1. Aortic stenosis and indication
for non-cardiac surgery
Jean-Pol Depoix, MD
Anaesthesiology Department
Bernard Iung, MD
Cardiology Department
Bichat Hospital, Paris, France

2. Case History
• 84 year-old woman
• Treated hypertension, prior thyroidectomy.
• Known cardiac murmur
• Preserved autonomy and activity. Asymptomatic
• Recent diagnosis of an adenocarcinoma of left colon
without other malignant location, indication of left
colectomy
• Referred before surgery because of cardiac murmur
• Mid-systolic murmur 3/6, decreased S2
• No signs of congestive heart failure
• Blood pressure 154/60 mmHg

3. Chest X-ray and ECG

4. Echocardiography: parasternal views
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5. Echocardiography: apical views
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6. Mean gradient 42 mmHg
V. Max 4.1 m/sec.
Valve area :
0.9 cm² (0.56 cm²/m² BSA)
LV 51/37 mm, SF 30%

7. Coronary angiography

8. Summary of case analysis
• Severe aortic stenosis
Consistency between:
− Aortic valve area < 1.0 cm² and < 0.6 cm²/ m² BSA
− Maximum jet velocity ≥ 4 m/sec
− Mean gradient ≥ 40 mmHg
• Hypertrophied left ventricle with preserved
ejection fraction
• No other cardiac disease
• Asymptomatic

9. What do you advise?
1. Contra-indicate colectomy
2. Perform colectomy with primary anastomosis,
without treatment of aortic stenosis
3. Consider less invasive surgery: resection +
colostomy (Hartmann procedure)
4. Perform balloon aortic valvuloplasty before
colectomy
5. Perform TAVI before colectomy

10. What do you advise?
1. Contra-indicate colectomy
2. Perform colectomy with primary anatomosis,
without treatment of aortic stenosis
3. Consider less invasive surgery: resection +
colostomy (Hartmann procedure)
4. Perform balloon aortic valvuloplasty before
colectomy
5. Perform TAVI before colectomy

11. Rationale for therapeutic decision
• Abdominal surgery is required since it is the
only curative treatment of colic cancer
• Less invasive intervention limits haemodynamic
stress but impairs quality of life (Hartmann
procedure was the first option of the referring team)
• Risk assessment should take into account:
− The risk of abdominal surgery
− The risk of cardiac complications due to aortic stenosis
− The risk and consequences of treating aortic stenosis before
abdominal surgery

12. Evaluation of the risk of non-cardiac surgery
30-day cardiac death and myocardial infarction
30-day rates of cardiac death and myocardial infarction
Guidelines for pre-operative cardiac risk assessment and perioperative cardiac
management in non-cardiac surgery. Eur Heart J 2009;30:2769-812.

13. Therapeutic options for aortic stenosis
• Low risk of complications of intermediate risk noncardiac surgery
No death or myocardial infarction in a series of 30
asymptomatic patients with severe aortic stenosis undergoing
non cardiac surgery (>75% at intermediate-risk)
(Calleja et al. Am J Cardiol 2010;105:1159-63)
• Treatment of AS before non-cardiac surgery is
considered only in symptomatic patients or for
high-risk surgery
Guidelines on the management of valvular heart disease (version 2012).
Eur Heart J 2012;33:2451-496.

14. Therapeutic options for aortic stenosis
• Risk of aortic valve replacement
− Euroscore I:
− Euroscore II:
10.1%
1.7%
• The only reason to favour TAVI over surgical aortic valve
replacement would be more rapid recovery.
Take into account the risk of TAVI and the need for
antiplatelet drugs.
• Balloon aortic valvuloplasty may be considered in patients
with symptomatic severe AS who require urgent major non-cardiac
surgery (IIbC)
 No indication in this case
Guidelines on the management of valvular heart disease (version 2012).
Eur Heart J 2012;33:2451-496.

15. Management of severe aortic stenosis and elective non-cardiac
surgery according to patient characteristics and the type of surgery
Severe AS and need for elective non-cardiac surgery
Symptoms
No
Yes
Risk of non-cardiac surgery
Low-moderate
High
Patient risk for AVR
High
Non-cardiac
surgery
www.escardio.org/guidelines
Non-cardiac
surgery
under strict
monitoring
Patient risk for AVR
Low
Low
AVR before
non-cardiac
surgery
High
Non-cardiac surgery
under strict monigoring
Consider BAV/TAVI
European Heart Journal 2012 - doi:10.1093/eurheartj/ehs109 &
European Journal of Cardio-Thoracic Surgery 2012 doi:10.1093/ejcts/ezs455).

16. Therapeutic decision
• Multidisciplinary meeting (anaesthesiologist,
cardiologist, surgeon)
• Decision of left colectomy with primary
anastomosis without prior treatment of aortic
stenosis
• Direct contact with the anaesthesiologist in
charge of the patient
• Specificities of anesthesia
• Choice of anaesthetic drugs
• Cardiac monitoring
• Post-operative care

17. Outcome
• Left colectomy with primary anastomosis
– Invasive arterial blood pressure monitoring using a
radial catheter
– Anaesthesia: hypnomidate, atracrium, desflurane and
remifentanil (short action opioid)
• Stable haemodynamic during anaesthesia
• Extubation at the end of abdominal surgery
• Uneventful post-operative course
• Patient discharged at home. She remains
asymptomatic

18. Take-Home messages
• Aortic stenosis should be carefully evaluated in
elderly patients needing non-cardiac surgery
because of the risk of cardiac complications
• In severe AS, risk stratification should take into
account:
−
−
−
−
Symptoms
Indication for non-cardiac surgery (vital vs. functional)
The risk of cardiac complications according to the type of surgery
The risks inherent to the treatment of AS
• Intermediate and low-risk surgery can be
performed safely in asymptomatic patients,
provided appropriate anaesthetic management is
planned

19. Join the ESC Working Group
on Valvular Heart Disease
and take part in its
activities !
Membership is FREE!