Case Discussion

[Ronin786]

Had this case recently, I'll fill in details as we go along.

72 yr old scheduled for a single level laminectomy. Hx of OSA, HTN and known AS. TTE from two years ago shows moderate AS, AVA of 1.2 and preserved EF. METs are limited by chronic back pain. Able to golf but needs a cart to get around since he can't walk.

Do you proceed with surgery or repeat TTE?

---

Members don't see this ad.

 

[2buckchuck]

Have access to phased array probe and ultrasound to do your own echo? If so, try to figure out LV function and gradient/DI on aortic valve. If not, might just put an art line in pre-op and do the case.

 

[Beeftenderloin]

100% needs new echo. AS can easily progress from moderate to severe in 6 months, let alone 2 years. Not to mention can’t get a gauge on function status because mets are limited by back pain. If it’s now severe he needs a SAVR/TAVR before he gets spine surgery.

This is all assuming it’s elective surgery. If he’s got an acute neuro defecit, cauda equina, etc, treat it like it’s severe and proceed. Pre-induction art line, gentle induction, phenylephrine rolling. Mean up, HR down.

If I was the first to respond I would have said there’s absolutely nothing controversial here even worth discussing, but @2buckchuck has already proved that assumption wrong.

 

[NICMAN]

Yeah, I am certified in basic echocardiography but I would want a cardiologist's read on an official documented TTE or TEE within the past year (preferentially within 6 months) in order to proceed. I would also get the cardiologist to do an examination and assessment. The standard of care is that they should be evaluated at least every 2 years but prior to a moderate risk surgery I think it would be negligence to not get a qualified (by somebody who has advanced echo certification) diagnostic assessment of the current status of his AS.

 

[dannyboy1]

Known AS and no recent echo. This needs a new echo and cardiology blessing.

 

[anbuitachi]

does he want his valve replaced???

 

[Urzuz]

Since we are discussing it I’m sure the case should be cancelled or delayed

But for the sake of getting to the case: as long as this lady hasn’t been passing out and syncopizing left and right, start some phenylephrine pre induction and go. Will take our spine guys 45 minutes once they start

 

[gator2886]

TTE to assess valve area. Case length is a moot point. These patients code on induction if SVR drops too much.

 

[DirtDocMD]

He waited 6 mos for his laminectomy (if it’s like any other lami that required 50 hoops to be jumped through, before “approval”). He can wait another 3-7 days to get an echo, and make sure his valve surface area is not so tight that you kill him with the propofol-induced afterload reduction/lack of coronary perfusion.

PS I’ll take a WAG and say his repeat echo showed a valve surface area of .6......

 

[vector2]

Get a repeat echo. Especially because functional capacity is unknown, so for all you know he has a symptomatic severe valvular lesion which would preclude proceeding with elective surgery per ACC/AHA guidelines.

 

[Radetzky]

I “echo” what everyone else has said

 

[kidthor]

He waited 6 mos for his laminectomy (if it’s like any other lami that required 50 hoops to be jumped through, before “approval”). He can wait another 3-7 days to get an echo, and make sure his valve surface area is not so tight that you kill him with the propofol-induced afterload reduction/lack of coronary perfusion.

PS I’ll take a WAG and say his repeat echo showed a valve surface area of .6......

This situation is a classic "blame anesthesia" for delaying to get a TTE vs proceeding and having a cardiac issue. Lose-lose.

If it was my family member I'd want a repeat TTE before proceeding. If the patient had no symptom changes then maybe it's ok to proceed, but not ideal. Ideally I'd want the same for my patients as I'd want for my family.

The best answer is that the patient would have gone to anesthesia pre-op clinic and they'd have sent him back for a TTE before coming in for surgery. Also the hospital subsidizes the pre-op clinic to facilitate no DOS cancellations and optimized patients with decreased risk. But that would be too logical.

 

[Urzuz]

TTE to assess valve area. Case length is a moot point. These patients code on induction if SVR drops too much.

I think most everyone agrees delaying for an echo is the correct answer. I was playing "devil's advocate" to get to the case.

Regarding the second part of your statement, the difference between a physician and a nurse is you should anticipate problems, not react to them. If you know that the SVR dropping too much during induction is going to kill this person, prevent the SVR from dropping too much during induction!

 

[Ronin786]

1) Surgery is completely elective.

2) For those advocating for a repeat TTE, what is your threshold for proceeding?

