Published on February 19, 2014
Aortic stenosis and indication for non-cardiac surgery Jean-Pol Depoix, MD Anaesthesiology Department Bernard Iung, MD Cardiology Department Bichat Hospital, Paris, France
Case History • 84 year-old woman • Treated hypertension, prior thyroidectomy. • Known cardiac murmur • Preserved autonomy and activity. Asymptomatic • Recent diagnosis of an adenocarcinoma of left colon without other malignant location, indication of left colectomy • Referred before surgery because of cardiac murmur • Mid-systolic murmur 3/6, decreased S2 • No signs of congestive heart failure • Blood pressure 154/60 mmHg
Chest X-ray and ECG
Echocardiography: parasternal views Watch video Watch video
Echocardiography: apical views Watch video Watch video
Mean gradient 42 mmHg V. Max 4.1 m/sec. Valve area : 0.9 cm² (0.56 cm²/m² BSA) LV 51/37 mm, SF 30%
Summary of case analysis • Severe aortic stenosis Consistency between: − Aortic valve area < 1.0 cm² and < 0.6 cm²/ m² BSA − Maximum jet velocity ≥ 4 m/sec − Mean gradient ≥ 40 mmHg • Hypertrophied left ventricle with preserved ejection fraction • No other cardiac disease • Asymptomatic
What do you advise? 1. Contra-indicate colectomy 2. Perform colectomy with primary anastomosis, without treatment of aortic stenosis 3. Consider less invasive surgery: resection + colostomy (Hartmann procedure) 4. Perform balloon aortic valvuloplasty before colectomy 5. Perform TAVI before colectomy
What do you advise? 1. Contra-indicate colectomy 2. Perform colectomy with primary anatomosis, without treatment of aortic stenosis 3. Consider less invasive surgery: resection + colostomy (Hartmann procedure) 4. Perform balloon aortic valvuloplasty before colectomy 5. Perform TAVI before colectomy
Rationale for therapeutic decision • Abdominal surgery is required since it is the only curative treatment of colic cancer • Less invasive intervention limits haemodynamic stress but impairs quality of life (Hartmann procedure was the first option of the referring team) • Risk assessment should take into account: − The risk of abdominal surgery − The risk of cardiac complications due to aortic stenosis − The risk and consequences of treating aortic stenosis before abdominal surgery
Evaluation of the risk of non-cardiac surgery 30-day cardiac death and myocardial infarction 30-day rates of cardiac death and myocardial infarction Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J 2009;30:2769-812.
Therapeutic options for aortic stenosis • Low risk of complications of intermediate risk noncardiac surgery No death or myocardial infarction in a series of 30 asymptomatic patients with severe aortic stenosis undergoing non cardiac surgery (>75% at intermediate-risk) (Calleja et al. Am J Cardiol 2010;105:1159-63) • Treatment of AS before non-cardiac surgery is considered only in symptomatic patients or for high-risk surgery Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012;33:2451-496.
Therapeutic options for aortic stenosis • Risk of aortic valve replacement − Euroscore I: − Euroscore II: 10.1% 1.7% • The only reason to favour TAVI over surgical aortic valve replacement would be more rapid recovery. Take into account the risk of TAVI and the need for antiplatelet drugs. • Balloon aortic valvuloplasty may be considered in patients with symptomatic severe AS who require urgent major non-cardiac surgery (IIbC) No indication in this case Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012;33:2451-496.
Management of severe aortic stenosis and elective non-cardiac surgery according to patient characteristics and the type of surgery Severe AS and need for elective non-cardiac surgery Symptoms No Yes Risk of non-cardiac surgery Low-moderate High Patient risk for AVR High Non-cardiac surgery www.escardio.org/guidelines Non-cardiac surgery under strict monitoring Patient risk for AVR Low Low AVR before non-cardiac surgery High Non-cardiac surgery under strict monigoring Consider BAV/TAVI European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 doi:10.1093/ejcts/ezs455).
Therapeutic decision • Multidisciplinary meeting (anaesthesiologist, cardiologist, surgeon) • Decision of left colectomy with primary anastomosis without prior treatment of aortic stenosis • Direct contact with the anaesthesiologist in charge of the patient • Specificities of anesthesia • Choice of anaesthetic drugs • Cardiac monitoring • Post-operative care
Outcome • Left colectomy with primary anastomosis – Invasive arterial blood pressure monitoring using a radial catheter – Anaesthesia: hypnomidate, atracrium, desflurane and remifentanil (short action opioid) • Stable haemodynamic during anaesthesia • Extubation at the end of abdominal surgery • Uneventful post-operative course • Patient discharged at home. She remains asymptomatic
Take-Home messages • Aortic stenosis should be carefully evaluated in elderly patients needing non-cardiac surgery because of the risk of cardiac complications • In severe AS, risk stratification should take into account: − − − − Symptoms Indication for non-cardiac surgery (vital vs. functional) The risk of cardiac complications according to the type of surgery The risks inherent to the treatment of AS • Intermediate and low-risk surgery can be performed safely in asymptomatic patients, provided appropriate anaesthetic management is planned
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