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Herrera RA, Smith MM, Mauermann WJ, Nkomo VT, Luis SA. Perioperative management of aortic stenosis in patients undergoing non-cardiac surgery. Front Cardiovasc Med 2023; 10:1145290. [PMID: 37089878 PMCID: PMC10117820 DOI: 10.3389/fcvm.2023.1145290] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/06/2023] [Indexed: 04/08/2023] Open
Abstract
Aortic stenosis is one of the most common cardiac valve pathologies in the world and its prevalence increases with age. Although previously associated with increased perioperative mortality, more recent studies suggest that mortality rates may be decreasing. Recent guidelines suggest that major non-cardiac surgery can be performed safely in asymptomatic severe aortic stenosis patients with close hemodynamic monitoring. Among symptomatic patients, the guidelines recommend aortic valve intervention prior to major non-cardiac surgery because of a reduction in the incidence of postoperative heart failure and improved rates of long-term overall survival. This review provides a comprehensive and contemporary review of the perioperative management of patients with severe aortic valve stenosis.
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Affiliation(s)
- Roberto A. Herrera
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Mark M. Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - William J. Mauermann
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Vuyisile T. Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Sushil Allen Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Correspondence: Sushil Allen Luis
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Dall'Ara G, Grotti S, Guerrieri G, Compagnone M, Spartà D, Galvani M, Tarantino F. Balloon aortic valvuloplasty: current status and future prospects. Expert Rev Cardiovasc Ther 2022; 20:389-402. [PMID: 35514027 DOI: 10.1080/14779072.2022.2074837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Balloon aortic valvuloplasty (BAV) improves hemodynamic and clinical status of patients with severe aortic stenosis (AS) for a limited period of 6-12 months. However, there is a high number of procedures performed worldwide and an upward trend over the last decades. AREAS COVERED Epidemiology of AS and the advent of transcatheter aortic valve implantation (TAVI) contribute to the extensive referral of patients. The expansion of recommendations for TAVI has occasionally led to financial reimbursement-related problems that do not exist for BAV. BAV is indicated as a bridge to valve replacement, to decision in complex cases, and to extracardiac surgery. BAV may play a role in preparing for TAVI and optimizing procedural results. The minimalist approach and reduced complication rate make it applicable in fragile patients. EXPERT OPINION In the near future, BAV will continue to be a useful asset in managing patients with AS given the multiple indications, broad applicability, safety profile, low cost, and repeatability. Specific studies are necessary to explore technical solutions, stronger indications, the finest technique, and to standardize the procedural result. Pending the development of potential competitive devices, the role that BAV plays will remain closely intertwined with the one played by TAVI.
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Affiliation(s)
| | - Simone Grotti
- Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | | | | | - Daniela Spartà
- Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Marcello Galvani
- Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy.,Cardiovascular Research Unit, Myriam Zito Sacco Heart Foundation, Forlì, Italy
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Mills J, Answine J, Martin S, Bryce N, Dikranis K, DiMarco L. Sleeve gastrectomy to aortic valve replacement: safe? Surg Obes Relat Dis 2021; 18:351-356. [PMID: 35067459 DOI: 10.1016/j.soard.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 11/03/2021] [Accepted: 12/05/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Bariatric surgery has favorable results on cardiac structure and function, but there is minimal research on its utility in the cardiac comorbid population. OBJECTIVES To determine if laparoscopic sleeve gastrectomy (SG) is safe in patients with symptomatic aortic stenosis (AS). SETTING Community hospital/bariatric center of excellence in Pennsylvania. METHODS Retrospective single center review of 18 patients with morbid obesity and clinically significant AS. All SGs were performed between June 2016 and June 2020. Outcomes including hospital length of stay, 30-day readmission, and 30-day mortality in the study population (n = 18) were compared with 100 patients without AS who underwent SG at the same institution during the same time. RESULTS There were no perioperative deaths. Mean hospital stay in the study group was 1.78 days compared with 1.3 days in the noncardiac group (P = .1154). Two of 18 patients (11.1%) required readmission within 30 days, both for clinically significant bleeding, compared with 2 of 100 noncardiac patients (2.0%) (P = .1097). Seventeen of 18 study patients went on to have definitive aortic valve replacement surgery. CONCLUSION SG appears safe in patients with clinically significant AS. Although the AS group did have a higher rate of complications, these were manageable and did not increase mortality or LOS. Further studies are required to determine if outcomes of definitive aortic valve replacement are improved after bariatric surgery.
