How to manage a patient with severe aortic stenosis and hip fracture needing surgery?

From the Guidelines

Managing a patient with severe aortic stenosis and hip fracture requires urgent hip fracture repair with careful perioperative planning and multidisciplinary coordination to minimize cardiac risk. The approach should involve preoperative cardiology consultation and echocardiogram to assess aortic stenosis severity, as recommended by the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1.

Preoperative Planning

• Obtain a cardiology consultation to assess the severity of aortic stenosis and guide management.
• Perform an echocardiogram to evaluate the aortic valve area and left ventricular function.
• Maintain euvolemia with judicious fluid management, avoiding both hypovolemia and fluid overload, as hypotension and tachycardia can lead to decreased coronary perfusion pressure and increased risk of myocardial injury or cardiac failure 1.

Intraoperative Management

• Anesthesia should be managed by an experienced cardiac anesthesiologist, with arterial line placement for continuous hemodynamic monitoring and careful titration of anesthetic agents to maintain stable blood pressure.
• Maintain normal sinus rhythm, as patients with severe aortic stenosis poorly tolerate tachycardia, bradycardia, or arrhythmias.
• Vasopressors like phenylephrine should be readily available to maintain adequate systemic vascular resistance and coronary perfusion.

Postoperative Care

• Monitor the patient in an ICU setting for at least 24-48 hours with continuous telemetry to quickly identify and manage any cardiac complications.
• Early mobilization should be initiated as soon as safely possible to prevent complications of immobility, such as deep vein thrombosis or pneumonia.
• The use of echocardiography in acute cardiovascular care, as recommended by the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association 1, can help guide management and assess the need for interventions such as balloon aortic valvuloplasty or transcatheter aortic valve implantation in high-risk patients.

This approach balances the urgency of hip fracture repair with the cardiac risk, as delays in hip surgery beyond 48 hours can increase mortality, while the fixed cardiac output limitation in severe aortic stenosis creates vulnerability to hemodynamic changes during surgery.

From the Research

Pre-operative Risk Stratification for Patients with Severe Aortic Stenosis and Hip Fracture

• Patients with severe aortic stenosis (SAS) and hip fracture pose a significant challenge for pre-operative risk stratification and management 2, 3, 4, 5.
• The treatment of SAS has evolved with the advent of minimally invasive structural heart interventions, including transcatheter aortic valve replacement (TAVR), which allows for faster recovery rates compared to valve surgery 2.
• Preoperative balloon aortic valvuloplasty (BAV) may be an attractive strategy for selected patients, as it can reduce mortality and improve outcomes in patients with severe AS undergoing hip fracture surgery 3.

Management Strategies

• A multidisciplinary approach is essential to optimize time for hip surgery and improve orthopedic and cardiovascular outcomes in patients presenting with hip fracture and SAS 2.
• Preoperative BAV can reduce mortality and improve survival in patients with severe AS undergoing hip fracture surgery, despite an increase in time to operation 3.
• The use of continuous spinal anesthesia can be a viable option for patients with severe AS undergoing hip surgery, as it allows for tailored anesthesia and minimizes the risk of dramatic consequences 6.

Predictive Factors for Mortality

• Postoperative delirium and acute congestive heart failure are predictive factors of 30-day mortality in patients with severe AS undergoing hip fracture surgery 3.
• Coronary disease, atrial fibrillation, age, and aortic gradient are independent predictors of mortality in patients with AS 5.

Outcome and Prognosis

• Patients with severe AS have a higher risk of postoperative myocardial infarction, 30-day and 1-year mortality, and a composite endpoint (30-day mortality + myocardial infarction) compared to those without AS 5.
• The risk of mortality is significantly higher for patients with severe AS, and a heart team evaluation may be suggested before discharge for most of these patients 5.