What is the next step in management for a 70-year-old man with severe aortic stenosis, reduced left ventricular ejection fraction, and multiple comorbidities, including type 2 diabetes mellitus (T2DM), chronic heart failure (CHF), benign prostatic hyperplasia (BPH), and hypertension, prior to elective transurethral resection of the prostate (TURP) gland?

From the Guidelines

The patient should undergo aortic valve replacement before elective transurethral resection of the prostate gland due to the presence of severe aortic stenosis and reduced left ventricular ejection fraction. Given the patient's severe aortic stenosis, with a valve area of 0.9 cm² and a mean aortic valve gradient of 50 mm Hg, and reduced left ventricular ejection fraction of 40%, the risk of worsening heart failure during elective non-cardiac surgery is significant 1. The management of severe aortic stenosis in the context of elective non-cardiac surgery, such as transurethral resection of the prostate, depends on the presence of symptoms and the type of surgery, as outlined in the 2017 ESC/EACTS guidelines for the management of valvular heart disease 1. Key considerations include:

• The patient's symptomatic status: although the patient was asymptomatic at the initial visit, the presence of severe aortic stenosis and reduced ejection fraction necessitates careful evaluation.
• The type of surgery: elective TURP implies potential large volume shifts, which may exacerbate heart failure in the setting of severe aortic stenosis.
• The patient's overall surgical risk: given the patient's multiple comorbidities, including type 2 diabetes mellitus, chronic heart failure, benign prostatic hyperplasia, and hypertension, careful preoperative optimization is crucial. In this scenario, consulting cardiothoracic surgery for elective aortic valve replacement is the most appropriate next step, as it addresses the valvular disease before proceeding with the elective urologic procedure, potentially preventing life-threatening complications during surgery 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps in Management

The patient has severe aortic stenosis with a valve area of 0.9 cm² and a mean aortic valve gradient of 50 mm Hg, in addition to a reduced left ventricular ejection fraction of 40% and multiple comorbidities. Considering these factors, the management of the aortic valve findings should be prioritized.

• The patient's condition suggests the need for intervention on the aortic valve, given the severity of the stenosis and its potential impact on cardiac function, especially in the context of reduced ejection fraction and heart failure 2.
• The presence of severe aortic stenosis, particularly with symptoms or signs of heart failure, reduced ejection fraction, and significant comorbidities, necessitates a thorough evaluation for the best approach to manage the valve disease.
• Consultation with cardiothoracic surgery for elective aortic valve replacement should be considered, as it offers a potential cure for the aortic stenosis and can improve the patient's quality of life and survival, especially when taking into account the patient's heart failure and reduced ejection fraction 2.
• Given the elective nature of the transurethral resection of the prostate (TURP) and the significant cardiac findings, addressing the aortic stenosis before proceeding with the TURP is crucial to minimize perioperative risks.

Considerations for Aortic Valve Replacement

• The decision to proceed with aortic valve replacement should be made in the context of a multidisciplinary team discussion, considering the patient's overall health status, the severity of the aortic stenosis, and the presence of heart failure with reduced ejection fraction.
• The choice between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) depends on the patient's surgical risk, valve anatomy, and other factors, with TAVR being an option for patients at high risk for surgical complications 2.

Preoperative Optimization

• Before any intervention, optimization of the patient's heart failure management and control of hypertension and diabetes are essential to reduce perioperative risks.
• The patient's current medications, including empagliflozin, sacubitril/valsartan, and tamsulosin, should be reviewed and adjusted as necessary to ensure optimal management of his comorbid conditions.