As a refresher:

Also, indications for AV replacement:

 

[Hoya11]

1) Surgery is completely elective.

2) For those advocating for a repeat TTE, what is your threshold for proceeding?

As a refresher:
View attachment 358595

Also, indications for AV replacement:
View attachment 358596

This is a non real world discussion because this lady would have cardiac clearance and the cardiologist would decide .. and I would just go with that ..

 

[Beeftenderloin]

1) Surgery is completely elective.

2) For those advocating for a repeat TTE, what is your threshold for proceeding?

As a refresher:
View attachment 358595

Also, indications for AV replacement:
View attachment 358596

It’s gotta be moderate-moderate. Not moderate-severe (ie. All parameter fall under moderate) and within 6 months. Would consider extending that out to a year if patient has >4mets, no decline in functional status over that time frame, and they pass the “eye test”.

 

[Ronin786]

This is a non real world discussion because this lady would have cardiac clearance and the cardiologist would decide .. and I would just go with that ..

Your real world is a lot cleaner than mine. This is a situation I found myself in. Cards consult is a lazy excuse and one that isn’t always available

 

[UscGhost]

Cardiac clearance is indicated since you can't evaluate exercise tolerance.

Anything else would be a risk, if there was a postop MI then it's likely you would be blamed for not following guidelines.

Even just an echo might not be enough alone, as they may want a stress test.

If it's an emergency then proceed and keep svr up and you would be fine. Unlikely that patient would have any issues if they are currently asymptomatic.

The cardiac clearance is primarily for CYA purposes as you already know what the issue is, and the treatment is likely going to be the same either way. I doubt any massively significant change from two years ago if the patient doesn't currently look like ish

 

[vector2]

1) Surgery is completely elective.

2) For those advocating for a repeat TTE, what is your threshold for proceeding?

As a refresher:
View attachment 358595

Also, indications for AV replacement:
View attachment 358596

Hemodynamics are king, and are definitely more relevant than whether the AVA as calculated by continuity (where there is usually a bunch of room for error) is 1.04 cm2 or 0.98 cm2.

I would punt the case if the guy had a mean gradient over ~35 mmHg with normal flow conditions. Now, if you tell me this guy's gradient is 35 mmHg but he's definitely pumping out 10 Mets without any symptoms then maybe it's a different story. But the fact that this guy can't even walk makes it much more likely I'd postpone.

After all, this isn't a cataract we're talking about. The physiologic derangements of getting intubated and flipped prone for a lami are significant.

 

[hiyaman]

I also thought AHA recommends tte surveillance for mod AS like every 2 to 3 years and severe AS every 1 to 2 years? This guy def needs new echo prior to elective surgery with an unknown functional capacity

 

[dchz]

Do you proceed with surgery or repeat TTE?

Why hasn't anyone asked about coronary artery workup?

I would be comfortable continuing if coronaries are normal, granted that pt and surgeon are ok with the increased risk. Will document the consent clearly. Repeating the TTE does not change my management if the pt/surgeon chooses to proceed.

My oral board answer is to repeat TTE and continue if EF is normal and gradient is less than 35. Otherwise any risk is unacceptable for a completely elective surgery.

 

[Ronin786]

Why hasn't anyone asked about coronary artery workup?

I would be comfortable continuing if coronaries are normal, granted that pt and surgeon are ok with the increased risk. Will document the consent clearly.

My oral Board answer is to repeat TTE and continue if EF is normal and gradient is less than 35.

Unknown METs + Low RCRI/ACS NSQIP + Moderate risk surgery = no further cardiac workup.

Aortic Stenosis doesn't factor into any of the MACE calculations.

 

[Ronin786]

To keep the discussion moving. This patient was seen in pre-op clinic and TTE was ordered. As per usual, TTE wasn't done until day before and read wasn't in until the morning of surgery.

EF 45-50%, DI 0.25, AVA 1.0 and gradient ~35mmhg

Are you proceeding with surgery?

 

[dchz]

Unknown METs + Low RCRI/ACS NSQIP + Moderate risk surgery = no further cardiac workup.

If this is equivalent to normal coronaries in your mind, then I would proceed with surgery.

In my mind, risk stratification is a lot different than actually knowing the pt has normal coronaries (either nuclear scan or LHC since stress test prob non diagnostic).

Knowing this pt's coronary artery status is way more important than fixating on whether or not a fixed defect is severe or moderate... The AS severity should not change your management, as you're gonna treat the pt like he has severe AS anyways.

