Download How I manage a patient with aortic valve stenosis scheduled

How I manage a patient with aortic
valve stenosis scheduled for
noncardiac surgery
Jean-Luc Fellahi, M.D., Ph.D.
[email protected]
Service d’Anesthésie-Réanimation, Hôpital Cardiologique Louis Pradel, Lyon, France
UFR de Médecine Lyon Est, Inserm U1060, UCBL1, Lyon, France
French National Congress
SFAR 2016
Mark your calendar !
22 – 24 September 2016
Paris
www.sfar.org
Conflicts of interest
• No conflict of interest to declare
Valvular diseases in Europe countries
Iung B, Eur Heart J 2003;24:1231-1243.
Valvular diseases
Prevalence (%)
Aortic stenosis
43
Mitral regurgitation
32
Aortic regurgitation
13
Mitral stenosis
12
Aortic stenosis is both the most frequent and the most serious
valvular disease in noncardiac surgery
Aortic stenosis: main causes
§ Degenerative disease
§ Calcifications
§ > 65 years old
§ Congenital bicuspid valve
§ < 60 years old
§ Isolated rheumatic disease
§ Aortic sclerosis
Aortic stenosis: a pressure overload
Concentric ventricular hypertrophy
wall stress = pressure x radius / 2 x wall thickness (Laplace’s law)
Diastolic dysfunction
Complexity in preload
management
Myocardial ischemia
Myocardial O2 supply/demand imbalance
Decrease in CPP (DBP – EDLVP)
Associated coronary disease (30-50%)
Relationship between transaortic pressure gradient
and cardiac output
Transaortic pressure gradient
In severe aortic stenosis:
- The gradient can be low in case of low cardiac output
- The increase in cardiac output is limited
Severe AS
Moderate AS
Mild AS
Cardiac output
Aortic stenosis: criteria of severity
Mild
Moderate
Severe
Aortic area > 1.5 cm2
Mean gradient < 25 mmHg
Peak velocity < 3m/s
1 < aortic area < 1.5 cm2
25 < mean gradient < 40 mmHg
3 < peak velocity < 4 m/s
Aortic area < 1 cm2 (0.6 cm2/m2)
Mean gradient > 40 mmHg
Peak velocity > 4 m/s
Aortic stenosis: an independent risk factor in noncardiac surgery
Study population
N = 324
Control group
n = 216
15 (14%)
AS group
n = 108
Moderate
n = 92
Severe
n = 16
4 (2%)
5 (31%)
AS
10 (11%)
Severe Moderate
Control
OR = 5.2 [1.6 – 17.0]
Kertai, Am J Med 2004
Aortic stenosis in noncardiac surgery
§ Cardiac complications: 17.3 %
§ Mortality: 13 %
§ The risk appears correlated to:
§ The degree of aortic stenosis and the presence of symptoms
§ An associated coronary disease
§ The type of noncardiac surgery
Preoperative and perioperative care for patients with suspected or established aortic stenosis facing
noncardiac surgery. Chest 2005
Preoperative evaluation
AS is unknown
AS is known
Discovered by cardiac auscultation
Preoperative TTE
Criteria of severity of AS +++
Associated
coronary disease
Coronarography
AS is symtomatic
Discuss AVR
Preserved
LV function
When operate on ?
ACC/AHA Guidelines: 2008 Focused Update Incorporation. Bonow et al.
AVR in elderly patients
The benefit/risk ratio of AVR
surgery is maintained after
80 years old
Filsoufi et al. Excellent early and late outcomes of aortic valve replacement in people aged 80 and older
J Am Geriatr Soc 2008;56:255-61.
Alternatives to conventional AVR surgery
Percutaneous aortic valve dilatation
§ Absence of calcification
§ Absence of aortic insufficiency
§ Young population
§ Emergency or palliative surgery
§ Pregnancy
§ Urgent noncardiac surgery
§ Decompensated heart failure
§ Efficacy on a short-term basis (6-12 months)
and risky (major complication rate 10%)
§ Stroke
§ Myocardial infarction
§ Aortic insufficiency
ACC/AHA Guidelines: 2008 Focused Update Incorporation. Bonow et al.
