What to do about severe aortic stenosis with reduced ejection fraction (EF) before elective Transurethral Resection of the Prostate (TURP)?

From the Guidelines

Valve intervention should be performed prior to the urologic procedure for a 70-year-old man with severe aortic stenosis and reduced ejection fraction (EF of 40%) before elective Transurethral Resection of the Prostate (TURP). The recommended approach is to proceed with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) first, followed by TURP after cardiac recovery, as suggested by the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1.

While waiting for valve intervention, the patient should be medically optimized with cautious use of beta-blockers (such as metoprolol 25-50mg twice daily), ACE inhibitors at low doses (like lisinopril 2.5-5mg daily), and diuretics as needed for volume management. Elective TURP should be postponed until at least 4-6 weeks after valve replacement to allow for recovery and stabilization of cardiac function.

This sequencing is crucial because the hemodynamic stress of TURP, including fluid shifts, bleeding risk, and anesthetic challenges, can precipitate heart failure or cardiovascular collapse in patients with severe aortic stenosis, particularly when ejection fraction is already compromised, as noted in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. The fixed cardiac output from aortic stenosis combined with reduced contractility creates a high-risk scenario where the heart cannot compensate for the physiologic demands of surgery.

Some key points to consider in the management of this patient include:

• The patient's severe aortic stenosis with a valve area of 0.9cm2 and mean aortic valve gradient of 50 mm Hg, which indicates a high-grade obstruction to left ventricular outflow.
• The reduced ejection fraction (EF of 40%), which suggests impaired left ventricular function and increased risk of cardiac complications during noncardiac surgery.
• The importance of careful perioperative management, including invasive hemodynamic monitoring and optimization of loading conditions, to minimize the risk of cardiac complications during TURP.
• The potential benefits of TAVR or SAVR in reducing the risk of cardiac complications and improving long-term outcomes in patients with severe aortic stenosis and reduced ejection fraction.

From the Research

Aortic Valve Findings and Recommendations

The patient has severe aortic stenosis with a valve area of 0.9cm2 and a mean aortic valve gradient of 50 mm Hg, along with a reduced ejection fraction (EF) of 40%. Considering the patient's condition and the need for elective Transurethral Resection of the Prostate (TURP), the following points are relevant:

• The patient's severe aortic stenosis and reduced EF indicate a high-risk condition for surgical intervention 2.
• Transcatheter aortic valve replacement (TAVR) has been shown to be a viable alternative to surgical aortic valve replacement in patients with severe aortic stenosis and heart failure with reduced ejection fraction, with comparable outcomes 2, 3.
• In intermediate-risk patients, TAVR has been found to be noninferior to surgical aortic valve replacement in terms of death or disabling stroke at 2 years 3.
• For low-risk patients, TAVR with a self-expanding supraannular bioprosthesis has been shown to be noninferior to surgery with respect to the composite end point of death or disabling stroke at 24 months 4.
• The patient's condition and the planned elective TURP procedure suggest that TAVR could be a suitable option to consider before proceeding with the TURP, given the potential risks associated with the patient's aortic stenosis and reduced EF.

Considerations for TURP

Regarding the TURP procedure itself:

• The patient's age and potential comorbidities increase the perioperative risk for TURP 5.
• Regional anesthesia, such as spinal anesthesia, may offer advantages over general anesthesia for TURP, including lower morbidity 5.
• Procedure-specific complications, such as TURP syndrome, bladder perforation, and septicemia, can be associated with significant morbidity and mortality but are amenable to early and aggressive therapeutic intervention 5.

Next Steps

Given the patient's severe aortic stenosis and reduced EF, it is essential to:

• Consult with a cardiologist to discuss the best approach for managing the patient's aortic stenosis before proceeding with the TURP procedure.
• Consider TAVR as a potential option to improve the patient's cardiac condition before the elective TURP.
• Carefully evaluate the patient's overall health and develop a comprehensive plan to minimize perioperative risks associated with both the TAVR (if chosen) and the TURP procedures.