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To determine the incidence of perioperative events in patients with aortic stenosis undergoing noncardiac surgery.
We studied 108 patients with moderate (mean gradient, 25 to 49 mm Hg) or severe (mean gradient, > or =50 mm Hg) aortic stenosis and 216 controls who underwent noncardiac surgery between 1991 and 2000 at Erasmus Medical Center. Controls...
Citations
... Most of the recent literature in cases of moderate-to-severe AS with high risk of major adverse cardiac events are limited to patients with laparotomies and orthopedic surgeries. [1][2][3] A 65-year-old female patient, a known case of severe AS (previous echocardiography showed aortic valve area of 0.8 cm 2 , mean gradient of 83 mmHg and peak trans-aortic valve gradient of 123 mmHg), was admitted for an aortic valve replacement. However, she sustained a fall in the same hospital admission for which she required an emergent evacuation of subdural hemorrhage (SDH)[ Figure 1a]. ...
... Surgery is the principal treatment approach for hip fractures [11]. However, the presence of concurrent AS can increase the risk of perioperative major cardiovascular events and mortality [12][13][14]. Existing literature on the outcomes of patients with AS undergoing hip fracture surgery has produced inconsistent findings. In a retrospective study by Adunsky et al [15] on elderly patients with mean age of 86 years, AS was associated with high inhospital postoperative mortality and major complications. ...
Background
Hip fractures frequently necessitate hospitalization, especially among patients aged 75 and above who might concurrently suffer from aortic stenosis (AS). This study focuses on postoperative outcomes, potential determinants of morbidity and mortality, as well as evolving trends in patients with AS undergoing surgical repair of hip fractures.
Methods
A retrospective analysis of the Nationwide Inpatient Sample from 2008 to 2019 was conducted. Hip fracture cases were identified, and a subgroup with AS was isolated using the ICD-9 and ICD-10 diagnostic codes. We compared baseline characteristics, postoperative in-hospital outcomes and trends in mortality and morbidity between patients with and without AS.
Results
From the dataset, 2,834,919 patients with hip fracture were identified on weighted analysis. Of these, 94,270 (3.3%) were found to have concurrent AS. The AS cohort was characterized by higher mean age and elevated burden of cardiovascular comorbidities, such as coronary artery disease, peripheral vascular disease, pulmonary hypertension, congestive heart failure and cardiac arrhythmias. Postoperative mortality following hip fracture surgery was greater in the AS groups compared to non-AS group (3.3% vs 1.57%, p < 0.001). Risk factors such as congestive heart failure (OR, 2.3[CI, 2.1–2.6]), age above 85 years (OR, 3.2[CI, 2.2–4.7]), cardiac arrhythmias (OR, 2.4[CI, 2.2–2.6]), end-stage renal disease (OR, 3.4[CI, 2.7–4.1]), malnutrition (OR, 2.3[CI, 2.1–2.7]) and AS (OR, 1.2[CI, 1.08–1.5] were associated with increased adjusted odds of postoperative mortality. AS was linked to higher adjusted odds of postoperative mortality (OR, 1.2 [CI, 1.1–1.5]) and complications such as acute myocardial infarction (OR, 1.2 [CI, 1.01–1.4]), cardiogenic shock (OR, 2.0[CI, 1.4–2.9]) and acute renal failure (OR, 1.1[CI, 1.02–1.2]). While hospital stay duration was comparable in both groups (average 5 days), the AS group incurred higher costs (mean $50,673 vs $44,607). The presence of acute heart failure in patients with AS and hip fracture significantly increased mortality, hospital stay, and cost. A notable decline in postoperative in-hospital mortality was observed in both groups from 2008–2019 though the rate of major in-hospital complications rose.
Conclusion
AS significantly influences postoperative in-hospital mortality and complication rates in hip fracture patients. While a reduction in postoperative mortality was observed in both AS and non-AS cohorts, the incidence of major in-hospital complications increased across both groups.
... Surgery is the principal treatment approach for hip fractures (11). However, the presence of concurrent AS can increase the risk of perioperative major cardiovascular events and mortality (12) , (13,14). Existing literature on the outcomes of patients with AS undergoing hip fracture surgery has produced inconsistent ndings. ...