Also what cardiologist would clear this pt for surgery without a coronary workup?

 

[vector2]

To keep the discussion moving. This patient was seen in pre-op clinic and TTE was ordered. As per usual, TTE wasn't done until day before and read wasn't in until the morning of surgery.

EF 45-50%, DI 0.25, AVA 1.0 and gradient ~35mmhg

Are you proceeding with surgery?

Absolutely not. His decreased function is a sign his AS has become very significant, his coronaries aren’t clean, or both.

Class I recommendation with LVEF < 50% even if he’s asymptomatic.

 

[Ronin786]

If this is equivalent to normal coronaries in your mind, then I would proceed with surgery.

In my mind, risk stratification is a lot different than actually knowing the pt has normal coronaries (either nuclear scan or LHC since stress test prob non diagnostic).

Knowing this pt's coronary artery status is way more important than fixating on whether or not a fixed defect is severe or moderate... The AS severity should not change your management, as you're gonna treat the pt like he has severe AS anyways.

Also what cardiologist would clear this pt for surgery without a coronary workup?

I'm not sure what you're getting at. You asked why nobody is asking for coronary workup.

The answer is because per the AHA/ACC guidelines, there is no role for further testing.

Do you get a LHC on every patient undergoing a laminectomy that has limited METs due to radiculopathy?

 

[vector2]

Valvular Heart Disease: Recommendations​

See the 2014 valvular heart disease CPG for the complete set of recommendations and specific definitions of disease severity15and Online Data Supplement 4 for additional information on valvular heart disease.

Class I​

1. It is recommended that patients with clinically suspected moderate or greater degrees of valvular stenosis or regurgitation undergo preoperative echocardiography if there has been either 1) no prior echocardiography within 1 year or 2) a significant change in clinical status or physical examination since last evaluation.60(Level of Evidence: C)
2. For adults who meet standard indications for valvular intervention (replacement and repair) on the basis of symptoms and severity of stenosis or regurgitation, valvular intervention before elective noncardiac surgery is effective in reducing perioperative risk.15(Level of Evidence: C)

Significant valvular heart disease increases cardiac risk for patients undergoing noncardiac surgery.37,48 Patients with suspected valvular heart disease should undergo echocardiography to quantify the severity of stenosis or regurgitation, calculate systolic function, and estimate right heart pressures. Evaluation for concurrent CAD is also warranted, with electrocardiography exercise testing, stress echocardiographic or nuclear imaging study, or coronary angiography, as appropriate.

Emergency noncardiac surgery may occur in the presence of uncorrected significant valvular heart disease. The risk of noncardiac surgery can be minimized by 1) having an accurate diagnosis of the type and severity of valvular heart disease, 2) choosing an anesthetic approach appropriate to the valvular heart disease, and 3) considering a higher level of perioperative monitoring (eg, arterial pressure, pulmonary artery pressure, transesophageal echocardiography), as well as managing the patient postoperatively in an intensive care unit setting.

2.4.1. Aortic Stenosis: Recommendation​

Class IIa​

1. Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe aortic stenosis (AS).48,75–84(Level of Evidence: B)

In the Original Cardiac Risk Index, severe AS was associated with a perioperative mortality rate of 13%, compared with 1.6% in patients without AS.48 The mechanism of MACE in patients with AS likely arises from the anesthetic agents and surgical stress that lead to an unfavorable hemodynamic state. The occurrence of hypotension and tachycardia can result in decreased coronary perfusion pressure, development of arrhythmias or ischemia, myocardial injury, cardiac failure, and death.

With the recent advances in anesthetic and surgical approaches, the cardiac risk in patients with significant AS undergoing noncardiac surgery has declined. In a single, tertiary-center study, patients with moderate AS (aortic valve area: 1.0 cm2 to 1.5 cm2) or severe AS (aortic valve area <1.0 cm2) undergoing nonemergency noncardiac surgery had a 30-day mortality rate of 2.1%, compared with 1.0% in propensity score–matched patients without AS (P=0.036).75 Postoperative MI was more frequent in patients with AS than in patients without AS (3.0% versus 1.1%; P=0.001). Patients with AS had worse primary outcomes (defined as composite of 30-day mortality and postoperative MI) than did patients without AS (4.4% versus 1.7%; P=0.002 for patients with moderate AS; 5.7% versus 2.7%; P=0.02 for patients with severe AS). Predictors of 30-day death and postoperative MI in patients with moderate or severe AS include high-risk surgery (odds ratio [OR]: 7.3; 95% CI: 2.6 to 20.6), symptomatic severe AS (OR: 2.7; 95% CI: 1.1 to 7.5), coexisting moderate or severe mitral regurgitation (MR) (OR: 9.8; 95% CI: 3.1 to 20.4), and pre-existing CAD (OR: 2.7; 95% CI: 1.1 to 6.2).

