Aortic Stenosis and Preoperative Evaluation for Noncardiac Surgery

Author: V. Dimov, M.D., Cleveland Clinic

A 83-year-old African American female (AAF) is admitted to the hospital with gallstone pancreatitis. She is evaluated by General Surgery in the ER and they recommend initial conservative management. On hospital day 3, amylase and lipase are trending down, pain has subsided and she is able to tolerate diet. The surgeon recommends laparoscopic cholecystectomy and asks the hospitalist team for preoperative evaluation.

Past medical history (PMH)

Aortic stenosis, hypertension (HTN).

Medications

Atenolol, lisinopril, amlodipine.

Physical examination

Stable vital signs (VSS).
Chest: Clear to auscultation bilaterally (CTA (B)).
CVS: Clear S1S2.
Abdomen: Soft, NT, ND, + BS.
Extremities: no c/c/e.

Laboratory results

Electrocardiogram (EKG): Normal sinus rhythm (NSR) with occasional premature ventricular contractions (PVCs), left atrial enlargement, left ventricular hypertrophy (LVH).

A transthoracic echocardiography (TTE) done 2 years ago: Normal LV size and systolic function with moderate LVH. LVEF~65%. Stage 1 diastolic dysfunction. Normal RV size and function. Mild calcified aortic stenosis based upon gradients. AVA~1.2cm2(continuity), AVA~1.3cm2 (planimetry). Pk/Mn gradients 25/12mmHg. Trivial MR and TR. RVSP~24mmHG. Mild LAE.

What things should be considered in the preoperative evaluation of a patient with aortic stenosis?

1. Cardiovascular risk
2. Endocarditis prophylaxis

We will discuss these consideration below.

1. What is the cardiovascular risk for this patient with aortic stenosis?

Approximately 50 percent of patients aged over 50 years with aortic stenosis also have coronary heart disease. Our patient has a good exercise tolerance corresponding to METs of 7. She is on a beta-blocker and has no symptoms of CAD and had a negative nuclear stress 4 years ago.

A peak aortic gradient 40 mmHg on TTE is associated with an increased risk of perioperative cardiac complications. Our patient's peak aortic gradient was 25 mmHg two years ago.

2. Should patients with aortic stenosis receive endocarditis prophylaxis with antibiotics?

No. According the 2007 AHA/ACC guidelines, antimicrobial prophylaxis is no more indicated for the following cardiac conditions:

- bicuspid aortic valve,
- acquired aortic or mitral valve disease (including mitral valve prolapse with regurgitation and those who have undergone prior valve repair)
- hypertrophic cardiomyopathy

What happened?

The patient had a repeat TTE which did not show significant progression of aortic stenosis. She had perioperative beta-blockers and an uneventful postoperative course.

Final diagnosis

Aortic Stenosis and Preoperative Evaluation for Noncardiac Surgery.

References

Noncardiac surgery in patients with aortic stenosis. UpToDate, 15.1.
Antimicrobial prophylaxis for bacterial endocarditis. UpToDate, 15.1.
Preoperative evaluation - 2010 National Guideline Clearinghouse.

Published: 05/28/2007
Updated: 10/31/2007

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