Alternatives to conventional AVR surgery
TAVI
§ Biological prosthetic valve
§ Several surgical options (femoral, aortic, carotid)
§ Indicated in end-stage inoperable and high-risk
patients
Transcatheter versus surgical aortic valve replacement in high-risk patients?
Smith and al. NEJM 2011
Transcatheter versus surgical aortic valve replacement in high-risk patients?
Smith and al. NEJM 2011
Principles of decision making
Messika-Zeitoun et al. Ann Cardiol Angeiol 2005;54:112-115.
Non severe AS
Asymptomatic patient
Eliminate an associated
coronary disease (exercise
tests are authorized)
Proceed to noncardiac
surgery
Severe AS
Elective surgery
Heart Team discussion
Consider prior AVR if
-
Symptomatic patient
AVR is expected to
increase life expectancy
The AVR risk is moderate
(EuroSCORE)
Prefer biological prosthesis
Severe AS
Emergency surgery
Consider the noncardiac
surgery-related risk
Proceed to noncardiac
surgery if the risk is low
to moderate
Consider prior aortic
valve dilatation or TAVI if
the risk is high
Anaesthetic management
Objectives
•
•
•
•
•
Avoid both hypotension and hypertension
Avoid tachycardia
Maintain or rapidly restore sinus rhythm
Avoid both hypovolemia and hypervolemia
Avoid myocardial ischemia
The objective is to decrease the incidence of major
adverse cardiac events and death
The choice of anaesthesia
General anaesthesia
Regional anaesthesia
• Avoid midazolam, thiopental
and propofol (except targeted
• Avoid neuraxial anaesthesia
• Prefer etomidate or ketamine
• Prefer peripheral regional or
local anaesthesia without any
hemodynamic consequences
control TIVA)
Major changes in LV preload
and afterload
No large scale RCT available
Intraoperative hemodynamic monitoring
LV hemodynamic
Preload
Afterload
Contractility
Rhythm
Heart rate
Objectives in severe AS
Keep constant (mind the pulmonary edema)
Avoid hypotension
Keep constant
Avoid arrhythmias
Avoid both bradycardia and tachycardia
Invasive continuous arterial blood pressure monitoring is encouraged
TEE, PAC and TPTD can be used at the discretion of the attending physician
Other less-invasive continuous cardiac output monitoring devices (oesophageal
Doppler monitoring, arterial pulse contour analysis, electrical bioimpedance cardiography)
are not validated
Petzoldt M, Reuter DA. J Clin Monit Comput 2015;29:429-30.
Acquired von Willebrand syndrome
- Rapidly disappear following aortic valve replacement
- Is not really associated with an increase in surgical bleeding and transfusion need
Acquired von Willebrand Syndrome in aortic Stenosis. Vincentelli and al. N Engl J Med 2003
Prevention of infectious endocarditis
Restricted indications
Surgery at risk
Dental surgery
Patients at risk
Prosthetic cardiac valves
Previous bacterial endocarditis
Congenital cardiac malformation with cyanosis
Drugs
Amoxicilline 2g oral or IV
Clindamycine 600 mg oral or IV
SFAR 2010
Postoperative management
• In a PACU or in ICU
• Hemodynamic optimization (LV preload,
afterload, contractility, rhythm and heart rate)
• Systematically look for myocardial infarction
(biological monitoring with troponins within 24-48h)
Conclusions
• AS is the most frequent and the most serious
valvular disease in Europe countries
• AS is an independent risk factor for MACE and
mortality in noncardiac surgery
• Both preoperative strategy and anaesthetic
management are challenging
• The decision making process should be
optimized by an operational Heart Team