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Bak M, Lee SH, Park SJ, Park J, Kim J, Kim D, Kim EK, Chang SA, Lee SC, Park SW. Perioperative Risk of Noncardiac Surgery in Patients With Asymptomatic Significant Aortic Stenosis: A 10-Year Retrospective Study. J Am Heart Assoc 2024; 13:e032675. [PMID: 38686895 PMCID: PMC11179948 DOI: 10.1161/jaha.123.032675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 03/25/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Aortic stenosis (AS) is a representative geriatric disease, and there is an anticipated rise in the number of patients requiring noncardiac surgeries in patients with AS. However, there is still a lack of research on the primary predictors of noncardiac perioperative complications in patients with asymptomatic significant AS. METHODS AND RESULTS Among the cohort of noncardiac surgeries under general anesthesia, with an intermediate to high risk of surgery from 2011 to 2019, at Samsung Medical Center, 221 patients were identified to have asymptomatic significant AS. First, to examine the impact of significant AS on perioperative adverse events, the occurrences of major adverse cardiovascular events and perioperative adverse cardiovascular events were compared between patients with asymptomatic significant AS and the control group. Second, to identify the factors influencing the perioperative adverse events in patients with asymptomatic significant AS, a least absolute shrinkage and selection operator regression model was used. There was no significant difference between the control group and the asymptomatic significant AS group in the event rate of major adverse cardiovascular events (4.6% at control group versus 5.5% at asymptomatic significant AS group; P=0.608) and perioperative adverse cardiovascular events (13.8% at control group versus 18.3% at asymptomatic significant AS group; P=0.130). Cardiac damage stage was a significant risk factor of major adverse cardiovascular events and perioperative adverse cardiovascular events. CONCLUSIONS There was no significant difference in major postoperative cardiovascular events between patients with asymptomatic significant AS and the control group. Advanced cardiac damage stage in significant AS is an important factor in perioperative risk of noncardiac surgery.
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Affiliation(s)
- Minjung Bak
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Seung-Hwa Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Jihoon Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Darae Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Sung-A Chang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Seung Woo Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
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Tabrizi NS, Demos RA, Schumann R, Musuku SR, Shapeton AD. Neuraxial Anesthesia in Patients With Aortic Stenosis: A Systematic Review. J Cardiothorac Vasc Anesth 2024; 38:505-516. [PMID: 37880038 DOI: 10.1053/j.jvca.2023.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/10/2023] [Accepted: 09/21/2023] [Indexed: 10/27/2023]
Abstract
Neuraxial anesthesia (NA) has been contraindicated in patients with aortic stenosis (AS) due to concerns of sympathetic blockade and hemodynamic instability. These considerations are based on precautionary expert recommendations, supported by expected physiologic effects, but in the absence of any published scientific evidence. In light of the increasing elderly population and the prevalence of AS, this systematic review compiles available literature on NA in patients with AS to address the understanding of the anesthetic practice and safety in this population. Using a systematic approach, PubMed, Embase, and Web of Science were searched for studies of patients with AS who exclusively received NA. Primary outcomes included intraoperative and postoperative complications. Of 1,433 citations, 61 met full-text inclusion criteria, including 3,228 patients undergoing noncardiac (n = 3,146, 97.5%), obstetric (n = 69, 2.1%), and cardiac (n = 13, 0.4%) procedures. Significant data heterogeneity (local anesthetic dosing, intraoperative interventions, and measured outcomes) prevented formal metanalysis, but descriptive data are presented. Spinal block (n = 2,856, 88.5%) and epidural anesthesia (n = 397, 12.3%) were administered most frequently. Hypotension requiring vasopressors was the most common intraoperative complication-noncardiac (n = 16, 9.9%), obstetric (n = 6, 13.0%), and cardiac (n = 1, 7.7%)-with resolution in all patients and no reported intraoperative cardiovascular collapse or mortality. The relative risk of different AS severities remains unclear, and optimal medication dosing remains elusive. The authors' data suggested that NA may not be contraindicated in carefully selected patients with AS. The authors' results should inform the design of future prospective studies comparing NA and general anesthesia in patients with AS.
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Affiliation(s)
| | | | - Roman Schumann
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, MA
| | | | - Alexander D Shapeton
- Veterans Affairs Boston Healthcare System, Boston, MA; Department of Anesthesia, Critical Care and Pain Medicine, Tufts University School of Medicine, Boston, MA
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Waldron NH, Sigurdsson MI, Mathew JP. Perioperative Management of Valvular Heart Disease. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00014-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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4
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Adverse outcomes after noncardiac surgery in patients with aortic stenosis. Sci Rep 2021; 11:19517. [PMID: 34593867 PMCID: PMC8484466 DOI: 10.1038/s41598-021-98507-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 09/08/2021] [Indexed: 11/10/2022] Open
Abstract
Whether aortic stenosis (AS) increases perioperative risk in noncardiac surgery remains controversial. Limited information is available regarding adequate anesthetic techniques for patients with AS. Using the reimbursement claims data of Taiwan’s National Health Insurance, we performed propensity score matching analyses to evaluate the risk of adverse outcomes in patients with or without AS undergoing noncardiac surgery between 2008 and 2013. We also compared the perioperative risk of AS patients undergoing general anesthesia or neuraxial anesthesia. Multivariable logistic regressions were applied to calculate the adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for postoperative mortality and major complications. The matching procedure generated 9741 matched pairs for analyses. AS was significantly associated with 30-day in-hospital mortality (aOR 1.31, 95% CI 1.03–1.67), acute renal failure (aOR 1.42, 95% CI 1.12–1.79), pneumonia (aOR 1.16, 95% CI 1.02–1.33), stroke (aOR 1.14, 95% CI 1.01–1.29), and intensive care unit stay (aOR 1.38, 95% CI 1.27–1.49). Compared with neuraxial anesthesia, general anesthesia was associated with increased risks of acute myocardial infarction (aOR 3.06, 95% CI 1.22–7.67), pneumonia (aOR 1.80, 95% CI 1.32–2.46), acute renal failure (aOR 1.82, 95% CI 1.11–2.98), and intensive care (aOR 4.05, 95% CI 3.23–5.09). The findings were generally consistent across subgroups. AS was an independent risk factor for adverse events after noncardiac surgery. In addition, general anesthesia was associated with greater postoperative complications in AS patients compared to neuraxial anesthesia. This real-world evidence suggests that neuraxial anesthesia should not be contraindicated in patients with AS.
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Fukuzumi M, Okano R, Gatate Y, Miyauchi T, Tedoriya T. Aortic valve replacement and coronary artery bypass grafting through a right thoracotomy for a patient with a left chest wall tumor. Asian Cardiovasc Thorac Ann 2021; 30:583-585. [PMID: 34027680 DOI: 10.1177/02184923211019541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 68-year-old man was diagnosed with severe aortic stenosis and right coronary artery occlusion on preoperative examination for total extirpation of a giant left breast liposarcoma. Prior to the intervention for the liposarcoma, he underwent successful aortic valve replacement and coronary artery bypass grafting via a right anterolateral thoracotomy to avoid the tumor close to the sternum. On postoperative day 28, the patient underwent a successful wide excision of the left chest wall tumor.
