From the Guidelines
The primary goal of anesthesia management for patients with aortic stenosis undergoing non-cardiac surgery is to maintain hemodynamic stability by preserving normal sinus rhythm, adequate preload, systemic vascular resistance, and contractility. A thorough preoperative assessment is essential, including echocardiography to determine stenosis severity, as recommended by the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1. Anesthetic management should focus on avoiding tachycardia, bradycardia, and hypotension. General anesthesia with careful titration of induction agents is recommended, with etomidate preferred over propofol. Maintaining normal sinus rhythm is crucial, as patients with aortic stenosis poorly tolerate atrial fibrillation or other arrhythmias.
Some key considerations in anesthesia management include:
- Ensuring adequate preload with judicious fluid administration while avoiding volume overload
- Maintaining systemic vascular resistance using vasopressors like phenylephrine or norepinephrine if needed
- Supporting myocardial contractility with inotropes such as dobutamine if cardiac output decreases
- Implementing invasive monitoring, including arterial line and possibly central venous pressure monitoring, for moderate to severe stenosis
- Avoiding regional techniques as the sole anesthetic in severe cases due to sympathectomy-induced hypotension
Postoperatively, it is essential to continue close hemodynamic monitoring in an appropriate setting, such as an ICU or step-down unit, for patients with severe stenosis. These strategies are crucial because aortic stenosis patients have fixed cardiac output and rely on adequate preload and afterload to maintain perfusion, as highlighted in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. The most recent guideline from 2020 1 further emphasizes the importance of optimizing loading conditions and maintaining sinus rhythm to reduce cardiac complications in patients with severe asymptomatic aortic stenosis undergoing noncardiac surgery.
From the Research
Anesthesia Management Goals for Aortic Stenosis (AS) in Non-Cardiac Surgery
The primary goal of anesthesia management for patients with aortic stenosis (AS) undergoing non-cardiac surgery is to minimize the risk of perioperative cardiac events. Key considerations include:
- Maintaining optimal hemodynamics, avoiding significant hypotension or hypertension, which can be achieved through close monitoring and prompt treatment of intraoperative hypotensive events, primarily with phenylephrine 2
- Selecting an appropriate anesthetic technique, such as general anesthesia or continuous spinal anesthesia, depending on the patient's condition and the type of surgery 2
- Ensuring the anesthesia team is aware of the severity of the AS and integrates this into the anesthetic plan 2
Perioperative Management Strategies
Perioperative management strategies for patients with AS undergoing non-cardiac surgery include:
- Close hemodynamic monitoring, particularly in asymptomatic severe AS patients 3
- Aortic valve intervention prior to major non-cardiac surgery in symptomatic patients to reduce the incidence of postoperative heart failure and improve long-term overall survival 3
- Consideration of transcatheter aortic valve replacement (TAVR) as a treatment option for AS, which may impact perioperative management 4
Risk Assessment and Management
Risk assessment and management for patients with AS undergoing non-cardiac surgery involve:
- Evaluating the severity of AS, clinical status, and complexity of the surgical procedure to determine the perioperative risk 5
- Recognizing that the significance of AS in patients undergoing non-cardiac surgery may be overemphasized in older studies, and that contemporary anesthesia and surgical techniques have improved outcomes 5, 6
- Adopting a practical approach to managing complex patients with AS, taking into account recent data and advances in treatment options 6