Background:
Hip fractures frequently necessitate hospitalization, especially among patients aged 75 and above who might concurrently suffer from aortic stenosis (AS). This study focuses on postoperative outcomes, potential determinants of morbidity and mortality, as well as evolving trends in patients with AS undergoing surgical repair of hip fractures.
Methods:
A retrospective analysis of the nationwide inpatient sample from 2008 to 2019 was conducted. Hip fracture cases were identified, and a subgroup with AS was isolated using the ICD-9 and ICD-10 diagnostic codes. We compared baseline characteristics, postoperative in-hospital outcomes and trends in mortality and morbidity between patients with and without AS.
Results:
From the dataset, 2,834,919 patients with hip fracture were identified on weighted analysis. Of these, 94,270 (3.3%) were found to have concurrent AS. The AS cohort was characterized by higher mean age and elevated burden of cardiovascular comorbidities, such as coronary artery disease, peripheral vascular disease, pulmonary hypertension, congestive heart failure and cardiac arrhythmias. Postoperative mortality following hip fracture surgery was greater in the AS groups compared to non-AS group (3.3% vs 1.57%, p < 0.001). Risk factors such as congestive heart failure (OR, 2.3[CI, 2.1–2.6]), age above 85 years (OR, 3.2[CI, 2.2–4.7]), cardiac arrhythmias (OR, 2.4[CI, 2.2–2.6]), end-stage renal disease (OR, 3.4[CI, 2.7–4.1]), malnutrition (OR, 2.3[CI, 2.1–2.7]) and AS (OR, 1.2[CI, 1.08–1.5] were associated with increased adjusted odds of postoperative mortality. AS was linked to higher adjusted odds of postoperative mortality (OR, 1.2 [CI, 1.1–1.5]) and complications such as acute myocardial infarction (OR, 1.2 [CI, 1.01–1.4]), cardiogenic shock (OR, 2.0[CI, 1.4–2.9]) and acute renal failure (OR, 1.1[CI, 1.02–1.2]). While hospital stay duration was comparable in both groups (average 5 days), the AS group incurred higher costs (mean $50,673 vs $44,607). The presence of acute heart failure in patients with AS and hip fracture significantly increased mortality, hospital stay, and cost. A notable decline in postoperative in-hospital mortality was observed in both groups from 2008–2019 though the rate of major in-hospital complications rose.
Conclusion:
AS significantly influences postoperative in-hospital mortality and complication rates in hip fracture patients. While a reduction in postoperative mortality was observed in both AS and non-AS cohorts, the incidence of major in-hospital complications increased across both groups.
... 12,13 AS has long been associated with worse perioperative outcomes [14][15][16] and increased perioperative mortality. 14,17,18 As a result, the American Heart Association/American College of Cardiology treatment guidelines recommend postponing surgery, particularly noncardiac surgery, until after treatment of AS with SAVR or TAVR. [19][20][21] The combination of the high frequency of procedures, increased prevalence of AS, and recommendations for preoperative treatment of AS makes understanding the incidence and outcomes of subsequent procedures in patients with prior TAVR critical. ...
... AS has long been associated with worse perioperative outcomes after noncardiac surgery, [14][15][16] with up to a 10-fold increase in perioperative mortality compared with patients without AS. 14,17,18 However, with advancements in techniques, valve durability, and expanded eligibility criteria, severe AS no longer precludes noncardiac surgery but merely postpones it until after management via SAVR or TAVR. 8,[19][20][21]24,25 Our results suggest that by correcting a patient's AS through TAVR, these patients can withstand subsequent procedures at a similar rate as the group without procedures, thus solidifying the importance of addressing AS before subsequent procedures in those with an indication for TAVR. ...
Objective
With expanding eligibility criteria, transcatheter aortic valve replacement is being performed on patients with longer life expectancy, and subsequent procedures after index transcatheter aortic valve replacement are inevitable. This study examines the incidence and outcomes of patients undergoing subsequent procedural readmissions after transcatheter aortic valve replacement.
