From the Guidelines
Prior to proceeding with a transurethral resection of the prostate (TURP) in this patient, a cardiology consultation and evaluation for aortic valve replacement should be obtained. This 70-year-old man has severe aortic stenosis (valve area <1.0 cm2 and mean gradient >40 mmHg) with reduced left ventricular function (ejection fraction of 40%), which significantly increases his perioperative cardiovascular risk 1. The cardiology evaluation should include a comprehensive assessment of his cardiac status, including echocardiography to confirm the severity of stenosis and left ventricular function.
Key Considerations
- The patient's severe aortic stenosis and reduced left ventricular function put him at high risk for major adverse cardiac events during and after TURP 1.
- According to the guidelines on the management of valvular heart disease, aortic valve replacement is indicated in patients with severe aortic stenosis and systolic left ventricular dysfunction (LVEF <50%) not due to another cause 1.
- The patient's mean aortic valve gradient of 50 mmHg and valve area of 0.9 cm2 confirm the severity of his aortic stenosis, and his ejection fraction of 40% indicates systolic left ventricular dysfunction.
Recommendations
- Aortic valve replacement should be considered before proceeding with TURP to minimize the risk of major adverse cardiac events during and after the procedure 1.
- The choice between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) should depend on the patient's surgical risk profile and anatomy 1.
- A comprehensive cardiology evaluation, including echocardiography, should be performed to confirm the severity of the patient's aortic stenosis and left ventricular function, and to guide the decision regarding aortic valve replacement 1.
From the Research
Patient Evaluation
Before proceeding with a Transurethral Resection of the Prostate (TURP), it is essential to evaluate the patient's cardiac condition, given the presence of aortic valve stenosis and a reduced ejection fraction of 40%.
- The patient's aortic valve area is 0.9 cm2, and the mean aortic valve gradient is 50 mmHg, indicating severe aortic stenosis 2.
- The patient's reduced ejection fraction increases the risk of operation and poorer long-term outcome 2, 3.
- Pharmacologic challenge may be necessary to identify those patients with true aortic stenosis and further helps determine those who would benefit from surgical intervention 2.
Risk Assessment
The patient's low ejection fraction and severe aortic stenosis increase the risk of cardiac complications during TURP.
- Studies have shown that patients with severe aortic stenosis and reduced ejection fraction have a higher risk of adverse outcomes, including cardiovascular mortality and heart failure hospitalization 3, 4.
- The patient's valve area and gradient suggest severe aortic stenosis, which may require aortic valve replacement (AVR) to improve outcomes 2, 5.
Preoperative Considerations
Before proceeding with TURP, the patient's cardiac condition should be optimized, and the risks and benefits of the procedure should be carefully weighed.
- The patient may require evaluation by a cardiologist to determine the best course of treatment for the aortic stenosis and to optimize cardiac function before TURP 2, 3.
- The patient's medications and medical history should be carefully reviewed to minimize the risk of cardiac complications during the procedure 6, 4.