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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