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Affiliation(s)
- Masaomi Fukuzumi
- Department of Cardiovascular Surgery, Ageo Central General Hospital, Ageo, Japan
| | - Ryoi Okano
- Department of Cardiovascular Surgery, Ageo Central General Hospital, Ageo, Japan
| | - Yuko Gatate
- Department of Cardiovascular Surgery, Ageo Central General Hospital, Ageo, Japan
| | - Tadamasa Miyauchi
- Department of Cardiovascular Surgery, Ageo Central General Hospital, Ageo, Japan
| | - Takeo Tedoriya
- Department of Cardiovascular Surgery, Ageo Central General Hospital, Ageo, Japan
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Mino T, Kimura S, Kitaura A, Iwamoto T, Yuasa H, Chiba Y, Nakao S. Can left ventricular hypertrophy on electrocardiography detect severe aortic valve stenosis? PLoS One 2020; 15:e0241591. [PMID: 33147268 PMCID: PMC7641401 DOI: 10.1371/journal.pone.0241591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/16/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Severe aortic stenosis (AS) is increasing in the aging society and is a serious condition for anesthetic management. However, approximately one-third of patients with severe AS are asymptomatic. Echocardiography is the most reliable method to detect AS, but it takes time and is costly. METHODS Data were obtained retrospectively from patients who underwent surgery and preoperative transthoracic echocardiography (TTE). LVH on ECG was determined by voltage criteria (Sv1 + Rv5 or 6 ≥3.5 mV) and/or the strain pattern in V5 and V6. Severe AS was defined as a mean transaortic pressure gradient ≥40 mmHg or aortic valve area ≤1.0 cm2 by TTE. RESULTS Data for 470 patients aged 28-94 years old were obtained. One hundred and twenty-six patients had severe AS. LVH on ECG by voltage criteria alone was detected in 182 patients, LVH by strain pattern alone was detected in 80 patients and LVH by both was detected in 55 patients. Multivariable logistic analysis revealed that LVH by the strain pattern or voltage criteria, diabetes mellitus, and age were significantly associated with severe AS. The AUC for the ROC curve for LVH by voltage criteria alone was 0.675 and the cut-off value was 3.84 mm V, and the AUC for the ROC for age was 0.675 and the cut-off value was 74 years old. CONCLUSION Our study suggests that patients who are 74 years old or over with LVH on ECG, especially those with DM, should undergo preoperative TTE in order to detect severe AS.
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Affiliation(s)
- Takashi Mino
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Seishi Kimura
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Atsuhiro Kitaura
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Tatsushige Iwamoto
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Haruyuki Yuasa
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Yasutaka Chiba
- Clinical Research Center, Kindai University Hospital, OsakaSayama, Osaka, Japan
| | - Shinichi Nakao
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
- * E-mail:
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Whitener SK, Francis LR, McMurray JD, Whitener GB. Asymptomatic Severe Aortic Stenosis and Noncardiac Surgery. Semin Cardiothorac Vasc Anesth 2020; 25:19-28. [PMID: 33136524 DOI: 10.1177/1089253220969576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The patient with severe asymptomatic aortic stenosis presenting for elective noncardiac surgery poses a unique challenge. These patients are not traditionally offered surgical aortic valve replacement or transcatheter aortic valve replacement given their lack of symptoms; however, they are at increased risk for postsurgical complications given the severity of their aortic stenosis. The decision to proceed with elective noncardiac surgery should be based on individual and surgical risk factors. However, severity of aortic stenosis is not accounted for in current surgical risk factor assessment scoring; therefore, extensive communication with patients and surgical teams is necessary to minimize a patient's risk. A clear intraoperative plan should be designed to manage the unique hemodynamics of these patients, and a discussion should address postoperative placement.
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Kawatani Y, Yamasaki M, Oguri A. Endovascular Aortic Repair under Extracorporeal Cardiac Support in a Patient with an Abdominal Aortic Aneurysm Impending Rupture and Aortic Stenosis: A Case Report. Ann Vasc Dis 2020; 13:339-342. [PMID: 33384743 PMCID: PMC7751089 DOI: 10.3400/avd.cr.20-00059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Aortic stenosis is a serious valvular disease that increases the risk of cardiac arrest and/or cardiogenic shock during noncardiac surgery. A 93-year-old woman with an abdominal aortic aneurysm impending rupture and aortic stenosis underwent endovascular abdominal aortic aneurysm repair. During surgery, the patient presented with ventricular tachycardia. Due to on-going cardiogenic shock, we did a direct cannulation into the right axillary artery for the immediate establishment of venoarterial extracorporeal membrane oxygenation. The endovascular treatment of the abdominal aortic aneurysm was completed according to the standard procedure. The patient recovered without any complications, including heart failure or neurological dysfunction.
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Affiliation(s)
- Yohei Kawatani
- Department of Cardiovascular Surgery, Takasaki Heart Hospital
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Omoto T, Aoki A, Maruta K, Masuda T, Horikawa Y. Influence of transcatheter aortic valve replacement on patients with severe aortic stenosis undergoing non-cardiac surgery. J Cardiothorac Surg 2020; 15:198. [PMID: 32727528 PMCID: PMC7391702 DOI: 10.1186/s13019-020-01237-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/20/2020] [Indexed: 11/23/2022] Open
Abstract
Objectives The purpose of this study was to clarify the influence of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis (AS) undergoing non-cardiac surgery. Methods Thirty-four patients with severe AS diagnosed by preoperative evaluation for non-cardiac surgery were reviewed and compared in two categories. First, patient profiles and surgical risk were compared before (pre-TAVR group; n = 10) and after (post-TAVR group; n = 24) the introduction of TAVR. Second, the completion rate of non-cardiac surgery and interval between the two cardiac and non-cardiac operations were compared between surgical aortic valve replacement (AVR) patients before the introduction of TAVR (pre-AVR group (n = 10)), in AVR patients after the introduction of TAVR (post-AVR (n = 12)), and in TAVR patients (TAVR group (n = 12)). Results Age and Japan score were higher in the post-TAVR group than in the pre-TAVR group. Malignancy was the most common non-cardiac disease (80%) in the pre-TAVR group, whereas orthopedic disease was the most common (50%) in the post-TAVR group. Completion rate of non-cardiac operation in the pre-AVR, post-AVR and TAVR groups was 70, 33, and 75% (post-AVR vs. TAVR: p = 0.010), and the interval between the two operations was 129 ± 98 days, 87 ± 40 days and 27 ± 15 days, respectively (pre AVR vs. TAVR: p = 0.034 and post AVR vs. TAVR: p = 0.025). In the post-TAVR group, AVR was selected because of a lack of fitness for TAVR in 5 of 12 patients. Conclusions After the introduction of TAVR, more senile and high-risk patients became candidates for a two-stage operation, and orthopedic conditions became the most common non-cardiac disease. Innovation in transcatheter valvular interventions and expansion of indications for patients currently evaluated as “unfit for TAVR” might be crucial issues for non-cardiac surgery with severe AS.