For patients who meet indications for aortic valve replacement (AVR) before noncardiac surgery but are considered high risk or ineligible for surgical AVR, options include proceeding with noncardiac surgery with invasive hemodynamic monitoring and optimization of loading conditions, percutaneous aortic balloon dilation as a bridging strategy, and transcatheter aortic valve replacement (TAVR). Percutaneous aortic balloon dilation can be performed with acceptable procedural safety, with the mortality rate being 2% to 3% and the stroke rate being 1% to 2%.76–78,84However, recurrence and mortality rates approach 50% by 6 months after the procedure. Single-center, small case series from more than 25 years ago reported the use of percutaneous aortic balloon dilation in patients with severe AS before noncardiac surgery.79–81 Although the results were acceptable, there were no comparison groups or long-term follow-up. The PARTNER (Placement of Aortic Transcatheter Valves) RCT demonstrated that TAVR has superior outcomes for patients who are not eligible for surgical AVR (1-year mortality rate: 30.7% for TAVR versus 50.7% for standard therapy) and similar efficacy for patients who are at high risk for surgical AVR (1-year mortality rate: 24.2% for TAVR versus 26.8% for surgical AVR).82,83However, there are no data for the efficacy or safety of TAVR for patients with AS who are undergoing noncardiac surgery.

 

[Katheudontas parateroumen]

For an elective case, I would have done a TTE in the preop clinic with referral to cardiology if worsening AS/reduced EF; that is the safe thing to do I believe; I am sure the cardiologist has more nuanced knowledge than me about the indications for AVR. Now if he just showed up without any work up as many do, here is what I think so far... I do believe that he would have been safe to proceed with surgery even without TTE as long as his clinical status has not changed since 2 years ago. We cannot eval his METs so we go to RCRI and appears only a 1 for elevated risk surgery (no mention of hx of HF, CVA, IDDM, CVA CKD). Although I realize RCRI doesn't take into account AS but it's the common tool we use for MACE. If RCRI is less than 2 then there is proceed with surgery with normal precautions with AS. Let's say we get to the situation as stated that the repeat TTE doesn't show up until the day of as presented. His numbers are all borderline moderate but still puts him in the moderate category. As he is generally asymptomatic (no CP,SOB) I don't believe he would be in the category of indication for AVR/TAVR. Generally as stated above, any patient in which they would have indication for AVR, delaying elective surgery until AVR would be correct.

I actually think the preop thoughts are the most interesting as "perioperative physicians". I think we are well versed at saving lives when the patient is already at the operating table, that's the focus of anesthesia residency. However, the real great docs can prevent issues and medically optimize them for the best outcomes. So many grey areas so great discussion so far.

 

[Urzuz]

Valvular Heart Disease: Recommendations​

See the 2014 valvular heart disease CPG for the complete set of recommendations and specific definitions of disease severity15and Online Data Supplement 4 for additional information on valvular heart disease.

Class I​

1. It is recommended that patients with clinically suspected moderate or greater degrees of valvular stenosis or regurgitation undergo preoperative echocardiography if there has been either 1) no prior echocardiography within 1 year or 2) a significant change in clinical status or physical examination since last evaluation.60(Level of Evidence: C)
2. For adults who meet standard indications for valvular intervention (replacement and repair) on the basis of symptoms and severity of stenosis or regurgitation, valvular intervention before elective noncardiac surgery is effective in reducing perioperative risk.15(Level of Evidence: C)

Significant valvular heart disease increases cardiac risk for patients undergoing noncardiac surgery.37,48 Patients with suspected valvular heart disease should undergo echocardiography to quantify the severity of stenosis or regurgitation, calculate systolic function, and estimate right heart pressures. Evaluation for concurrent CAD is also warranted, with electrocardiography exercise testing, stress echocardiographic or nuclear imaging study, or coronary angiography, as appropriate.

