Aortic stenosis and indication

for non-cardiac surgery

Jean-Pol Depoix, MDAnaesthesiology DepartmentBernard Iung, MDCardiology DepartmentBichat Hospital, Paris, France

Case History

• 84 year-old woman

• Treated hypertension, prior thyroidectomy.

• Known cardiac murmur

• Preserved autonomy and activity. Asymptomatic

• Recent diagnosis of an adenocarcinoma of left colon

without other malignant location, indication of left

colectomy

• Referred before surgery because of cardiac murmur

• Mid-systolic murmur 3/6, decreased S2

• No signs of congestive heart failure

• Blood pressure 154/60 mmHg

Chest X-ray and ECG

Echocardiography: parasternal views

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Echocardiography: apical views

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Mean gradient 42 mmHg LV 51/37 mm, SF 30%V. Max 4.1 m/sec.

Valve area :0.9 cm² (0.56 cm²/m² BSA)

Coronary angiography

Summary of case analysis

• Severe aortic stenosisConsistency between:− Aortic valve area < 1.0 cm² and < 0.6 cm²/ m² BSA− Maximum jet velocity ≥ 4 m/sec− Mean gradient ≥ 40 mmHg

• Hypertrophied left ventricle with preserved ejection fraction

• No other cardiac disease

• Asymptomatic

What do you advise?

1. Contra-indicate colectomy

2. Perform colectomy with primary anastomosis, without treatment of aortic stenosis

3. Consider less invasive surgery: resection + colostomy (Hartmann procedure)

4. Perform balloon aortic valvuloplasty before colectomy

5. Perform TAVI before colectomy

What do you advise?

1. Contra-indicate colectomy

2. Perform colectomy with primary anatomosis, without treatment of aortic stenosis

3. Consider less invasive surgery: resection + colostomy (Hartmann procedure)

4. Perform balloon aortic valvuloplasty before colectomy

5. Perform TAVI before colectomy

Rationale for therapeutic decision

• Abdominal surgery is required since it is the only curative treatment of colic cancer

• Less invasive intervention limits haemodynamic stress but impairs quality of life (Hartmann procedure was the first option of the referring team)

• Risk assessment should take into account:− The risk of abdominal surgery− The risk of cardiac complications due to aortic stenosis− The risk and consequences of treating aortic stenosis before

abdominal surgery

30-day cardiac death and myocardial infarction

Evaluation of the risk of non-cardiac surgery

30-day rates of cardiac death and myocardial infarction

Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J 2009;30:2769-812.

Therapeutic options for aortic stenosis

• Low risk of complications of intermediate risk non-cardiac surgery No death or myocardial infarction in a series of 30 asymptomatic patients with severe aortic stenosis undergoing non cardiac surgery (>75% at intermediate-risk)(Calleja et al. Am J Cardiol 2010;105:1159-63)

• Treatment of AS before non-cardiac surgery is considered only in symptomatic patients or for high-risk surgery

Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012;33:2451-496.

Therapeutic options for aortic stenosis

• Risk of aortic valve replacement− Euroscore I: 10.1%− Euroscore II: 1.7%

• The only reason to favour TAVI over surgical aortic valve replacement would be more rapid recovery.

Take into account the risk of TAVI and the need for antiplatelet drugs.

• Balloon aortic valvuloplasty may be considered in patients with symptomatic severe AS who require urgent major non-cardiac surgery (IIbC)

No indication in this case

Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012;33:2451-496.

www.escardio.org/guidelines

Management of severe aortic stenosis and elective non-cardiacsurgery according to patient characteristics and the type of surgery

Non-cardiacsurgery

under strictmonitoring

Severe AS and need for elective non-cardiac surgery

No Yes

Low-moderate High

Patient risk for AVR Patient risk for AVR

High Low Low High

Non-cardiacsurgery

AVR beforenon-cardiac

surgery

Non-cardiac surgeryunder strict monigoring

Consider BAV/TAVI

Symptoms

Risk of non-cardiac surgery

European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 -

doi:10.1093/ejcts/ezs455).

Therapeutic decision

• Multidisciplinary meeting (anaesthesiologist, cardiologist, surgeon)

• Decision of left colectomy with primary anastomosis without prior treatment of aortic stenosis

• Direct contact with the anaesthesiologist in charge of the patient

• Specificities of anesthesia• Choice of anaesthetic drugs• Cardiac monitoring• Post-operative care

Outcome

• Left colectomy with primary anastomosis– Invasive arterial blood pressure monitoring using a

radial catheter– Anaesthesia: hypnomidate, atracrium, desflurane and

remifentanil (short action opioid)

• Stable haemodynamic during anaesthesia

• Extubation at the end of abdominal surgery

• Uneventful post-operative course

• Patient discharged at home. She remains asymptomatic

Take-Home messages

• Aortic stenosis should be carefully evaluated in elderly patients needing non-cardiac surgery because of the risk of cardiac complications

• In severe AS, risk stratification should take into account:

− Symptoms− Indication for non-cardiac surgery (vital vs. functional)− The risk of cardiac complications according to the type of surgery− The risks inherent to the treatment of AS

• Intermediate and low-risk surgery can be performed safely in asymptomatic patients, provided appropriate anaesthetic management is planned

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