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Affiliation(s)
- Tadashi Omoto
- Department of Cardiovascular Surgery, Showa University, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8666, Japan.
| | - Atsushi Aoki
- Department of Cardiovascular Surgery, Showa University, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Kazuto Maruta
- Department of Cardiovascular Surgery, Showa University, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Tomoaki Masuda
- Department of Cardiovascular Surgery, Showa University, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Yui Horikawa
- Department of Cardiovascular Surgery, Showa University, Hatanodai 1-5-8, Shinagawa-ku, Tokyo, 142-8666, Japan
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Aortic Stenosis: What Risks Do the Stresses of Noncardiac Surgery or Pregnancy Pose and How Should They Be Managed? Cardiol Clin 2019; 38:139-148. [PMID: 31753173 DOI: 10.1016/j.ccl.2019.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Studies suggest that patients with aortic stenosis have increased risk in pregnancy and delivery and during anesthesia and surgery, although there are significant degrees of uncertainty as to the exact risks and best way to manage such patients. This article reviews current literature regarding impact of aortic stenosis on pregnancy and anesthesia during noncardiac surgery. There are shortcomings in the scientific evidence. Most of the available studies are observational and often retrospective and therefore there is a great deal of bias. This leads to difficulty in drawing conclusions in terms of how to apply the published information to clinical management.
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Okuno T, Yahagi K, Horiuchi Y, Sato Y, Tanaka T, Koseki K, Osanai A, Yokozuka M, Miura S, Tanabe K. The role of transcatheter aortic valve replacement in the patients with severe aortic stenosis requiring major non-cardiac surgery. Cardiovasc Interv Ther 2019; 34:345-351. [DOI: 10.1007/s12928-019-00575-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
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12
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Preoperative Evaluation of Aortic Stenosis Patient. J Nurse Pract 2019. [DOI: 10.1016/j.nurpra.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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13
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MacIntyre PA, Scott M, Seigne R, Clark A, Deveer F, Minchin I. An observational study of perioperative risk associated with aortic stenosis in non-cardiac surgery. Anaesth Intensive Care 2018; 46:207-214. [PMID: 29519225 DOI: 10.1177/0310057x1804600211] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This prospective multicentre observational study investigated the risk of non-cardiac surgery in patients with moderate or severe aortic stenosis (AS). Patients with AS undergoing non-cardiac surgery in five New Zealand hospitals between August 2011 and September 2015 were studied. Preoperative variables were analysed for a significant association with postoperative major adverse cardiac events (MACE) and 30-day mortality. Of the 147 patients recruited, 13 (9%) died within 30 days and 33 (22%) had a MACE. Using univariate analysis, patients with severe AS had four times higher 30-day mortality than patients with moderate AS (16% versus 4%, <i>P</i>=0.007). Other factors associated with increased 30-day mortality included having a smaller aortic valve area, smaller dimensionless severity index, concomitant mitral regurgitation, and higher overall surgical risk. Patients with symptoms attributable to AS had a higher incidence of MACE compared to patients without symptoms (36% versus 16%, <i>P</i>=0.011). Variables significantly associated with both 30-day mortality and MACE were age, American Society of Anesthesiologists physical status, emergency surgery, New York Heart Association classification, preoperative albumin level, frailty, and history of congestive heart failure. Using multivariate analysis, emergency surgery, symptoms attributable to AS, preoperative albumin level, and AVA remained significantly associated with adverse outcome. While these findings should be interpreted with caution due to the observational nature of the study, limited power and multiple simultaneous comparisons, they suggest that patients with severe AS have a higher risk of adverse outcome after non-cardiac surgery than patients with moderate AS.
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Goel N, Kumar MG, Barwad P, Puri GD. Noncardiac surgery in two severe aortic stenosis patients: General or epidural anesthesia? Saudi J Anaesth 2018; 12:367-369. [PMID: 29628867 PMCID: PMC5875245 DOI: 10.4103/sja.sja_648_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Nitika Goel
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - M Ganesh Kumar
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Parag Barwad
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Goverdhan Dutt Puri
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Calicchio F, Guarracino F, Giannini C, De Caro F, Baldassarri R, De Carlo M, Petronio AS. Balloon aortic valvuloplasty before noncardiac surgery in severe aortic stenosis. J Cardiovasc Med (Hagerstown) 2017; 18:109-113. [DOI: 10.2459/jcm.0000000000000331] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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16
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Prasad A, Ghosh A, Nag T. Regional anaesthesia in a patient with aortic stenosis for bladder tumour resection. Indian J Anaesth 2017; 61:441-442. [PMID: 28584359 PMCID: PMC5444228 DOI: 10.4103/ija.ija_109_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Aalekh Prasad
- Department of Anaesthesia and Critical Care, Vivekananda Institute of Medical Sciences, Ramakrishna Mission Seva Pratishthan, Kolkata, West Bengal, India
| | - Abhik Ghosh
- Department of Anaesthesia and Critical Care, Vivekananda Institute of Medical Sciences, Ramakrishna Mission Seva Pratishthan, Kolkata, West Bengal, India
| | - Tulsi Nag
- Department of Anaesthesia and Critical Care, Vivekananda Institute of Medical Sciences, Ramakrishna Mission Seva Pratishthan, Kolkata, West Bengal, India
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Horiuchi Y, Izumo M, Kusuhara T, Yokozuka M, Taketani T, Tanabe K. Combined transcatheter aortic valve implantation and type II endoleak repair after endovascular repair for abdominal aortic aneurysm. Cardiovasc Interv Ther 2016; 32:304-307. [DOI: 10.1007/s12928-016-0425-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 08/21/2016] [Indexed: 10/21/2022]
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18
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Goswami D, Sharma A, Vyas V, Vasudevan B. Association of OHVIRA syndrome with aortic stenosis and block vertebra: A case report and anaesthetic management. J OBSTET GYNAECOL 2016; 36:764-766. [PMID: 27013360 DOI: 10.3109/01443615.2016.1157156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Varuna Vyas
- b Department of Paediatrics , All India Institute Medical Sciences , New Delhi , India
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Keswani A, Lovy A, Khalid M, Blaufarb I, Moucha C, Forsh D, Chen D. The effect of aortic stenosis on elderly hip fracture outcomes: A case control study. Injury 2016; 47:413-8. [PMID: 26556487 DOI: 10.1016/j.injury.2015.10.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 10/05/2015] [Accepted: 10/08/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Aortic stenosis (AS) is an established predictor of perioperative complications following both cardiac and non-cardiac surgery. The purpose of this study was to evaluate the risk of mortality and perioperative complications among surgically treated hip fractures in elderly patients with moderate or severe AS compared to those without AS (negative controls). MATERIALS AND METHODS A retrospective case-controlled review (1:2) of elderly (≥65 years) surgically treated hip fractures from 2011 to 2015 with moderate/severe AS (according to American Heart Association criteria) was conducted. Postoperative complication rates, 30 days and 1 year mortality were reviewed. RESULTS Moderate/severe AS was identified in 65 hip fracture cases and compared to 129 negative controls. AS cases were significantly older with higher rates of coronary artery disease and atrial fibrillation (p<0.05). Rates of any 30-day perioperative complication (74% vs. 37%, p<0.001) and severe non-cardiac 30-day perioperative complication (52% vs. 26%, p=0.002) were significantly higher among AS cases compared to controls. Kaplan Meier estimates of 30-day mortality (14.7% vs. 4.2%, p<0.001) and 1-year mortality (46.8% vs. 14.1%, p<0.001) were significantly higher in AS cases compared to controls. Multivariate analysis of severe 30-day postoperative complications identified moderate/severe AS (OR 4.02, p=0.001), pulmonary disease (OR 7.36, p=0.002) and renal disease (OR 3.27, p=0.04) as independent predictors. Moderate/severe AS (OR 3.38, p=0.03), atrial fibrillation (OR 3.73, p=0.03) and renal disease (OR 4.44, p=0.02) were independent predictors of 30-day mortality. Moderate/severe AS (OR 5.79, p<0.001) and renal disease (OR 3.39, p=0.02) were independent predictors of 1-year mortality. CONCLUSION Aortic stenosis is associated with a significantly increased risk of perioperative complications, 30-day mortality and 1-year mortality in elderly patients undergoing surgical treatment of hip fractures.
