperative complications and mortality 1.
• The management of pharmacological cardiovascular treatments should be based on the latest guidelines, including the continuation of beta-blockers, statins, and the careful management of renin-angiotensin-aldosterone system inhibitors perioperatively 1.

Conclusion of Recommendations

The key to successful perioperative management of this patient is a multidisciplinary approach, including cardiology, anesthesiology, and surgery, to optimize cardiac function, manage anticoagulation, and minimize the risk of perioperative complications. By following these recommendations and considering the latest evidence 1, the patient's morbidity, mortality, and quality of life can be significantly improved.

From the Research

Patient Conditions

• Atrial fibrillation (AF)
• Hypertension (HTN)
• Heart failure with preserved ejection fraction (HFpEF) due to nonischemic cardiomyopathy
• History of mitral clip placement
• Severe tricuspid regurgitation (TR)
• Hypothyroidism
• Chronic kidney disease (CKD) stage 3a

Preoperative Evaluation and Management

• The patient's AF and HFpEF increase the risk of stroke, requiring oral anticoagulation or left atrial appendage closure 2
• The presence of AF and severe TR may increase the risk of late tricuspid regurgitation, especially if the tricuspid annulus is dilated 3
• Mitral valve repair may be effective in reducing mitral regurgitation and improving heart failure symptoms in patients with atrial functional mitral regurgitation 4
• Combining mitral valve transcatheter edge-to-edge repair and left atrial appendage occlusion in one procedure may be a viable option for patients with AF and mitral regurgitation 5
• The relationship between AF, mitral regurgitation, and heart failure subtype is complex, and the presence of AF may increase the risk of mortality in patients with HFpEF and moderate/severe mitral regurgitation 6

Considerations for Robotic-Assisted Hip Replacement

• The patient's severe TR and CKD stage 3a may increase the risk of perioperative complications, such as cardiac arrhythmias and acute kidney injury
• Careful preoperative evaluation and management of the patient's cardiac and renal conditions are necessary to minimize the risk of complications
• The use of robotic assistance may help reduce the risk of surgical complications, such as bleeding and infection, but the patient's underlying conditions must be carefully managed perioperatively 2, 6, 5, 4, 3