How is aortic stenosis (AS) managed in noncardiac surgery patients?

Updated: Jul 16, 2021
  • Author: Lindsay A (Finger) Raleigh, MD; Chief Editor: Sheela Pai Cole, MD  more...
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Answer

Answer

Key action points in the management of aortic stenosis (AS) in noncardiac surgery patients include the following:

  • AS results in changes to the left ventricular (LV) myocardium (eg, hypertrophy, reduced compliance, and increased end-diastolic pressures), and these changes make the patient more sensitive to increases in myocardial oxygen demand and decreases in systemic vascular resistance (SVR), coronary perfusion pressure (CPP), or preload; in severe AS, the LV cannot increase cardiac output by increasing stroke volume
  • Patients with AS are at risk for increased complications after noncardiac surgery, including hypotension, myocardial ischemia or infarction, arrhythmias, heart failure, stroke, and death
  • Proper triaging of AS patients for noncardiac surgery depends on identifying the urgency and risk of surgery, the degree of stenosis, the presence of symptoms related to valve pathology, the systolic function of the LV, and the presence of other valvular lesions
  • Maintaining CPP, sinus rhythm, and adequate preload is important for anesthetic management of AS patients
  • Appropriate hemodynamic monitoring for AS patients includes continuous arterial blood pressure (BP) monitoring and American Society of Anesthesiologists (ASA) standard monitors, and it may include monitoring with echocardiography or pulmonary artery catheterization (as dictated by the clinical scenario)
  • Phenylephrine is the agent of choice for treatment of hypotension in AS patients; through its effect on alpha receptors, it increases systemic vascular resistance and maintains CPP without increasing chronotropy

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