Should a patient undergo knee replacement surgery if they are scheduled for a valve replacement surgery?

Valve Replacement Timing for Patients Requiring Both Knee and Heart Valve Surgery

For patients requiring both knee replacement and valve replacement surgery, the heart valve replacement should be performed first, followed by the knee replacement after full recovery from cardiac surgery. 1

Rationale for Prioritizing Valve Replacement

Cardiac Risk Assessment

• Patients with valvular heart disease have increased cardiovascular morbidity and mortality when undergoing non-cardiac surgery 1
• The specific approach depends on:
  • Type and severity of valve disease
  • Presence of symptoms
  • Left ventricular function
  • Type of non-cardiac surgery planned 1

Specific Valve Conditions

Aortic Stenosis

• In symptomatic patients with severe aortic stenosis, valve replacement (surgical AVR or TAVI) should be performed before knee replacement 1
• For asymptomatic patients with severe aortic stenosis, knee replacement can be performed safely, though with risk of worsening heart failure 1
• If knee surgery involves large volume shifts, aortic valve replacement should be performed first 1

Mitral Stenosis

• For patients with significant mitral stenosis who are symptomatic or have pulmonary artery pressure >50 mmHg, valve correction should be performed before knee surgery 1
• Patients with non-significant mitral stenosis (valve area >1.5 cm²) can safely undergo knee replacement first 1

Aortic and Mitral Regurgitation

• Asymptomatic patients with severe regurgitation and preserved LV function can safely undergo knee replacement 1
• If symptoms or LV dysfunction are present, valve surgery should be considered first 1
• With severe LV dysfunction (ejection fraction <30%), knee replacement should only be performed if absolutely necessary and after optimization of heart failure therapy 1

Perioperative Considerations

Risk Stratification

• Non-cardiac surgery risk is classified as high (>5%), intermediate (1-5%), or low (<1%) for cardiac complications 1
• Knee arthroplasty typically falls in the intermediate risk category 1

Monitoring Requirements

• Patients with valve disease undergoing non-cardiac surgery require:
  • Careful heart rate control (particularly with mitral stenosis) 1
  • Meticulous fluid management (particularly with aortic stenosis) 1
  • Consideration of transesophageal echocardiography monitoring 1

Recovery Timeline

• Full recovery from cardiac valve surgery typically requires 2-3 months before safely undergoing elective knee replacement 1
• This timeline allows:
  • Proper wound healing
  • Stabilization of anticoagulation if required
  • Return to baseline functional status 1

Special Considerations

Elderly Patients

• Advanced age alone is not a contraindication to valve surgery followed by knee replacement 2
• Quality of life improvements after valve replacement in patients >80 years are comparable to the general elderly population 2

Anticoagulation Management

• Patients with mechanical valves require careful anticoagulation management during subsequent knee surgery 1
• Coordination between cardiac and orthopedic teams is essential for bridging anticoagulation therapy 1

Conclusion

Prioritizing valve replacement before knee arthroplasty provides the safest approach by:

1. Reducing cardiac risk during non-cardiac surgery 1
2. Improving hemodynamic stability during knee replacement 1
3. Optimizing outcomes for both procedures 1, 2