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Affiliation(s)
- Aakash Keswani
- Icahn School of Medicine at Mount Sinai, E 98th St., NY 10029, USA; Mount Sinai Hospital, Department of Orthopaedic Surgery, 5 E 98th St., NY 10029, USA.
| | - Andrew Lovy
- Icahn School of Medicine at Mount Sinai, E 98th St., NY 10029, USA; Mount Sinai Hospital, Department of Orthopaedic Surgery, 5 E 98th St., NY 10029, USA
| | - Mian Khalid
- Icahn School of Medicine at Mount Sinai, E 98th St., NY 10029, USA; Mount Sinai Hospital, Department of Orthopaedic Surgery, 5 E 98th St., NY 10029, USA
| | - Ira Blaufarb
- Icahn School of Medicine at Mount Sinai, E 98th St., NY 10029, USA; Mount Sinai Hospital, Department of Orthopaedic Surgery, 5 E 98th St., NY 10029, USA
| | - Calin Moucha
- Icahn School of Medicine at Mount Sinai, E 98th St., NY 10029, USA; Mount Sinai Hospital, Department of Orthopaedic Surgery, 5 E 98th St., NY 10029, USA
| | - David Forsh
- Icahn School of Medicine at Mount Sinai, E 98th St., NY 10029, USA; Mount Sinai Hospital, Department of Orthopaedic Surgery, 5 E 98th St., NY 10029, USA
| | - Darwin Chen
- Icahn School of Medicine at Mount Sinai, E 98th St., NY 10029, USA; Mount Sinai Hospital, Department of Orthopaedic Surgery, 5 E 98th St., NY 10029, USA
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Duncan D, Wijeysundera DN. Preoperative Cardiac Evaluation and Management of the Patient Undergoing Major Vascular Surgery. Int Anesthesiol Clin 2016; 54:1-32. [PMID: 26967800 PMCID: PMC5087846 DOI: 10.1097/aia.0000000000000091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Dallas Duncan
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Duminda N. Wijeysundera
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, ON, Canada
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21
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McSwain JR, Matos JR, Henderson BL, Wilson SH. Hip Hemiarthroplasty in Two Patients with Severe Aortic Stenosis: Ethical Questions from an Anesthesiologist's Perspective. ACTA ACUST UNITED AC 2015; 5:213-5. [PMID: 26657700 DOI: 10.1213/xaa.0000000000000214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
As the population ages, geriatric patients with preexisting cardiac disease are presenting for noncardiac surgery in escalating numbers. The decision to proceed with surgery in such patients often is multifactorial. With this in mind, we describe 2 patients with severe aortic stenosis who required hip operations: one urgent and one elective. Both patients had different anesthetic plans and did well intraoperatively. However, both patients died postoperatively because of their comorbidities. Although published guidelines are sparse, we hope this report will increase awareness and discussion about caring for geriatric patients with severe aortic stenosis.
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Affiliation(s)
- Julie R McSwain
- From the Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
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22
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Pislaru SV, Abel MD, Schaff HV, Pellikka PA. Aortic Stenosis and Noncardiac Surgery: Managing the Risk. Curr Probl Cardiol 2015; 40:483-503. [DOI: 10.1016/j.cpcardiol.2015.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Samarendra P, Mangione MP. Aortic stenosis and perioperative risk with noncardiac surgery. J Am Coll Cardiol 2015; 65:295-302. [PMID: 25614427 DOI: 10.1016/j.jacc.2014.10.051] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 10/21/2014] [Indexed: 11/24/2022]
Abstract
Aortic stenosis (AS) is characterized as a high-risk index for cardiac complications during noncardiac surgery. The American College of Cardiology/American Heart Association guidelines define severe AS as aortic valve area ≤1 cm(2), mean gradient of ≥40 mm Hg, and peak velocity of ≥4 m/s. As per current clinical practice, any of these characteristic features label a patient as at high risk for noncardiac surgery. However, these parameters appear inconsistent, particularly with respect to the aortic valve area cutoff value. The perioperative risk associated with AS during noncardiac surgery depends upon its severity (moderate vs. severe), clinical status, and the complexity of the surgical procedure (low to intermediate risk vs. high risk). A critical analysis of old and new data from published studies indicates that the significance of the presence of AS in patients undergoing noncardiac surgery is overemphasized in studies that predate the more recent advances in echocardiography and cardiac catheterization in assessment of aortic stenosis, anesthetic and surgical techniques, as well as post-operative patient care.
