What is a case example of emergency noncardiac surgery in a patient with severe aortic stenosis (AS)?

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

Answer

A 72-year-old woman with known severe AS and normal LV systolic function presents with a femoral neck fracture after a fall down a flight of stairs at home. She reports occasional shortness of breath and lightheadedness when doing light housework.

Resolution

The surgical treatment this patient requires is an emergency and therefore should proceed. If the patient’s last echocardiogram was more than 1 year ago, preoperative TTE to assess for disease progression or a worsening ejection fraction is reasonable for guiding intraoperative management.

Either general or neuraxial anesthesia can be considered for this case, depending on the comorbid conditions present, the surgical plan, and the patient's preference. If a neuraxial technique is chosen, care should be taken to avoid hypotension, with fluid boluses and administration of phenylephrine to counteract the decrease in SVR caused by the local anesthetics. As in case example 2, a preinduction arterial line should be placed for BP monitoring.

It is also reasonable to perform TTE or TEE during the procedure to provide continuous monitoring or to aid in diagnosis should hemodynamic instability arise. Finally, it is important to discuss the patient’s valvular pathology with the surgical team so that intraoperative hemodynamic goals can be appropriately addressed.


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