Methods
All patients who underwent index transcatheter aortic valve replacement and were discharged alive from January 2012 to December 2019 at a single institution were evaluated. Study end points were mortality and readmission for procedure with more than 1-day hospital stay. Effect on survival was evaluated by treating procedural readmission as a time-dependent variable by Cox proportional hazard model and competing risk analysis.
Results
A total of 1092 patients met inclusion criteria with a median follow-up time of 34 months. A total of 218 patients (20.0%) had 244 subsequent procedural readmissions. During the 244 procedural readmissions, there were 260 procedures; 96 (36.9%) were cardiac (most commonly pacemaker implantation, percutaneous coronary interventions, and surgical aortic valve replacements), and 164 (63.1%) were noncardiac (most commonly orthopedic and gastrointestinal procedures). The overall procedural readmission rates were 32%, 39%, and 42%, and all-cause mortality was 27%, 44%, and 54% at 20, 40, and 60 months, respectively. Procedural readmissions were not associated with a survival penalty in any surgical risk group or on Cox regression (hazard ratio, 1.25; 0.91-1.64, P = .17).
Conclusions
After transcatheter aortic valve replacement, procedural interventions are seen frequently, with most procedures occurring within the first year after transcatheter aortic valve replacement. However, subsequent procedural readmissions do not appear to have a survival penalty for patients after transcatheter aortic valve replacement. After transcatheter aortic valve replacement with resolution of aortic stenosis, subsequent procedures can and should be pursued if they are needed.
... AS patients routinely drop their arterial blood pressure after induction of general anesthesia and have higher rates of hypotension compared to normal subjects. [19] Prior studies of grading discrepancies between pre-CPB and preoperative TTE failed to rigorously take this into account. [10][11][12] Thus, blood pressure correction was a reasonable target to eliminate discrepancies between the two imaging modalities. ...
Background
Aortic stenosis (AS) grading discrepancies exist between pre-cardiopulmonary (pre-CPB) transesophageal echocardiography (TEE) and preoperative transthoracic echocardiography (TTE). Prior studies have not systematically controlled blood pressure.
Aims
We hypothesized that normalizing arterial blood pressure during pre-CPB TEE for patients undergoing valve replacement for AS would result in equivalent grading measurements when compared to TTE.
Setting
Single University Hospital
Design
Prospective, Interventional
Methods
Thirty-five adult patients underwent procedures for valvular AS between February 2017 and December 2020 at Medical University of South Carolina. Study participants had a TTE within 90 days of their procedure that documented blood pressure, peak velocity (Vp), mean gradient (PGm), aortic valve area (AVA), and dimensionless index (DI). During pre-CPB TEE, if a patient’s mean arterial pressure (MAP) fell more than 20% below their baseline blood pressure obtained during TTE, measurements were recorded as “out of range.” Phenylephrine was administered to restore MAP to the baseline range and repeat TEE measurements were recorded as “in-range.”
Statistical Analysis
Differences between imaging modalities and grading parameters were examined using a series of linear mixed models. P values were Bonferroni-adjusted to account for multiple comparisons.
Main Results
Significant discrepancies between TEE and TTE were observed for Vp, PGm, and DI despite blood pressure normalization across all subjects and for out-of-range measures and corrected measures. There were no statistically significant differences between TEE and TTE for AVA.
Conclusions
Blood pressure normalization during pre-CPB TEE is not sufficient to avoid AS grading discrepancies with preoperative TTE.
... The prevalence of valvular heart disease in patients with ESLD is currently unknown and there is a paucity of literature and guidelines about management of structural heart disease in LT candidates [100]. The presence of valvular diseases such as severe aortic stenosis can pose a prohibitive risk to live transplant due to an increased risk of intraoperative complications and a risk of perioperative mortality greater than 30% [101,102]. Similarly, the hemodynamics of ESLD can preclude candidacy for valve surgery making these patients extremely high-risk for both procedures [101]. Additionally, the severity of aortic stenosis has been found to correspond with perioperative mortality in patients undergoing noncardiac surgery [102]. ...
... The presence of valvular diseases such as severe aortic stenosis can pose a prohibitive risk to live transplant due to an increased risk of intraoperative complications and a risk of perioperative mortality greater than 30% [101,102]. Similarly, the hemodynamics of ESLD can preclude candidacy for valve surgery making these patients extremely high-risk for both procedures [101]. Additionally, the severity of aortic stenosis has been found to correspond with perioperative mortality in patients undergoing noncardiac surgery [102]. ...