Emergency noncardiac surgery may occur in the presence of uncorrected significant valvular heart disease. The risk of noncardiac surgery can be minimized by 1) having an accurate diagnosis of the type and severity of valvular heart disease, 2) choosing an anesthetic approach appropriate to the valvular heart disease, and 3) considering a higher level of perioperative monitoring (eg, arterial pressure, pulmonary artery pressure, transesophageal echocardiography), as well as managing the patient postoperatively in an intensive care unit setting.

2.4.1. Aortic Stenosis: Recommendation​

Class IIa​

1. Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe aortic stenosis (AS).48,75–84(Level of Evidence: B)

In the Original Cardiac Risk Index, severe AS was associated with a perioperative mortality rate of 13%, compared with 1.6% in patients without AS.48 The mechanism of MACE in patients with AS likely arises from the anesthetic agents and surgical stress that lead to an unfavorable hemodynamic state. The occurrence of hypotension and tachycardia can result in decreased coronary perfusion pressure, development of arrhythmias or ischemia, myocardial injury, cardiac failure, and death.

With the recent advances in anesthetic and surgical approaches, the cardiac risk in patients with significant AS undergoing noncardiac surgery has declined. In a single, tertiary-center study, patients with moderate AS (aortic valve area: 1.0 cm2 to 1.5 cm2) or severe AS (aortic valve area <1.0 cm2) undergoing nonemergency noncardiac surgery had a 30-day mortality rate of 2.1%, compared with 1.0% in propensity score–matched patients without AS (P=0.036).75 Postoperative MI was more frequent in patients with AS than in patients without AS (3.0% versus 1.1%; P=0.001). Patients with AS had worse primary outcomes (defined as composite of 30-day mortality and postoperative MI) than did patients without AS (4.4% versus 1.7%; P=0.002 for patients with moderate AS; 5.7% versus 2.7%; P=0.02 for patients with severe AS). Predictors of 30-day death and postoperative MI in patients with moderate or severe AS include high-risk surgery (odds ratio [OR]: 7.3; 95% CI: 2.6 to 20.6), symptomatic severe AS (OR: 2.7; 95% CI: 1.1 to 7.5), coexisting moderate or severe mitral regurgitation (MR) (OR: 9.8; 95% CI: 3.1 to 20.4), and pre-existing CAD (OR: 2.7; 95% CI: 1.1 to 6.2).

For patients who meet indications for aortic valve replacement (AVR) before noncardiac surgery but are considered high risk or ineligible for surgical AVR, options include proceeding with noncardiac surgery with invasive hemodynamic monitoring and optimization of loading conditions, percutaneous aortic balloon dilation as a bridging strategy, and transcatheter aortic valve replacement (TAVR). Percutaneous aortic balloon dilation can be performed with acceptable procedural safety, with the mortality rate being 2% to 3% and the stroke rate being 1% to 2%.76–78,84However, recurrence and mortality rates approach 50% by 6 months after the procedure. Single-center, small case series from more than 25 years ago reported the use of percutaneous aortic balloon dilation in patients with severe AS before noncardiac surgery.79–81 Although the results were acceptable, there were no comparison groups or long-term follow-up. The PARTNER (Placement of Aortic Transcatheter Valves) RCT demonstrated that TAVR has superior outcomes for patients who are not eligible for surgical AVR (1-year mortality rate: 30.7% for TAVR versus 50.7% for standard therapy) and similar efficacy for patients who are at high risk for surgical AVR (1-year mortality rate: 24.2% for TAVR versus 26.8% for surgical AVR).82,83However, there are no data for the efficacy or safety of TAVR for patients with AS who are undergoing noncardiac surgery.

Blade, is that you?

 

[woopedazz]

Elective surgery. Elderly man. AS fitting criteria for either C2 (Asymptomatic severe AS with LV systolic dysfunction) or D2 (Symptomatic severe low-flow, low-gradient AS with reduced LVEF).

The low pressure gradient... The guidelines say we should get a dobutamine stress echo (if he's actually asymptomatic) to exclude them having **** myocardium causing an underlying HFrEF. I.e. the **** AVA is being exaggerated by an underlying trash heart and low flow state --> they actually only have moderate AS, but it looks worse than it is.

But... When you look at the DI being 0.25 = makes it more likely we got severe AS driving the LV dysfunction and you can probably avoid requesting a stress echo and leave that up to cards/cardiothoracics as he's going for an AVR +/- grafts/PCIs before he gets his laminectomy anyway.

