Aortic stenosis
<td class="text-Critical">
Critical
| Anesthetic relevance | |
|---|---|
| Anesthetic management |
{{{anesthetic_management}}} |
| Specialty |
Cardiology |
| Signs and symptoms |
Decreased exercise tolerance, dyspnea, syncope, chest pain |
| Diagnosis | |
| Treatment |
Valve replacement surgery |
| Article information | |
| Editor rating | |
| Likes | 0 |
| Top authors | |
| Chris Rishel | |
Aortic stenosis is the narrowing of the outflow tract of the left ventricle due to calcification of the aortic valve.
Anesthetic implications
Preoperative optimization
Asymptomatic aortic stenosis may be initially detected on physical exam. Peripheral pulses may be weak and late (sometimes called pulsus parvus et tardus). A loud systolic crescendo-decrescendo murmur may also be present, which is best heard at the right upper sternal border at the 2nd intercostal space. This murmur may also radiate to the carotid arteries.
Patients with suspected aortic stenosis should undergo Transthoracic echocardiogram to confirm the diagnosis and evaluate the severity of the disease. For severe disease, valve replacement therapy should be considered prior to proceeding with elective surgery.
Intraoperative management
Monitoring
- For severe disease, a pre-induction arterial line should be placed to rapidly detect hemodynamic changes.
- Advanced monitoring such as a pulmonary artery catheter or transesophageal echocardiography can be considered.
Hemodynamics
- Hypotension should be avoided to preserve afterload (i.e. coronary perfusion pressure). Treat with afterload increasing agents such as phenylephrine.
- Bradycardia should be avoided as these patients are often heart rate dependent to preserve adequate cardiac output. A heart rate of 60-90 bpm is optimal.
- Tachycardia and hypertension should be avoided to preserve left ventricular diastolic filling and reduce myocardial oxygen demand. Treat with increasing anesthetic depth or short-acting beta-blockade with esmolol.
Neuraxial anesthesia
Central neuraxial anesthesia is contraindicated in all but mild disease due to the risk of decreased systemic vascular resistance leading to decreased diastolic blood pressure and reduced myocardial perfusion