Is severe mitral regurgitation and tricuspid regurgitation secondary to atrial fibrillation a contraindication to elective hip surgery?

Severe Mitral and Tricuspid Regurgitation Secondary to AF is NOT an Absolute Contraindication to Elective Hip Surgery

Severe valvular regurgitation secondary to atrial fibrillation represents a high-risk condition for noncardiac surgery but is not an absolute contraindication—the decision depends on symptom severity, ventricular function, and the urgency of the orthopedic procedure. 1

Risk Stratification Framework

Absolute Contraindications (Surgery Should Be Postponed)

• Symptomatic severe mitral regurgitation with heart failure that is not medically optimized should prompt postponement of elective surgery 1
• Severe aortic stenosis is the valvular lesion that poses the greatest risk and typically requires valve intervention before elective noncardiac surgery, but this is not your patient's primary issue 1

High-Risk But Potentially Manageable Conditions

Your patient's severe mitral and tricuspid regurgitation secondary to AF falls into this category:

• Patients with severe mitral regurgitation can undergo noncardiac surgery if they are asymptomatic or if symptoms are well-controlled with medical optimization 1
• The combination of severe functional MR and TR in AF patients is associated with poor prognosis (21% event-free rate at 24 months), but this reflects long-term cardiac outcomes rather than immediate surgical contraindication 2

Preoperative Optimization Strategy

Hemodynamic Stabilization (Critical Before Hip Surgery)

• Maximize afterload reduction with vasodilators (such as ACE inhibitors or hydralazine) to reduce regurgitant volume and improve forward cardiac output 1, 3
• Aggressive diuresis to manage volume overload and reduce pulmonary congestion 1, 3
• Rate control of atrial fibrillation is essential, as tachycardia reduces diastolic filling time and worsens hemodynamics 1

Ventricular Function Assessment

• Even mildly reduced LVEF may indicate significantly compromised ventricular reserve in patients with chronic mitral regurgitation, as the ejection fraction overestimates true LV performance 1, 3
• If LVEF is preserved (>50-60%) and the patient is asymptomatic or minimally symptomatic with optimized medical therapy, noncardiac surgery can proceed 1

Anticoagulation Management

• Bridging anticoagulation with intravenous heparin or low-molecular-weight heparin should be planned for the perioperative period in patients with permanent AF at high risk for thromboembolism 1

Intraoperative Anesthetic Considerations

Hemodynamic Goals

• Maintain forward cardiac output by reducing systemic vascular resistance (avoid excessive vasoconstriction) 3
• Avoid bradycardia, which reduces cardiac output in patients dependent on heart rate to maintain adequate perfusion 3
• Preserve adequate preload while avoiding volume overload that could precipitate pulmonary edema 3

Monitoring Requirements

• Consider invasive hemodynamic monitoring (arterial line at minimum; pulmonary artery catheter may be warranted if pulmonary hypertension is present) 3
• Transesophageal echocardiography may be considered in very high-risk cases to guide intraoperative fluid and vasopressor management 3

Decision Algorithm

Proceed with Hip Surgery If:

1. Patient is asymptomatic or has only mild symptoms (NYHA Class I-II) 1
2. LVEF is preserved (>50%) or only mildly reduced with stable function 1
3. Medical therapy has been optimized (afterload reduction, diuretics, rate control) 1, 3
4. No evidence of decompensated heart failure at time of surgery 1
5. Experienced anesthesia team is available for careful hemodynamic management 3

Postpone Hip Surgery and Consider Cardiac Intervention If:

1. Symptomatic heart failure (NYHA Class III-IV) despite medical optimization 1
2. Progressive decline in ventricular function or new-onset reduced LVEF 1
3. Recurrent hospitalizations for heart failure in recent months 2
4. Severe pulmonary hypertension (SPAP >60 mmHg) with right ventricular dysfunction 4

Critical Pitfalls to Avoid

• Do not assume that asymptomatic patients are low-risk—patients with chronic severe MR may have limited exercise capacity that masks symptoms, and even mild LVEF reduction signals advanced disease 1, 5
• Do not proceed without optimizing heart rate control in AF—uncontrolled tachycardia dramatically increases the risk of perioperative pulmonary edema 1
• Do not underestimate the combined impact of severe MR and TR—this combination in AF patients predicts significantly worse outcomes than either lesion alone 2
• Recognize that AF with severe functional regurgitation represents advanced atrial cardiomyopathy with worse long-term prognosis even after successful valve repair 5

Practical Recommendation

For an elective hip surgery, proceed if the patient is medically optimized, asymptomatic or minimally symptomatic, and has preserved ventricular function. 1 The mortality risk for noncardiac surgery in optimized patients with severe valvular regurgitation is elevated but acceptable for necessary procedures. 1 However, if the patient has decompensated heart failure or severe symptoms, postpone the hip surgery and refer to a Heart Team for consideration of valve intervention before proceeding with the orthopedic procedure. 4