Is breast augmentation safe for a woman with normal left ventricular systolic function (EF 65%) and diastolic function, normal right ventricular systolic function (S' 12.3 cm/s, TAPSE 2.0 cm), possible atrial septal defect, mild anterior mitral valve prolapse with mild mitral regurgitation, mild pulmonary hypertension (PASP 38 mmHg), elevated right atrial pressure (dilated IVC, 15 mmHg), trace aortic regurgitation, and a mildly dilated ascending aorta (3.3 cm, indexed 2.0 cm/m²)?

Breast Augmentation Should Be Deferred Until Cardiac Evaluation and Management Are Complete

This patient should NOT proceed with elective breast augmentation until her possible atrial septal defect (ASD) is definitively evaluated and her elevated right atrial pressures are addressed. The combination of a possible ASD, mild pulmonary hypertension, and significantly elevated right atrial pressure (15 mmHg with dilated IVC) represents undiagnosed and potentially progressive cardiac pathology that requires resolution before any elective surgery.

Primary Cardiac Concerns That Preclude Surgery

The Possible Atrial Septal Defect Is the Critical Issue

• A possible ASD must be definitively confirmed or excluded before proceeding with any elective procedure. ASDs can remain clinically silent for decades but lead to progressive right-sided chamber dilation, pulmonary hypertension, arrhythmias, and heart failure 1.
• Your patient already demonstrates concerning signs: mild pulmonary hypertension (PASP 38 mmHg) and significantly elevated right atrial pressure (15 mmHg), which may indicate hemodynamically significant shunting.
• The presence of an unrepaired ASD creates substantial perioperative risk, particularly regarding paradoxical embolism during surgery and anesthesia.

Elevated Right Atrial Pressure Indicates Hemodynamic Compromise

• The dilated IVC with no inspiratory collapse indicating 15 mmHg right atrial pressure is not normal and suggests either significant right heart dysfunction or a hemodynamically significant shunt.
• This finding, combined with mild pulmonary hypertension, suggests the cardiovascular system is already under stress and may not tolerate the additional hemodynamic demands of surgery and anesthesia.

Perioperative Risk Assessment Framework

According to ACC/AHA perioperative guidelines, valvular heart disease requires careful evaluation before noncardiac surgery 2. While your patient has only mild mitral regurgitation and trace aortic regurgitation (which are generally well-tolerated), the guidelines emphasize that:

• Undiagnosed or inadequately evaluated cardiac conditions should be characterized before elective surgery
• Patients with valvular disease and signs of hemodynamic compromise require optimization before proceeding
• The mild mitral valve prolapse with regurgitation requires endocarditis prophylaxis consideration, though this is manageable

Required Pre-Surgical Workup

Before considering breast augmentation, this patient needs:

1. Transesophageal echocardiography (TEE) to definitively characterize the possible ASD - size, location, hemodynamic significance, and suitability for closure 1
2. Right heart catheterization if ASD is confirmed, to measure Qp/Qs ratio and pulmonary vascular resistance
3. Cardiology consultation to determine if ASD closure (percutaneous or surgical) is indicated
4. Investigation of the elevated right atrial pressure - determine if this is due to the ASD, right ventricular dysfunction, or another etiology

Additional Considerations Specific to Breast Augmentation

Breast Implants Complicate Future Cardiac Monitoring

• Left-sided breast implants significantly impair echocardiographic image quality, with adequate imaging achieved in only 50% of cases 3
• Women with breast implants have higher rates of false-positive cardiac functional studies and undergo more coronary angiography but fewer interventions, indicating increased false-positive testing 4
• If this patient requires ongoing cardiac monitoring (which she will with her valvular disease and possible ASD), placing breast implants will substantially compromise future diagnostic capabilities

Surgical Risk of the Procedure Itself

• While breast augmentation is generally safe, it carries risks including bleeding that can lead to hemodynamic compromise 5
• The anesthetic and surgical stress, though modest, is unnecessary risk in a patient with unresolved cardiac pathology
• Breast augmentation can be safely performed after cardiac issues are resolved, as demonstrated in patients who underwent minimally invasive cardiac valve surgery with implant removal and replacement 6

Clinical Algorithm

Step 1: Refer to cardiology immediately for TEE to evaluate the possible ASD

Step 2: If ASD is confirmed and hemodynamically significant (Qp/Qs >1.5), proceed with closure before any elective surgery

Step 3: If ASD is excluded, investigate and treat the cause of elevated right atrial pressure

Step 4: Once cardiac status is optimized and stable, reassess surgical candidacy with cardiology clearance

Step 5: Only after complete cardiac evaluation and any necessary interventions should breast augmentation be reconsidered

Critical Pitfall to Avoid

Do not dismiss the "possible ASD" as incidental or insignificant. The combination of this finding with mild pulmonary hypertension and elevated right atrial pressure suggests this is likely real and hemodynamically relevant. Proceeding with elective surgery without definitive evaluation risks catastrophic complications including paradoxical embolism, acute right heart failure, or arrhythmias during the perioperative period.

The breast augmentation can be safely performed later, but cardiac complications during surgery cannot be easily reversed. Prioritize definitive cardiac diagnosis and treatment first 2, 1.