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Affiliation(s)
- Padmaraj Samarendra
- Non-Invasive Cardiology and Echocardiography Laboratory, VA Medical Center, Pittsburgh, Pennsylvania; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Michael P Mangione
- Department of Anesthesia, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania; Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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24
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Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Creager MA, Curtis LH, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK, Stevenson WG, Yancy CW. 2014 AHA/ACC guideline for the management of patients with valvular heart disease. J Thorac Cardiovasc Surg 2014; 148:e1-e132. [DOI: 10.1016/j.jtcvs.2014.05.014] [Citation(s) in RCA: 631] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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25
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Osnabrugge RL, Kappetein AP, Serruys PW. Non-cardiac surgery in patients with severe aortic stenosis: time to revise the guidelines?: Figure 1. Eur Heart J 2014; 35:2346-8. [DOI: 10.1093/eurheartj/ehu116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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26
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Rokhtabnak F, Zamani MM, Kholdebarin A, Pournajafian A, Ghodraty MR. Anesthetic management for lower limb fracture in severe aortic valve stenosis and fat embolism: a case report and review of literature. Anesth Pain Med 2014; 4:e13713. [PMID: 24910815 PMCID: PMC4030264 DOI: 10.5812/aapm.13713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 08/22/2013] [Accepted: 09/11/2013] [Indexed: 11/18/2022] Open
Abstract
Introduction: Anesthesia in severe aortic stenosis, which describes a valve surface area less than 1 cm2, can result in rapid clinical deterioration and patient mortality. These patients may require treatment for aortic stenosis before any surgical intervention. In suitable patients percutaneous balloon aortic valvutomy appears to carry lower risk, but in emergency situations, it is important to determine which kind of anesthesia technique has the lowest risk for these patients, without any cardiac intervention. Case Presentation: In this case report, we present a patient who had tibia and fibula fractures and a symptomatic severe critical aortic stenosis which was diagnosed during a preoperative visit. The patient had exertional dyspnea, palpitations and fainting history, but he had not received any medical therapy before the present admission. During hospitalization and preoperative evaluation, a fat embolism occurred and the patient was admitted to the intensive care unit. Immediately after his recovery, we successfully managed the tibia and fibula fracture fixation without any cardiac intervention. Conclusions: Our anesthesia method was sciatic and femoral nerve block under double ultrasonic and nerve stimulator guidance.
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Affiliation(s)
- Faranak Rokhtabnak
- Department of Anesthesiology and Pain Medicine, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mahdi Zamani
- Department of Anesthesiology and Pain Medicine, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Kholdebarin
- Department of Anesthesiology and Pain Medicine, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Pournajafian
- Department of Anesthesiology and Pain Medicine, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Ghodraty
- Department of Anesthesiology and Pain Medicine, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
- Corresponding author: Mohammad Reza Ghodraty, Department of Anesthesiology, Firoozgar Hospital, Behafarin St., Karim Khan Ave, P. O. Box: 1593748771, Tehran, Iran.Tel: +98-2184902450, Fax: +98-2188633039, E-mail:
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27
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Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129:2440-92. [PMID: 24589852 DOI: 10.1161/cir.0000000000000029] [Citation(s) in RCA: 1015] [Impact Index Per Article: 101.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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28
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Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129:e521-643. [PMID: 24589853 DOI: 10.1161/cir.0000000000000031] [Citation(s) in RCA: 867] [Impact Index Per Article: 86.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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29
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Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:2438-88. [PMID: 24603191 DOI: 10.1016/j.jacc.2014.02.537] [Citation(s) in RCA: 1338] [Impact Index Per Article: 133.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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30
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Tashiro T, Pislaru SV, Blustin JM, Nkomo VT, Abel MD, Scott CG, Pellikka PA. Perioperative risk of major non-cardiac surgery in patients with severe aortic stenosis: a reappraisal in contemporary practice. Eur Heart J 2014; 35:2372-81. [PMID: 24553722 DOI: 10.1093/eurheartj/ehu044] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Severe aortic stenosis (SAS) is a major risk factor for death after non-cardiac surgery, but most supporting data are from studies over a decade old. We evaluated the risk of non-cardiac surgery in patients with SAS in contemporary practice. METHODS AND RESULTS SAS patients (valve area ≤1 cm(2), mean gradient ≥40 mmHg or peak aortic velocity ≥4 m/s) undergoing intermediate or high-risk surgery were identified from surgical and echo databases of 2000-2010. Controls were matched for age, sex, and year of surgery. Post-operative (30 days) death and major adverse cardiovascular events (MACE), including death, stroke, myocardial infarction, ventricular tachycardia/fibrillation, and new or worsening heart failure, and 1-year survival were determined. There were 256 SAS patients and 256 controls (age 76 ± 11, 54.3% men). There was no significant difference in 30-day mortality (5.9% vs. 3.1%, P = 0.13). Severe aortic stenosis patients had more MACE (18.8% vs. 10.5%, P = 0.01), mainly due to heart failure. Emergency surgery, atrial fibrillation, and serum creatinine levels of >2 mg/dL were predictors of post-operative death by multivariate analysis [area under the curve: 0.81, 95% confidence intervals: 0.71-0.91]; emergency surgery was the strongest predictor of 30-day mortality for both SAS and controls. Severe aortic stenosis was the strongest predictor of 1-year mortality. CONCLUSION Severe aortic stenosis is associated with increased risk of MACE. In contemporary practice, perioperative mortality of patients with SAS is lower than previously reported and the difference from controls did not reach statistical significance. Emergency surgery is the strongest predictor of post-operative death. These results have implications for perioperative risk assessment and management strategies in patients with SAS.
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Affiliation(s)
- Teruko Tashiro
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Sorin V Pislaru
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Jodi M Blustin
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Vuyisile T Nkomo
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Martin D Abel
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
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31
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Rahimtoola SH. The year in valvular heart disease. J Am Coll Cardiol 2014; 63:1948-58. [PMID: 24530661 DOI: 10.1016/j.jacc.2014.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 12/19/2013] [Accepted: 01/07/2014] [Indexed: 01/29/2023]
Affiliation(s)
- Shahbudin H Rahimtoola
- Griffith Center, Division of Cardiovascular Medicine, Department of Medicine, LAC+USC Medical Center, Keck School of Medicine at University of Southern California, Los Angeles, California.
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32
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Abstract
Aortic stenosis is the most commonly encountered valvular disease in the elderly, with approximately 2-3% of individuals over 65 years of age afflicted. The most common cause of acquired aortic stenosis is calcific degeneration, characterized by a slowly progressive, asymptomatic period which can last decades. Once symptomatic, the clinical manifestation of aortic stenosis is from functional obstruction of left ventricular outflow and the additional hemodynamic effects on the left ventricle and vasculature. With advances in echocardiography, individuals with aortic stenosis are increasingly diagnosed in the asymptomatic latent period. However, echocardiographic measures alone cannot identify clinically significant outflow obstruction as there is considerable overlap in hemodynamic severity between symptomatic and asymptomatic individuals. Current clinical guidelines predicate the timing of surgical valve replacement on the presence or absence of symptoms. Management for symptomatic, significant stenosis is surgical valve replacement as there are no current medical therapies reliably proven to decrease aortic stenosis severity or improve long-term outcomes. However, recent retrospective studies have demonstrated an association between atherosclerotic disease risk factors, such as hyperlipidemia and aortic stenosis. Given these findings, there are now advocates for prospective primary prevention trials for aortic stenosis in patients with mild or moderate valvular disease. The following paper will discuss etiology, diagnostic evaluation and therapeutic options of acquired aortic stenosis. This review will discuss etiology, diagnostic evaluation, and therapeutic options of acquired aortic stenosis.