I.e. Cancel: Proceed as per cardiology/cardiothoracics.

 

[Beeftenderloin]

To keep the discussion moving. This patient was seen in pre-op clinic and TTE was ordered. As per usual, TTE wasn't done until day before and read wasn't in until the morning of surgery.

EF 45-50%, DI 0.25, AVA 1.0 and gradient ~35mmhg

Are you proceeding with surgery?

Patient now has an AVA of 1.0, DI 0.25, low EF, equivocal functional status. This is a slam dunk. Dude needs a valve before elective surgery. Tell me you know a heart surgeon that wouldn’t be champing at the bit to do a SAVR on this guy and I’ll tell you I don’t believe you.

 

[dchz]

I'm not sure what you're getting at. You asked why nobody is asking for coronary workup.

The answer is because per the AHA/ACC guidelines, there is no role for further testing.

Do you get a LHC on every patient undergoing a laminectomy that has limited METs due to radiculopathy?

I, the anesthesiologist, don't/would't get a LHC on every pt with limited METs.

Every cardiologist would get a coronary workup on every 72 year old pt with reduced EF and Mod to severe AS to see if the pt needs a stent/tavr vs cabg/savr. The coronary workup should have been done 2 years ago.

My point:
RCRI is not perfect. If the pre test probability for CAD is high, then the best course of action might contradict recommendations from RCRI.

See this thread by Blade from years back. (obviously you can tell my thoughts have shifted throughout the years).

I believe this pt gets the greatest perioperative MACE reduction from fixing the coronaries than fixing the valve. But oral board answer is fixing both.

If this is my mother, I'd want a coronary workup before surgery. I would be comfortable proceeding if coronaries are normal and I'm getting a competent anesthesiologist. The oral board answer is still to delay the surgery until her heart is perfect.

 

[dchz]

Patient now has an AVA of 1.0, DI 0.25, low EF, equivocal functional status. This is a slam dunk. Dude needs a valve before elective surgery. Tell me you know a heart surgeon that wouldn’t be champing at the bit to do a SAVR on this guy and I’ll tell you I don’t believe you.

I know several world class heart surgeons that would send this pt for TAVR if coronaries are normal (can you tell I believe that coronary workup is really important in this patient??).

I would do the same for my mother (I should add that I love my mother).

 

[Beeftenderloin]

I know several world class heart surgeons that would send this pt for TAVR if coronaries are normal (can you tell I believe that coronary workup is really important in this patient??).

I would do the same for my mother

I was more so trying to suggest that you won’t find a cardiothoracic surgeon out there who won’t say this guy needs a new aortic valve, whether that’s a TAVR or SAVR is irrelevant to the specific case being discussed.

TAVR is a totally reasonable option in this patient (assuming clean coronaries). Though most surgeons I’ve worked with would offer this guy a SAVR via mini sternotomy. Unless he needed bypasses, then he gets the whole shebang. I actually have one surgeon I work with, a little over a year out of training, does all his own TAVRs without cards.

 

[vector2]

For an elective case, I would have done a TTE in the preop clinic with referral to cardiology if worsening AS/reduced EF; that is the safe thing to do I believe; I am sure the cardiologist has more nuanced knowledge than me about the indications for AVR. Now if he just showed up without any work up as many do, here is what I think so far... I do believe that he would have been safe to proceed with surgery even without TTE as long as his clinical status has not changed since 2 years ago. We cannot eval his METs so we go to RCRI and appears only a 1 for elevated risk surgery (no mention of hx of HF, CVA, IDDM, CVA CKD). Although I realize RCRI doesn't take into account AS but it's the common tool we use for MACE. If RCRI is less than 2 then there is proceed with surgery with normal precautions with AS. Let's say we get to the situation as stated that the repeat TTE doesn't show up until the day of as presented. His numbers are all borderline moderate but still puts him in the moderate category. As he is generally asymptomatic (no CP,SOB) I don't believe he would be in the category of indication for AVR/TAVR. Generally as stated above, any patient in which they would have indication for AVR, delaying elective surgery until AVR would be correct.

I actually think the preop thoughts are the most interesting as "perioperative physicians". I think we are well versed at saving lives when the patient is already at the operating table, that's the focus of anesthesia residency. However, the real great docs can prevent issues and medically optimize them for the best outcomes. So many grey areas so great discussion so far.