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Affiliation(s)
- John Mills
- UPMC Pinnacle Community General Hospital, Harrisburg, Pennsylvania.
| | - Joseph Answine
- UPMC Pinnacle Community General Hospital, Harrisburg, Pennsylvania
| | - Sean Martin
- UPMC Pinnacle Community General Hospital, Harrisburg, Pennsylvania
| | - Nicole Bryce
- UPMC Pinnacle Community General Hospital, Harrisburg, Pennsylvania
| | - Kristi Dikranis
- UPMC Pinnacle Community General Hospital, Harrisburg, Pennsylvania
| | - Luciano DiMarco
- UPMC Pinnacle Community General Hospital, Harrisburg, Pennsylvania
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Sorrentino R, Santoro C, Bardi L, Rigolin V, Gentile F. Non-cardiac surgery in patients with valvular heart disease. Heart 2021; 108:1171-1178. [PMID: 34815334 DOI: 10.1136/heartjnl-2021-319160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/02/2021] [Indexed: 12/30/2022] Open
Abstract
In patients with significant valvular heart disease (VHD) undergoing non-cardiac surgery (NCS), perioperative adverse cardiac events are a relevant issue. Although postoperative outcomes can be adversely affected by valve-related haemodynamic instability, recommended perioperative risk scores prioritise the risk of the surgical procedure and the presence of cardiovascular risk factors, neglecting the presence or extent of VHD. Perioperative management and anaesthetic approach should focus on the underlying type and severity of VHD, the compensatory mechanisms deployed by left ventricle and right ventricle and the type and risk of NCS. Due to the lack of randomised trials investigating different therapeutic approaches of valvular intervention prior to NCS, recommendations mainly rely on consensus opinion and inference based on large observational registries. As a general rule, valvular intervention is recommended prior to NCS in symptomatic patients or in those who meet standard criteria for cardiac intervention. In the absence of such conditions, it is reasonable to perform NCS with tailored anaesthetic management and close invasive perioperative haemodynamic monitoring. However, patient-specific management strategies should be discussed with the heart team preoperatively. Symptomatic patients with severe VHD or those undergoing high-risk NCS should ideally be treated at a high-volume medical centre that is equipped to manage haemodynamically complex patients during the perioperative period.
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Affiliation(s)
- Regina Sorrentino
- Department of Advanced Biomedical Science, Federico II University Hospital, Napoli, Italy.,Centro Cardiologico Gentile, Napoli, Campania, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Science, Federico II University Hospital, Napoli, Italy
| | - Luca Bardi
- Department of Advanced Biomedical Science, Federico II University Hospital, Napoli, Italy
| | - Vera Rigolin
- Medicine/Cardiology, Northwestern University, Chicago, Illinois, USA
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Ferré F, Viarnes M, Martin C, Bosch L, Bouisset F, Lhermusier T, Reina N, Lairez O, Minville V. Is preoperative balloon aortic valvuloplasty of interest for severe aortic stenosis in hip fracture surgery? Injury 2021; 52:1438-1444. [PMID: 32998825 DOI: 10.1016/j.injury.2020.09.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/16/2020] [Accepted: 09/22/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE In elderly patients, the discovery and management of a severe aortic stenosis (AS) prior to emergency non-cardiac surgery is a frequent and controversial issue. The objective of this study was to evaluate preoperative balloon aortic valvuloplasty (BAV) for severe AS in hip fracture surgery. METHODS We conducted an observational, monocentric, retrospective study from 2011 to 2018. Survival (30-day, 90-day and 180-day mortality) and the occurrence of perioperative complications were analyzed and compared between control (i.e. no BAV prior to surgery) and preoperative BAV groups in patients with hip fracture surgery and a formal transthoracic echocardiographic diagnosis of severe AS (aortic valve area < 1 cm²). Patients' allocation to the intervention and control groups was after a discussion between cardiologist, anesthesiologist and the surgeon. RESULTS Among the 8506 patients who underwent hip fracture surgery, 29 patients in the control group and 30 patients in the BAV group were finally included. Kaplan-Meier survival analysis demonstrated a significant decrease in mortality in the BAV group (p=0.014) despite an increase in median time to operation of about 48 hours (p<0.0001). Multivariate analysis (stepwise logistic regression) showed that postoperative delirium (OR [95%CI]: 17.5 [1.8-168]; p=0.013) and postoperative acute congestive heart failure (OR [95%CI]: 59.4 [5.0-711.1]; p=0.0013) were predictive factors of 30-day mortality with an area under ROC curve of 0.90 (95%CI: 0.80-0.97; p<0.0001). CONCLUSIONS preoperative BAV for severe AS could reduce the mortality of hip fracture patients despite an increase in time to operation. This improved survival could be linked to the decrease in cardiologic and neurologic adverse events. A larger prospective randomized study is necessary before generalizing our results.