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Affiliation(s)
- Rosario V Freeman
- Division of Cardiology, University of Washington, Seattle 98109, USA.
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33
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Garvin S, Stundner O, Memtsoudis SG. Transesophageal echocardiography during cardiac arrest in orthopedic surgery patients: a report of two cases and a review of the literature. HSS J 2013; 9:275-7. [PMID: 24426880 PMCID: PMC3772165 DOI: 10.1007/s11420-013-9331-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 03/27/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cardiac arrest situations represent an enormous clinical challenge to the physicians involved. Research suggests that the utilization on transesophageal echocardiography (TEE) may provide important diagnostic information and allows for institution of more specific treatment, while not hampering resuscitation efforts. CASE DESCRIPTION In this review, we highlight the usefulness of TEE in cardiac arrest situations in the orthopedic setting, by presenting two perioperative cases. In one case, TEE was used to diagnose intraoperative pulmonary embolism and guide thrombolytic therapy. The second case highlights the use of TEE in management of hemodynamic instability in a patient with aortic stenosis. LITERATURE REVIEW Memtsoudis et al. showed that in 19 of 22 cardiac arrests, an underlying pathological process could be established with TEE, leading to specific interventions beyond the institution of advanced cardiac life support measures. CLINICAL RELEVANCE TEE can provide rapid diagnostic information guiding treatment in patients with hemodynamic compromise. The use is expanding beyond the cardiac operating theater and given the potential clinical impact consideration should be given to utilizing this valuable imaging modality in appropriate clinical situation.
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Affiliation(s)
- Sean Garvin
- />Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA , />Weill Medical College of Cornell University, New York, NY 10065 USA
| | - Ottokar Stundner
- />Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA , />Weill Medical College of Cornell University, New York, NY 10065 USA
| | - Stavros G. Memtsoudis
- />Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA , />Weill Medical College of Cornell University, New York, NY 10065 USA
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34
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Agarwal S, Rajamanickam A, Bajaj NS, Griffin BP, Catacutan T, Svensson LG, Anabtawi AG, Tuzcu EM, Kapadia SR. Impact of Aortic Stenosis on Postoperative Outcomes After Noncardiac Surgeries. Circ Cardiovasc Qual Outcomes 2013; 6:193-200. [DOI: 10.1161/circoutcomes.111.000091] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shikhar Agarwal
- From the Heart and Vascular Institute (S.A., B.P.G., L.G.S., E.M.T., A.G.A., S.R.K.), Department of Internal Medicine (N.S.B.), and Department of Hospital Medicine (A.R., T.C.), Cleveland Clinic, Cleveland, OH
| | - Anitha Rajamanickam
- From the Heart and Vascular Institute (S.A., B.P.G., L.G.S., E.M.T., A.G.A., S.R.K.), Department of Internal Medicine (N.S.B.), and Department of Hospital Medicine (A.R., T.C.), Cleveland Clinic, Cleveland, OH
| | - Navkaranbir S. Bajaj
- From the Heart and Vascular Institute (S.A., B.P.G., L.G.S., E.M.T., A.G.A., S.R.K.), Department of Internal Medicine (N.S.B.), and Department of Hospital Medicine (A.R., T.C.), Cleveland Clinic, Cleveland, OH
| | - Brian P. Griffin
- From the Heart and Vascular Institute (S.A., B.P.G., L.G.S., E.M.T., A.G.A., S.R.K.), Department of Internal Medicine (N.S.B.), and Department of Hospital Medicine (A.R., T.C.), Cleveland Clinic, Cleveland, OH
| | - Thadeo Catacutan
- From the Heart and Vascular Institute (S.A., B.P.G., L.G.S., E.M.T., A.G.A., S.R.K.), Department of Internal Medicine (N.S.B.), and Department of Hospital Medicine (A.R., T.C.), Cleveland Clinic, Cleveland, OH
| | - Lars G. Svensson
- From the Heart and Vascular Institute (S.A., B.P.G., L.G.S., E.M.T., A.G.A., S.R.K.), Department of Internal Medicine (N.S.B.), and Department of Hospital Medicine (A.R., T.C.), Cleveland Clinic, Cleveland, OH
| | - Abdel G. Anabtawi
- From the Heart and Vascular Institute (S.A., B.P.G., L.G.S., E.M.T., A.G.A., S.R.K.), Department of Internal Medicine (N.S.B.), and Department of Hospital Medicine (A.R., T.C.), Cleveland Clinic, Cleveland, OH
| | - E. Murat Tuzcu
- From the Heart and Vascular Institute (S.A., B.P.G., L.G.S., E.M.T., A.G.A., S.R.K.), Department of Internal Medicine (N.S.B.), and Department of Hospital Medicine (A.R., T.C.), Cleveland Clinic, Cleveland, OH
| | - Samir R. Kapadia
- From the Heart and Vascular Institute (S.A., B.P.G., L.G.S., E.M.T., A.G.A., S.R.K.), Department of Internal Medicine (N.S.B.), and Department of Hospital Medicine (A.R., T.C.), Cleveland Clinic, Cleveland, OH
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35
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Cowie B. Focused Transthoracic Echocardiography Predicts Perioperative Cardiovascular Morbidity. J Cardiothorac Vasc Anesth 2012; 26:989-93. [DOI: 10.1053/j.jvca.2012.06.031] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Indexed: 02/02/2023]
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36
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Wright DE, Hunt DP. Core competency review: aortic stenosis and noncardiac surgery. J Hosp Med 2012; 7:655-60. [PMID: 22733448 DOI: 10.1002/jhm.1952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 04/16/2012] [Accepted: 05/06/2012] [Indexed: 11/11/2022]
Abstract
Aortic stenosis (AS) poses a risk of adverse cardiac events for patients undergoing surgical procedures. Perioperative mortality for patients with severe AS is as high as 14%. This review examines the accuracy of the history and physical examination in detecting AS and, subsequently, in assessing severity. The utility of echocardiography is addressed, and the relevant pathophysiology of AS is summarized. We also summarize what is known about perioperative risk for patients with AS.