Per the ACC/AHA periop guidelines, before you even go down the METS/RCRI pathway, you first need to ask:

1. Is this an emergency surgery?

2. Does the patient have an ongoing acute coronary syndrome, decompensated CHF, significant arrhythmia, or a severe valvular abnormality?

Since this is not emergency surgery and the patient has a severe valvular abnormality with a newly decreased LVEF, further workup (and possibly treatment) is definitely indicated before we even start hemming and hawing about his other risk factors or his questionable exercise capacity, etc.

 

[anaesthetic]

Per the ACC/AHA periop guidelines, before you even go down the METS/RCRI pathway, you first need to ask:

1. Is this an emergency surgery?

2. Does the patient have an ongoing acute coronary syndrome, decompensated CHF, significant arrhythmia, or a severe valvular abnormality?

Since this is not emergency surgery and the patient has a severe valvular abnormality with a newly decreased LVEF, further workup (and possibly treatment) is definitely indicated before we even start hemming and hawing about his other risk factors or his questionable exercise capacity, etc.

Yep. Not even sure if there’s anything to discuss, IMO. Pretty clear this guy needs further workup prior to an elective surgery.

 

[Beeftenderloin]

Anesthesiologists need to stop owning cancellations like this like it’s something they did. The patient’s the one with the disease.

 

[pgg]

does he want his valve replaced???

I think what you're suggesting (?) is that there's no point doing a TTE to see if the AS has progressed, if this patient is going to refuse AVR anyway? Ask him if he'd want to get his valve fixed IF it was terrible, and if he says nah then proceed with his spine today?

I'd argue that the patient can't really make an informed decision about whether to get an AVR, without accurate and current information about his valve.

Once we've met the standard for evaluating this patient's heart, then he can decide to refuse intervention, and then he can decide to accept the excess risk of the spine procedure absent an AVR. I don't think it's OK to pose hypotheticals like this to patients, and ask them to make that kind of decision without information that can be easily obtained from a zero-risk test.

 

[vector2]

does he want his valve replaced???

He's probably got two reasons why he rides the cart instead of walking the course when he golfs. But he erroneously thinks he's only got one which needs fixed.

If you tell a guy in his 70s who still plays golf the natural history of untreated severe aortic stenosis, I'm pretty sure he'll let you know he has no intention of dying from a preventable cause in the next 5 years.

 

[Ronin786]

Good discussion everybody. The reason I felt this case was intriguing was:

1) Despite the fact that everybody seems to agree a repeat TTE is warranted, there's going to be some disagreement about what to do with those results.

2) The question that came to mind was whether this patient could be too sick for an elective laminectomy but not severe enough with his AS to warrant valve replacement. To me that would be an indication to pursue TAVR/SAVR despite not meeting all the severe criteria (assume his EF wasn't depressed) because it's going to need to be replaced anyways at some point.

 

[Ronin786]

Anesthesiologists need to stop owning cancellations like this like it’s something they did. The patient’s the one with the disease.

Great point. The patient is also the one that failed to follow-up with their cardiologist in a reasonable fashion.

With regards to the case, results came in day of surgery. I spoke with the surgeon and patient and explained that there's a real risk from proceeding and that patient needs to see their cardiologist first.

Of course, patient goes to see cardiologist and this is what cardiologist has to say


"Patient meets criteria for moderate-severe AS, we will refer him to our structural heart team for TAVR workup. In the meantime, due to absence of risk factors for CAD, he is cleared to proceed with surgery for his back"

Now what do you do?

 

[Iso4ane]

Everything has pretty much been discussed, but he was unable to complete his own exercise stress test. So he’s only asymptomatic because his heart rate probably doesn’t get that high.

But with that TTE, and for a single level lami, art line and just do it. But, if it was a larger back whack for a whack back, definitely put on hold, until maybe a stress echo is done.

 

[vector2]

"Patient meets criteria for moderate-severe AS, we will refer him to our structural heart team for TAVR workup. In the meantime, due to absence of risk factors for CAD, he is cleared to proceed with surgery for his back"

That cardiologist isn't really the sharpest tool in the shed, is he...


