Preoperative Consultation

You are asked to provide preoperative assessment and recommendations for a 94 year old frail woman who fell in her bathroom fracturing her hip in multiple places. She was living independently. There is no history of chest pain, palpitations, lightheadedness, or loss of consciousness. She otherwise has no significant past medical history except for hypertension. She takes a diuretic. You were consulted to provide 'cardiac clearance' because she requires extensive surgery under general anesthesia to repair her broken hip.

Her examination is remarkable for marked delay in her carotid upstroke with decreased pulse volume. The first heart sound is normal and a fourth sound is also present. The second heart sound is difficult to hear and is inaudible by the time your stethoscope reaches the 5th intercostal space. A late peaking, harsh III/VI murmur radiates through the aortic area into the neck.

Her ECG shows LVH and left anterior hemiblock. No pathologic Q waves or ischemic changes are present. Her labs are as expected for a 94 year old. The orthopedic surgeon has an opening in the OR in 3 hours and wants to know if he can proceed with surgery. What do you do?

You suspect that your patient has severe to critical Aortic Stenosis based on your exam findings. She does not have any apparent symptoms suggestive of this valve abnormality but you are concerned about her perioperative risks given the fact that she needs major surgery to repair her hip. You decide to order an echocardiogram.

2D echocardiography shows left ventricular hypertrophy with preserved left ventricular function. No wall motion changes are seen. There is extensive calcification of the mitral annulus and aortic valve. The aortic valve is fixed and immobile. Doppler echocardiography confirms critical Aortic Stenosis. The mean trans-aortic valve pressure gradient is 80 mmHg with an estimated valve area of < 0.5 cm2. Moderate pulmonary hypertension in present.

What do you do now?

The patient is 'not afraid to die' but is terrified of having a major stroke or becoming a burden to her family.

After discussion with the patient, her family, the orthopedic surgeon, and a consulting cardiac surgeon, you cancel surgery and perform balloon aortic valvuloplasty . You explain to the patient that this is not a curative procedure but that it has the potential to lessen her risk of serious cardiac complications from general anesthesia and major orthopedic surgery. You achieve a decrease in the mean Aortic valve pressure gradient from 80 to 40 mmHg with a corresponding increase in cardiac output and Aortic Valve area from 0.45cm2 to 0.8 cm2. Realizing that despite a successful valvuloplasty, patients still have severe-critical aortic stenosis, a Swan-Ganz catheter is used perioperatively to monitor filling pressures. The patient has uncomplicated orthopedic surgery and an uneventful convalescence and is discharged to short term rehab. Several weeks later, she moves in with her family and continues her convalescence without cardiac limitations. She is not interested in having curative aortic valve surgery and remains free of angina, heart failure, and syncope.