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Affiliation(s)
- Douglas E Wright
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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37
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Rao JY, Yeriswamy MC, Santhosh MJ, Shetty GG, Varghese K, Patil CB, Iyengar SS. A look into Lee's score: peri-operative cardiovascular risk assessment in non-cardiac surgeries-usefulness of revised cardiac risk index. Indian Heart J 2012; 64:134-8. [PMID: 22572486 PMCID: PMC3860848 DOI: 10.1016/s0019-4832(12)60047-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The revised cardiac risk index (RCRI/Lee's score) was designed for peri-operative risk assessment before elective major non-cardiac surgeries. Through this article, we report the usefulness of RCRI in our daily practice, while evaluating patients undergoing surgeries of varying risk. METHODS Only referred patients, aged ≥ 40 years, were included. Risk stratification was done using RCRI scoring system. Patients were categorised into 4 classes depending on 0, 1, 2, and ≥3 risk predictors (risk predictors were high-risk surgery, history of ischaemic heart disease (IHD), diabetes on insulin, history of stroke (cerebrovascular accident [CVA]), history of congestive heart failure (CHF) and serum creatinine of >2 mg%). Electrocardiograms (ECG) were done in all patients, while troponin I in intermediate and high-risk patients, and in others if symptomatic. Perioperative cardiovascular events were managed appropriately. RESULTS Of the 920 patients included, only 853 patients were analysed as 67 patients were not operated upon. The mean age was 59 ± 11years and 46% of the patients were women. Two hundred and ninety-two underwent high-risk surgeries, 97 patients had history of IHD, 89 had history of CHF, 36 gave history of CVA, 269 patients were diabetics on insulin and 68 had serum creatinine >2 mg%. Number of patients in Lee's classes I, II, III, and IV were 311, 347, 150, and 52, respectively. 26 out of 853 patients had peri-operative events. Of the six variables in RCRI, only history of IHD was an independent predictor of events. Event rates increased as the RCRI class increased, i.e. 1.7%, 2.0%, 6.7%, and 7.7% for classes I-IV, respectively. Age >70 years, poor general medical condition, emergency surgery and left bundle branch block (LBBB) on ECG, were significantly associated with peri-operative events. CONCLUSION The RCRI is a useful tool in pre-operative risk stratification. It should perhaps be further updated to improve its predictive accuracy.
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38
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Elmariah S, Arzamendi D, Palacios IF. Balloon Aortic Valvuloplasty in the Transcatheter Aortic Valve Replacement Era. Interv Cardiol Clin 2012; 1:129-137. [PMID: 28582063 DOI: 10.1016/j.iccl.2011.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Initial enthusiasm for balloon aortic valvuloplasty (BAV) as an alternative to surgical aortic valve replacement waned because of the perceived failure of the procedure to alter the natural history of calcific severe aortic valve stenosis (AS) and significant initial procedural morbidity. Despite technical and procedural advances, BAV has been reserved as a palliative procedure for patients who cannot undergo valve replacement or as a bridge to surgery in hemodynamically unstable patients. This article reviews the indications, technical aspects, and outcomes of BAV for calcific AS and discusses the current role of BAV in the era of transcatheter aortic valve replacement.
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Affiliation(s)
- Sammy Elmariah
- Interventional Cardiology, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GBR 800, Boston, MA 02114, USA; Structural Heart Disease, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GBR 800, Boston, MA 02114, USA
| | - Dabit Arzamendi
- Interventional Cardiology, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GBR 800, Boston, MA 02114, USA; Structural Heart Disease, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GBR 800, Boston, MA 02114, USA
| | - Igor F Palacios
- Interventional Cardiology, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GBR 800, Boston, MA 02114, USA; Structural Heart Disease, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GBR 800, Boston, MA 02114, USA.
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39
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The preoperative assessment of patients with valvular heart disease as a comorbidity. ACTA CHIRURGICA IUGOSLAVICA 2011; 58:31-7. [PMID: 21879648 DOI: 10.2298/aci1102031m] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In patients with valvular heart disease planned for any type of surgery preoperative evaluation and preparation are especially important for a successfull outcome of the surgery. Preoperative preparation and intraoperative treatment of patients with valvular heart disease are different de-Spending on the type of valvular disease: aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation or mitral valve prolapse. In this paper we have outlined the criteria for evaluating the severity of valvular disease, given that the risk in surgery is proportional to the degree of valvular disease. Also, given that the risk in surgery is also directly proportional to the type and extent of non cardiac surgery, it will be presented recommendations for intraoperative monitoring, with the purpose of evaluating patient's hemodynamic state, as well as recommendations for perioperative treatment of hypotension, tachycardia, and other hemodynamic disturbances. In the paper we will separately discuss bacterial endocarditis profilaxys which can occur after the surgery of patients with valvular disease. Since the patients with valvular disease, and especially the ones with implanted prosthetic valve or heart arrhythmia, are usually on oral anticoagulation therapy, it will be given recommendations for treatment of patients on oral anticoagulation therapy as part of preoperative preparations.
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Bergmann L, Kahlert P, Eggebrecht H, Frey U, Peters J, Kottenberg E. Transfemoral aortic valve implantation under sedation and monitored anaesthetic care - a feasibility study. Anaesthesia 2011; 66:977-82. [DOI: 10.1111/j.1365-2044.2011.06788.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Cowie B, Kluger R. Evaluation of systolic murmurs using transthoracic echocardiography by anaesthetic trainees. Anaesthesia 2011; 66:785-90. [DOI: 10.1111/j.1365-2044.2011.06786.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cowie B. Three years' experience of focused cardiovascular ultrasound in the peri-operative period. Anaesthesia 2011; 66:268-73. [PMID: 21401539 DOI: 10.1111/j.1365-2044.2011.06622.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Ultrasound applications in peri-operative medicine have become common place in modern anaesthesia practice. Anaesthetists have performed transoesophageal echocardiography in cardiac and selected non-cardiac surgery for over two decades. We aimed to assess the indications, impact on clinical management and accuracy of focused cardiovascular ultrasound performed by anaesthetists in the peri-operative period. One hundred and seventy patients over a 3-year period had a focused transthoracic echocardiogram. Adequate images to answer the clinical question were obtained in 167 out of 170 patients (98%). The undifferentiated systolic murmur was the commonest indication (98 out of 170, 58%). Some degree of aortic stenosis was present in 47 out of 170 (26%) of patients; mitral valve disease (30 out of 170 (18%)) and pulmonary hypertension (25 out of 170 (14%)) were also common. Changes in peri-operative management occurred in 140 out of 170 (82%) patients and major findings correlated with a formal cardiology transthoracic echocardiogram in 52 out of 57 (92%) patients. Focused cardiovascular ultrasound performed by anaesthetists in the peri-operative period accurately detects major cardiac pathology and significantly alters peri-operative management.
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Affiliation(s)
- B Cowie
- Department of Anaesthesia, St. Vincent's Hospital, Melbourne, Australia.