... Additionally, the severity of aortic stenosis has been found to correspond with perioperative mortality in patients undergoing noncardiac surgery [102]. Additionally, patients with uncorrected severe aortic stenosis undergoing LT have been found to have a higher rate of cardiac complications, including cardiac death, myocardial infarction, and requirement of aortic valve replacement in the post-transplant period compared to patients without valvular disease [101,103]. As per the AHA/ACC 2014 guidelines, elevated-risk elective noncardiac surgery is reasonable to perform in patients with either severe asymptomatic aortic stenosis, mitral regurgitation, or severe asymptomatic aortic regurgitation with normal LVEF [104]. ...
Cardiovascular diseases (CVD) form a principal consideration in patients with end-stage liver disease (ESLD) undergoing evaluation for liver transplant (LT) with prognostic implications in the peri- and post-transplant periods. As the predominant etiology of ESLD continues to evolve, addressing CVD in these patients has become increasingly relevant. Likewise, as the number of LTs increase by the year, the proportion of older adults on the waiting list with competing comorbidities increase, and the demographics of LT candidates evolve with parallel increases in their CVD risk profiles. The primary goal of cardiac risk assessment is to preemptively reduce the risk of cardiovascular morbidity and mortality that may arise from hemodynamic stress in the peri- and post-transplant periods. The complex hemodynamics shared by ESLD patients in the pre-transplant period with adverse cardiovascular events occurring in only some of these recipients continue to challenge currently available guidelines and their uniform applicability. This review focusses on cardiac assessment of LT candidates in a stepwise manner with special emphasis on preoperative patient optimization. We hope that this will reinforce the importance of cardiovascular optimization prior to LT, prevent futile LT in those with advanced CVD beyond the stage of optimization, and thereby use the finite resources prudently.
... The prevalence of VHD is 2.5% in industrialized countries. The risk of perioperative outcomes is increased with associated aortic stenosis [1], cardiac failure, and arrhythmias. Thorough knowledge of pathophysiology, preoperative optimization, and monitoring can give a favorable clinical outcome [2]. ...
... Severe aortic stenosis (AS) is a significant risk factor for perioperative mortality and morbidity in noncardiac surgery [1][2][3][4]. Indeed, according to the 2014 American College of Cardiology/ American Heart Association (ACC/AHA) guidelines on the management of valvular heart disease in patients with moderate to severe AS, the 30-day mortality is higher for patients with AS (2.1%) than for propensity score-matched controls (1%) because of the higher risk of postoperative myocardial infarction [5]. ...
Background
Severe aortic stenosis (AS) is increasing in the aging society and is a serious condition for anesthetic management. However, approximately one-third of patients with severe AS are asymptomatic. Echocardiography is the most reliable method to detect AS, but it takes time and is costly.
Methods
Data were obtained retrospectively from patients who underwent surgery and preoperative transthoracic echocardiography (TTE). LVH on ECG was determined by voltage criteria (Sv1 + Rv5 or 6 ≥3.5 mV) and/or the strain pattern in V5 and V6. Severe AS was defined as a mean transaortic pressure gradient ≥40 mmHg or aortic valve area ≤1.0 cm² by TTE.
Results
Data for 470 patients aged 28–94 years old were obtained. One hundred and twenty-six patients had severe AS. LVH on ECG by voltage criteria alone was detected in 182 patients, LVH by strain pattern alone was detected in 80 patients and LVH by both was detected in 55 patients. Multivariable logistic analysis revealed that LVH by the strain pattern or voltage criteria, diabetes mellitus, and age were significantly associated with severe AS. The AUC for the ROC curve for LVH by voltage criteria alone was 0.675 and the cut-off value was 3.84 mm V, and the AUC for the ROC for age was 0.675 and the cut-off value was 74 years old.
Conclusion
Our study suggests that patients who are 74 years old or over with LVH on ECG, especially those with DM, should undergo preoperative TTE in order to detect severe AS.