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Affiliation(s)
- Fabrice Ferré
- Centre Hospitalier Universitaire de Toulouse Purpan, Place du Dr Baylac, TSA 40 031, 31059 Toulouse, France
| | - Morgane Viarnes
- Centre Hospitalier Universitaire de Toulouse Purpan, Place du Dr Baylac, TSA 40 031, 31059 Toulouse, France
| | - Charlotte Martin
- Centre Hospitalier Universitaire de Toulouse Purpan, Place du Dr Baylac, TSA 40 031, 31059 Toulouse, France
| | - Laetitia Bosch
- Centre Hospitalier Universitaire de Toulouse Purpan, Place du Dr Baylac, TSA 40 031, 31059 Toulouse, France
| | - Frédéric Bouisset
- Cardiologie, Pôle cardiovasculaire et métabolique, CHU Rangueil, Toulouse, France
| | - Thibault Lhermusier
- Cardiologie, Pôle cardiovasculaire et métabolique, CHU Rangueil, Toulouse, France
| | - Nicolas Reina
- Département de chirurgie Orthopédique et Traumatologique, Hôpital Pierre-Paul Riquet, CHU Purpan, Toulouse, France
| | - Olivier Lairez
- Cardiologie, Pôle cardiovasculaire et métabolique, CHU Rangueil, Toulouse, France
| | - Vincent Minville
- Centre Hospitalier Universitaire de Toulouse Purpan, Place du Dr Baylac, TSA 40 031, 31059 Toulouse, France.
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72-e227. [PMID: 33332150 DOI: 10.1161/cir.0000000000000923] [Citation(s) in RCA: 527] [Impact Index Per Article: 175.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 721] [Impact Index Per Article: 240.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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The effect of multiple-inflation balloon aortic valvuloplasty. Heart Vessels 2020; 35:1557-1562. [PMID: 32474647 DOI: 10.1007/s00380-020-01626-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 05/15/2020] [Indexed: 10/24/2022]
Abstract
Recent improvements of balloon aortic valvuloplasty (BAV) devices and procedures have provided improved outcomes, but it is not clear whether the multiple-inflation BAV technique is effective in patients with symptomatic severe aortic valve stenosis (AS). We conducted an analysis of the impact of multiple-inflation BAV (at least 6 times inflation) on the mean aortic valve area (AVA) and mean aortic valve pressure gradient (AV-PG) in patients with symptomatic severe aortic stenosis as compared with conventional BAV (from single to three times inflation). We identified two studies of multiple-inflation BAV with antegrade approach using Inoue-balloon catheter (425 patients) and four studies of conventional BAV (170 patients) with retrograde approach. Using a random intercept model, we found that multiple-inflation BAV significantly increased mean AVA (mean difference (MD) [95% indicates confidence interval (CI)] = 0.25 [0.16-0.34], P < 0.001) and significantly decreased mean AV-PG (MD [95% CI] = - 20.2 [- 27.8, - 12.70], P < 0.001) as compared with the conventional BAV. Furthermore, despite an extremely high Society of Thoracic Surgeons (STS) score (9.2-14.5), the all-cause mortality rate at one year of multiple-inflation BAV was 16-17%. The results of our analyses indicate that the multiple-inflation BAV technique seem to be effective for patients with symptomatic severe AS as compared with conventional BAV.
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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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Kennon S, Archbold A. Expert Opinion: Guidelines for the Management of Patients with Aortic Stenosis Undergoing Non-cardiac Surgery: Out of Date and Overly Prescriptive. Interv Cardiol 2017; 12:133-136. [PMID: 29588742 DOI: 10.15420/icr.2017:20:2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Patients with severe aortic stenosis who require non-cardiac surgery present a difficult clinical problem. The most recent clinical practice guidelines from the American College of Cardiology/American Heart Association and the European Society of Cardiology for the perioperative cardiovascular assessment and management of patients undergoing noncardiac surgery were both published in 2014. These guidelines are reviewed in the light of recently published randomised controlled trial data regarding the efficacy of transcatheter aortic valve implantation to treat aortic stenosis.
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Affiliation(s)
- Simon Kennon
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
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