"Coronary artery disease (CAD) and severe aortic valve stenosis frequently coexist. CAD is prevalent in >60% of patients undergoing surgical aortic valve replacement (SAVR)1 and up to 65% of patients undergoing transcatheter aortic valve replacement (TAVR).2 This strong association is thought to be due to the common pathophysiology involving low‐density lipoprotein–mediated inflammatory response resulting in an accelerated atherosclerotic process and shares similar risk factors including age, smoking, hypertension, and hyperlipidemia.3"

https://www.ahajournals.org/doi/10.1161/JAHA.117.005593#:~:text=Coronary%20artery%20disease%20(CAD)%20and,aortic%20valve%20replacement%20(TAVR).

 

[Beeftenderloin]

Great point. The patient is also the one that failed to follow-up with their cardiologist in a reasonable fashion.

With regards to the case, results came in day of surgery. I spoke with the surgeon and patient and explained that there's a real risk from proceeding and that patient needs to see their cardiologist first.

Of course, patient goes to see cardiologist and this is what cardiologist has to say


"Patient meets criteria for moderate-severe AS, we will refer him to our structural heart team for TAVR workup. In the meantime, due to absence of risk factors for CAD, he is cleared to proceed with surgery for his back"

Now what do you do?

From a “patient first” standpoint, they should see a new cardiologist and get at least a stress test, but probably go straight to LHC since now they’re getting worked up for a S/TAVR, because as @vector2 said, bad AS in and of its self is a strong predictor of clinically significant CAD, and the closest this guys coronaries have come to a stress test in recent memory is probably a particularly firm bowel movement.

From a practical standpoint, you can either personally reach out the cardiologist and explain to them how how bad they are at their job, or do the case. Cardiologist documentation protects you medico-legally to some extent. However, I would still explain to patient that despite cardiologist clearance they are 2x likely to die and 3x likely to have an MI perioperatively relative to gen pop. If they’re comfortable proceeding knowing that, document everything and do the case. If they’d rather wait until after their valve is replaced and their risk profile more closely approximates gen pop, then congratulate them on a wise choice and move on to the next case.

 

[woopedazz]

Now what do you do?

I'm nearly always in the "just do it" camp, but I don't see the grey area here... I put this guy to sleep for only 2 reasons:
1. It's emergency surgery
2. It's for his AVR

The likelihood of there being a problem intraop is very low, but that doesn't mean I should do it. What about his recovery? PT pushing this guy in a post-op state? The risk is real, and there are real guidelines in place.

Edit: maybe 3 reasons, with reason 3 being palliative

 

[cchoukal]

...back whack for a whack back...

Can we take a quick time out and focus on this great line this is here?

 

[Silo004]

The low pressure gradient... The guidelines say we should get a dobutamine stress echo (if he's actually asymptomatic) to exclude them having **** myocardium causing an underlying HFrEF. I.e. the **** AVA is being exaggerated by an underlying trash heart and low flow state --> they actually only have moderate AS, but it looks worse than it is.

I wouldn't be enthusiastic about the dobutamine stress echo in a guy with this kind of AS.

 

[woopedazz]

I wouldn't be enthusiastic about the dobutamine stress echo in a guy with this kind of AS.

It's relatively contraindicated given the DI pretty much tells us what's going on

 

[dchz]

"Patient meets criteria for moderate-severe AS, we will refer him to our structural heart team for TAVR workup. In the meantime, due to absence of risk factors for CAD, he is cleared to proceed with surgery for his back"

Now what do you do?

This is a joke, right? a cardiologist actually said that rather than just send him for a LHC/NM scan?

 

[NICMAN]

Elective surgery. Elderly man. AS fitting criteria for either C2 (Asymptomatic severe AS with LV systolic dysfunction) or D2 (Symptomatic severe low-flow, low-gradient AS with reduced LVEF).

The low pressure gradient... The guidelines say we should get a dobutamine stress echo (if he's actually asymptomatic) to exclude them having **** myocardium causing an underlying HFrEF. I.e. the **** AVA is being exaggerated by an underlying trash heart and low flow state --> they actually only have moderate AS, but it looks worse than it is.

But... When you look at the DI being 0.25 = makes it more likely we got severe AS driving the LV dysfunction and you can probably avoid requesting a stress echo and leave that up to cards/cardiothoracics as he's going for an AVR +/- grafts/PCIs before he gets his laminectomy anyway.

I.e. Cancel: Proceed as per cardiology/cardiothoracics.

That was my thought when I looked at the dimensionless index. Agree with course.

If the guy refuses open AVR or TAVR after seeing a cardiologist/CT surgeon then I would have a long discussion with family, surgeon, patient and plenty of witnesses and document the high risk and only then proceed.