... Preexisting aortic stenosis (AS) is a high risk factor for non-cardiac surgery [1,2]. Guidelines from the American College of Cardiology and the American Heart Association (ACC/AHA) recommend aortic valve replacement (AVR) before non-cardiac surgery [3]. ...
Objectives:
The purpose of this study was to clarify the influence of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis (AS) undergoing non-cardiac surgery.
Methods:
Thirty-four patients with severe AS diagnosed by preoperative evaluation for non-cardiac surgery were reviewed and compared in two categories. First, patient profiles and surgical risk were compared before (pre-TAVR group; n = 10) and after (post-TAVR group; n = 24) the introduction of TAVR. Second, the completion rate of non-cardiac surgery and interval between the two cardiac and non-cardiac operations were compared between surgical aortic valve replacement (AVR) patients before the introduction of TAVR (pre-AVR group (n = 10)), in AVR patients after the introduction of TAVR (post-AVR (n = 12)), and in TAVR patients (TAVR group (n = 12)).
Results:
Age and Japan score were higher in the post-TAVR group than in the pre-TAVR group. Malignancy was the most common non-cardiac disease (80%) in the pre-TAVR group, whereas orthopedic disease was the most common (50%) in the post-TAVR group. Completion rate of non-cardiac operation in the pre-AVR, post-AVR and TAVR groups was 70, 33, and 75% (post-AVR vs. TAVR: p = 0.010), and the interval between the two operations was 129 ± 98 days, 87 ± 40 days and 27 ± 15 days, respectively (pre AVR vs. TAVR: p = 0.034 and post AVR vs. TAVR: p = 0.025). In the post-TAVR group, AVR was selected because of a lack of fitness for TAVR in 5 of 12 patients.
Conclusions:
After the introduction of TAVR, more senile and high-risk patients became candidates for a two-stage operation, and orthopedic conditions became the most common non-cardiac disease. Innovation in transcatheter valvular interventions and expansion of indications for patients currently evaluated as "unfit for TAVR" might be crucial issues for non-cardiac surgery with severe AS.
... Preexisting aortic stenosis (AS) is a high risk for non-cardiac surgery [1,2]. Guidelines from the American College of Cardiology and the American Heart Association (ACC/AHA) have recommended aortic valve replacement (AVR) before non-cardiac surgery [3]. However, elder patients, especially with numerous comorbid conditions or frail patients, tend to refuse two successive major operations. ...
Objectives: The purpose of this study was to clarify the influence of introduction of transcatheter aortic valve replacement (TAVR)on patients with aortic stenosis(AS) undergoing non-cardiac surgery.
Methods: Thirty-four patients with severe AS diagnosed by preoperative evaluation for non-cardiac surgery were reviewed and compared in following two categories. First,patient’s profile and surgical risk were compared between pre-TAVR group (n=10) and post-TAVR group (n=24)according to before or after the introduction of TAVR. Second, completion rate of non-cardiac surgery and interval between two operation were compared between surgical aortic valve replacement(AVR)patients before introduction of TAVR (pre-AVR group (n=10)), AVR patientsafter introduction of TAVR (post-AVR (n=12)), and TAVR patients (TAVR group (n=12)).
Results: Ageand Japan score were higherin post-TAVR group than in pre-TAVR group. Malignancy was the most common non-cardiac disease (80%) in pre-TAVR group, however, orthopedic disease became the most common (50%) in post-TAVR group. Completion rate of non-cardiac operation in pre-AVR, post-AVR and TAVR group were 70%, 33%, and 75% (post-AVR vs. TAVR: p=0.010), and interval between two operations were 129±98 days, 87±40 days and 27±15 days, respectively (pre AVR vs. TAVR: p=0.034 and post AVR vs. TAVR: p=0.025).In Post-TAVR group, AVR was selected because of unfit condition for TAVR in 5 out of 12 patients.
Conclusions:After introduction of TAVR, more senile and high-risk patients became the candidate for two staged operation and orthopedics became the most common non-cardiac disease. Innovation of transcatheter valvular interventionsand expansion of indication for currently evaluated as “unfit for TAVR” might be crucial issue for non-cardiac surgery with severe AS.