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Iyer GB, Durbridge J, Cox M. Management of the pregnant cardiac patient. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2011. [DOI: 10.1016/j.cacc.2010.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
Ultrasound applications in perioperative medicine have expanded enormously over the past decade. Transoesophageal echocardiography has been performed by anaesthetists during cardiac surgery for over 20 years. With the increasing availability of portable ultrasound systems, the use of ultrasound to assist in vascular cannulation and regional anaesthesia has been well described. Portable ultrasound systems come with a range of probes for different applications, including transthoracic echocardiography. While transthoracic echocardiography has traditionally been the domain of cardiologists, its use has been increasing in critical care, the emergency room and, recently, by anaesthetists in the perioperative period. Unlike formal cardiology-based transthoracic echocardiography, focused, goal-directed transthoracic echocardiography is often more appropriate in the perioperative period to address a particular question and can be performed in just a few minutes. Transthoracic echocardiography allows rapid, noninvasive, point-of-care assessment of ventricular function, valvular integrity, volume status and fluid responsiveness. It can help distinguish undifferentiated systolic murmurs preoperatively, give valuable information on the aetiology of unexplained hypotension and cardiovascular collapse and assess response to therapeutic interventions such as vasoactive drugs and volume resuscitation. Focused transthoracic echocardiography should include qualitative assessment of left and right ventricular function, an estimate of aortic valve gradient, right ventricular systolic pressure and intravascular volume status as minimum requirements. Transthoracic echocardiography is a valuable tool in the perioperative period and ideally the equipment and expertise should be available in all operating rooms.
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Affiliation(s)
- B. S. Cowie
- Department of Anaesthesia, St. Vincent's Hospital, Melbourne, Victoria, Australia
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KAPADIA SAMIRR, GOEL SACHINS, YUKSEL UYGAR, AGARWAL SHIKHAR, PETTERSSON GOSTA, SVENSSON LARSG, SMEDIRA NICHOLASG, WHITLOW PATRICKL, LYTLE BRUCEW, TUZCU EMURAT. Lessons Learned from Balloon Aortic Valvuloplasty Experience from the Pre-transcatheter Aortic Valve Implantation Era. J Interv Cardiol 2010; 23:499-508. [DOI: 10.1111/j.1540-8183.2010.00577.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Calleja AM, Dommaraju S, Gaddam R, Cha S, Khandheria BK, Chaliki HP. Cardiac risk in patients aged >75 years with asymptomatic, severe aortic stenosis undergoing noncardiac surgery. Am J Cardiol 2010; 105:1159-63. [PMID: 20381670 DOI: 10.1016/j.amjcard.2009.12.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 12/03/2009] [Accepted: 12/03/2009] [Indexed: 10/19/2022]
Abstract
Severe aortic stenosis (AS) is a known predictor of cardiac risk during noncardiac surgery. However, for patients with asymptomatic AS, it is unclear whether aortic valve surgery should precede noncardiac surgery. We studied 30 patients with asymptomatic, severe AS with a mean age of 78 + or - 9 years, an aortic valve area of 0.77 + or - 0.16 cm(2), a mean gradient of 50.1 + or - 9.5 mm Hg, and a peak gradient of 84 + or - 22 mm Hg. They were compared to 60 age-matched (within 2 years) and gender-matched (ratio of 1:2) patients with mild-to-moderate AS (controls). The primary end point of the study was a composite of death, myocardial infarction, heart failure, ventricular arrhythmias before dismissal, and intraoperative hypotension requiring vasopressor administration. Most patients (>75%) and controls underwent intermediate-risk surgical procedures that were similar with respect to the nature of the surgery, type of anesthesia used, and preoperative risk assessment. Combined postoperative events were more common for the patients (n = 10; 33%) than for the controls (n = 14; 23%), but the difference was not statistically significant (p = 0.06). Intraoperative hypotension requiring vasopressor use was more likely for the patients (n = 9; 30%) than for the controls (n = 10; 17%; odds ratio 2.5; p = 0.11). The perioperative myocardial infarction rates were similar for both groups (3%; p = 0.74). No deaths, heart failure events, or ventricular arrhythmias occurred in the patients and 1 death and 1 ventricular arrhythmia episode occurred in the controls. In conclusion, intermediate-to-low-risk noncardiac surgery for patients with severe, asymptomatic AS can be performed relatively safely. Intraoperative hypotension was frequent and required prompt and aggressive treatment.
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Frogel J, Galusca D. Anesthetic considerations for patients with advanced valvular heart disease undergoing noncardiac surgery. Anesthesiol Clin 2010; 28:67-85. [PMID: 20400041 DOI: 10.1016/j.anclin.2010.01.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Patients with valvular heart disease represent a growing segment of the population and can present major challenges to clinical anesthesiologists. This review focuses on patients with advanced left-sided valvular disease undergoing noncardiac surgery. The pathophysiology and anesthetic implications of aortic stenosis and insufficiency and mitral stenosis and insufficiency are discussed, with a focus on optimizing perioperative management and decision making for patients with these conditions.
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Affiliation(s)
- Jonathan Frogel
- Department of Anesthesiology, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA.
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2009; 54:e13-e118. [PMID: 19926002 DOI: 10.1016/j.jacc.2009.07.010] [Citation(s) in RCA: 232] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation 2009; 120:e169-276. [PMID: 19884473 DOI: 10.1161/circulationaha.109.192690] [Citation(s) in RCA: 209] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Bergmann L, Kottenberg E, Heine T, Kahlert P, Eggebrecht H, Wendt D, Thielmann M, Jakob H, Erbel R, Peters J. [Anesthesia with transfemoral and transapical aortic valve implantation. Periinterventional management and hemodynamic observations]. Herz 2009; 34:381-7. [PMID: 19711034 DOI: 10.1007/s00059-009-3258-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Percutaneous transfemoral and transapical aortic valve implantations are novel procedures that often confront the anesthesiologist with bigger challenges than surgical aortic valve replacements using cardiopulmonary bypass. Due to old age and the presence of severe comorbidities including pulmonary vascular hypertension, most patients have a very high risk. Individual comorbidities and their severity are as important for the choice of the anesthetic technique as pharmacological cardiovascular therapy and communication during the respective phases of the intervention. Since severe hemodynamic alterations (cardiogenic shock, coronary ischemia, arrhythmias) and potential interventional complications (bleeding, ventricular and vascular injury) may occur, the authors routinely perform an extended cardiovascular monitoring. General endotracheal anesthesia may be advantageous even for transfemoral valve implantation and was not associated with a worse outcome. Following valve implantation a substantial increase in cardiac index, but also of all filling pressures was measured. Anesthesia coverage time for the first 100 cases averaged 263 min (+/- 96) for transfemoral and 297 (+/- 78) for transapical valve implantation, which appears greater than for conventional aortic valve replacement surgery, but it decreased significantly for transfemoral valve implantation over the course of interventions. Accordingly, the anesthesiologist, besides providing anesthesia and managing the airway, assumes responsibility for invasive cardiopulmonary monitoring, cardiovascular pharmacotherapy tailored to intervention phases, and "troubleshooting" in the event of complications for these still developing interventions.
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Affiliation(s)
- Lars Bergmann
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany.
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