What is the recommended peri-operative management for patients with aortic stenosis undergoing non-cardiac surgery?

Perioperative Management of Aortic Stenosis for Non-Cardiac Surgery

Patients with severe aortic stenosis should undergo clinical and echocardiographic evaluation before non-cardiac surgery, with symptomatic patients requiring aortic valve replacement prior to elective procedures. 1, 2

Risk Assessment

• Severe aortic stenosis (valve area <1 cm², indexed valve area ≤0.6 cm²/m², mean gradient ≥40 mm Hg, or peak velocity ≥4 m/s) is a well-established risk factor for perioperative mortality and myocardial infarction 1, 2
• The severity of aortic stenosis is highly predictive of perioperative complications, with severe stenosis carrying significantly higher risk than moderate stenosis 3
• Patients with severe aortic stenosis face approximately 10% mortality risk when undergoing non-cardiac surgery if they refuse or are not candidates for valve replacement 1, 4

Management Algorithm Based on Symptoms and Surgical Urgency

Symptomatic Severe Aortic Stenosis

• For elective non-cardiac surgery: Aortic valve replacement should be performed before the non-cardiac procedure 1, 2
• For patients at high risk for valve surgery: Consider transcatheter aortic valve replacement (TAVR) or balloon aortic valvuloplasty as a bridge to non-cardiac surgery 1, 5
• For urgent/emergency non-cardiac surgery: Proceed with surgery under strict hemodynamic monitoring 1, 2

Asymptomatic Severe Aortic Stenosis

• For low to intermediate-risk non-cardiac surgery: Can proceed with surgery with appropriate hemodynamic monitoring 1, 6
• For high-risk non-cardiac surgery: Further clinical assessment for potential aortic valve replacement 1
• If high risk for valve replacement: Perform non-cardiac surgery only if strictly needed, with strict hemodynamic monitoring 1
• Otherwise: Consider aortic valve replacement as the initial procedure 1

Perioperative Hemodynamic Management

• Maintain sinus rhythm and avoid tachycardia to prevent decreased diastolic filling time and coronary perfusion 2
• Use intraarterial blood pressure monitoring for closer hemodynamic surveillance 7
• Treat hypotensive events promptly, with phenylephrine being the preferred vasopressor 7
• Avoid beta-adrenergic agonists as they may worsen hemodynamics in aortic stenosis 2
• Maintain euvolemia and avoid rapid changes in volume status that could precipitate hemodynamic collapse 2
• Consider intensive care unit monitoring postoperatively, even if the patient appears stable 2

Common Pitfalls and Considerations

• Overestimation of risk: Some studies suggest that the perioperative risk associated with aortic stenosis may be overemphasized in older literature that predates modern anesthetic techniques and perioperative care 8, 6
• Refusing valve surgery: Patients who refuse indicated valve surgery face substantially higher perioperative risks during any future surgeries 4
• Delayed intervention: Postponing necessary valve surgery can lead to development of irreversible left ventricular dysfunction and onset of atrial fibrillation 4
• Anticoagulation management: When valve surgery is needed before non-cardiac surgery, a bioprosthesis may be preferred to avoid anticoagulation issues during subsequent non-cardiac procedures 2

Special Considerations for Other Valvular Conditions

• Mitral stenosis: Control heart rate during the perioperative period to avoid tachycardia, which can lead to pulmonary congestion due to reduced diastolic filling period 1
• Severe mitral stenosis with pulmonary artery pressure >50 mmHg: Consider percutaneous mitral commissurotomy before high-risk surgery 1, 2
• Mitral regurgitation: Patients with severe mitral regurgitation may benefit from afterload reduction and diuretics to optimize hemodynamics before high-risk surgery 1

By following this evidence-based approach to perioperative management of aortic stenosis, clinicians can minimize the risk of adverse outcomes in this high-risk population undergoing non-cardiac surgery.