Aortic stenosis and indication for non-cardiac surgery

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Aortic stenosis and indication for non-cardiac surgery

  1. 1. Aortic stenosis and indication for non-cardiac surgery Jean-Pol Depoix, MD Anaesthesiology Department Bernard Iung, MD Cardiology Department Bichat Hospital, Paris, France
  2. 2. 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
  3. 3. Chest X-ray and ECG
  4. 4. Echocardiography: parasternal views Watch video Watch video
  5. 5. Echocardiography: apical views Watch video Watch video
  6. 6. Mean gradient 42 mmHg V. Max 4.1 m/sec. Valve area : 0.9 cm² (0.56 cm²/m² BSA) LV 51/37 mm, SF 30%
  7. 7. Coronary angiography
  8. 8. Summary of case analysis • Severe aortic stenosis Consistency between: − Aortic valve area < 1.0 cm² and < 0.6 cm²/ m² BSA − Maximum jet velocity ≥ 4 m/sec − Mean gradient ≥ 40 mmHg • Hypertrophied left ventricle with preserved ejection fraction • No other cardiac disease • Asymptomatic
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. Evaluation of the risk of non-cardiac surgery 30-day cardiac death and myocardial infarction 30-day rates of cardiac death and myocardial infarction Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J 2009;30:2769-812.
  13. 13. Therapeutic options for aortic stenosis • Low risk of complications of intermediate risk noncardiac surgery No death or myocardial infarction in a series of 30 asymptomatic patients with severe aortic stenosis undergoing non cardiac surgery (>75% at intermediate-risk) (Calleja et al. Am J Cardiol 2010;105:1159-63) • Treatment of AS before non-cardiac surgery is considered only in symptomatic patients or for high-risk surgery Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012;33:2451-496.
  14. 14. Therapeutic options for aortic stenosis • Risk of aortic valve replacement − Euroscore I: − Euroscore II: 10.1% 1.7% • The only reason to favour TAVI over surgical aortic valve replacement would be more rapid recovery. Take into account the risk of TAVI and the need for antiplatelet drugs. • Balloon aortic valvuloplasty may be considered in patients with symptomatic severe AS who require urgent major non-cardiac surgery (IIbC)  No indication in this case Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012;33:2451-496.
  15. 15. Management of severe aortic stenosis and elective non-cardiac surgery according to patient characteristics and the type of surgery Severe AS and need for elective non-cardiac surgery Symptoms No Yes Risk of non-cardiac surgery Low-moderate High Patient risk for AVR High Non-cardiac surgery www.escardio.org/guidelines Non-cardiac surgery under strict monitoring Patient risk for AVR Low Low AVR before non-cardiac surgery High Non-cardiac surgery under strict monigoring Consider BAV/TAVI European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery 2012 doi:10.1093/ejcts/ezs455).
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. Join the ESC Working Group on Valvular Heart Disease and take part in its activities ! Membership is FREE!

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