Previous article Table of Contents  Next article

LETTERS TO EDITOR
Year : 2018  |  Volume : 12  |  Issue : 2  |  Page : 367-369

Noncardiac surgery in two severe aortic stenosis patients: General or epidural anesthesia?


1 Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Dr. Nitika Goel
HN0-165, Sector 15 A, Chandigarh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.SJA_648_17

Rights and Permissions
Date of Web Publication9-Mar-2018
 


How to cite this article:
Goel N, Kumar M G, Barwad P, Puri GD. Noncardiac surgery in two severe aortic stenosis patients: General or epidural anesthesia?. Saudi J Anaesth 2018;12:367-9

How to cite this URL:
Goel N, Kumar M G, Barwad P, Puri GD. Noncardiac surgery in two severe aortic stenosis patients: General or epidural anesthesia?. Saudi J Anaesth [serial online] 2018 [cited 2018 May 27];12:367-9. Available from: http://www.saudija.org/text.asp?2018/12/2/367/227011



Sir,

Anesthesia in severe aortic stenosis (SAS) can result in rapid clinical deterioration and patient mortality. The current American College of Cardiology (ACC) guidelines recommend aortic valve surgery [1] before elective noncardiac surgery in symptomatic SAS patients. In some clinical circumstances, aortic valve surgery cannot be performed due to high surgical risk or patient refuses aortic valve surgery. In such situation, it is important to determine which anesthesia technique has the lowest risk for these patients for undergoing noncardiac surgery. Here, we discuss anesthetic management of series of two SAS patients coming for emergency noncardiac surgery.

A 92-year-old male diagnosed with SAS with atrial fibrillation 14 years back was posted for emergency surgery for obstructed inguinal hernia at our institute. He was taking tablet acitrom 1 mg, digoxin 0.25 mg, atorvastatin 40 mg, and lasilactone 20 mg. He had pulse rate of 130/min irregularly irregular, blood pressure 150/70 mmHg, respiratory rate 26/min, breath holding time 5 seconds, and room air saturation of 85%–88%. His preoperative blood investigations were normal except for INR of 2.1, blood urea – 78 mg/dl, and serum creatinine – 1.4 mg/dl. Electrocardiography showed atrial fibrillation with heart rate of 120/min. Chest and abdomen roentgenogram showed the presence of thoracolumbar scoliosis with hyperinflated lungs. His echocardiography showed calcified aortic valve with peak and mean gradient of 110 mmHg and 52 mmHg, severe pulmonary artery hypertension leading to severe tricuspid regurgitation, moderate mitral stenosis, and mitral regurgitation, and ejection fraction of 55%–60%. In operation theater, after establishing electrocardiography, invasive arterial, pulse oximetry, and capnography, general anesthesia was administered using injection fentanyl 60 μg, propofol 30 mg, and atracurium 15 mg. The mean arterial pressure was maintained above 65 mmHg using titrated dose of phenylephrine between 0.3–0.6 μg/kg/min. The intraoperative vitals were stable [Figure 1], and completion echocardiography showed good biventricular function with inferior vena cava (IVC) diameter of 1.8 cm showing <50% collapsibility. The patient was extubated and shifted to postanesthesia care unit with phenylephrine infusion tapered at the end of surgery. After monitoring for the next 2 days, the patient was subsequently discharged home in hemodynamically stable condition.
Figure 1: The intraoperative hemodynamic parameters of our first patient

Click here to view


A 32-year-old female primigravida at 19 weeks of gestation, a known case of chronic hypertension, came to our institute with complaints of breathlessness, palpitations, and syncopal attacks. She had height of 125 cm and weighed 42 kg. She was presently taking tablet dytor and labetalol. On examination, her pulse rate was 80/min, blood pressure 110/70 mmHg, and respiratory rate 12/min. Routine blood investigations were normal except for urea which was 148 mg/dl and creatinine 4.8 mg/dl. Her echocardiography showed bicuspid aortic valve with peak and mean gradient of 118 mmHg and 61 mmHg, severe aortic regurgitation with aortic root dilatation, and ejection fraction was 55%–60%. Her chest roentgenogram showed the presence of thoracic scoliosis [Figure 2]. Pulmonary function tests showed the presence of severe restrictive lung disease. Abdominal ultrasound revealed bilateral parenchymal thickening in both kidneys which was diagnosed as chronic kidney disease Stage IV. It was decided to perform surgical abortion in operation theater as it could be performed in a planned manner in the presence of adequate monitoring. Her baseline heart rate was 70 beats/min, blood pressure of 96/60 mmHg, and room air saturation of 97%. In operating room, after establishing electrocardiography, invasive blood pressure, central venous pressure, pulse oximeter, and capnography, general anesthesia was administered with fentanyl 60 μg, propofol 30 mg, and atracurium 20 mg. After induction, phenylephrine infusion started at 0.1–0.3 μg/kg/min to maintain mean arterial pressure above 65 mmHg. Suction curettage proceeded uneventfully with phenylephrine being tapered off at end. The patient was extubated and shifted to recovery room. She was monitored for 2 days in high dependency unit and subsequently discharged.
Figure 2: The chest roentgenogram of our second patient

Click here to view


There is no consensus on which anesthetic technique is safer for noncardiac surgery in SAS patients. In elderly cardiac patient for obstructed inguinal hernia surgery, one may prefer regional anesthesia. Since patients with SAS have limited stroke volume, any major reduction in systemic vascular resistance may result in sudden fall in perfusion pressure; therefore, spinal anesthesia in patient with aortic stenosis (AS) should be avoided. Although various studies have described the use of graded epidural anesthesia in SAS patients,[2] administration of regional anesthesia at INR >1.5 has been associated with increased risk of vertebral canal hematoma.[3] Therefore, in patients with deranged coagulogram, decision for regional anesthesia should be omitted.

Administration of regional anesthesia in short-statured patients has been associated with variable levels of block height. Although successful graded epidural anesthesia has been reported in short-statured patients for cesarean section,[4] two cases have reported high levels of block.[5] Nevertheless, administration of regional anesthesia in the presence of short stature and scoliosis can lead to variable level of block height which is not desirable in SAS patients.

Very few studies have compared general versus epidural anesthesia for noncardiac surgery in SAS patients. In two studies comparing the mortality rate between general and epidural anesthesia for noncardiac surgery in SAS patients, they found a mortality rate of <5%.[6],[7] In both these studies, authors have proven that SAS patients though not a candidate for cardiac surgery can undergo emergent noncardiac surgery with acceptable risk and found that severity of AS and emergency surgery are most important predictors of major adverse cardiovascular events following noncardiac surgery. Thus, we can say that the question whether to give general or epidural depends totally on anesthesiologist's discretion who takes into consideration patient's perioperative condition, severity of AS, type of surgery, and previous experience.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: A report of the American college of cardiology/American heart association task force on practice guidelines (Writing committee to revise the 2002 guidelines on perioperative cardiovascular evaluation for noncardiac surgery) developed in collaboration with the American society of echocardiography, American society of nuclear cardiology, heart rhythm society, society of cardiovascular anesthesiologists, society for cardiovascular angiography and interventions, society for vascular medicine and biology, and society for vascular surgery. J Am Coll Cardiol 2007;50:e159-241.  Back to cited text no. 1
[PUBMED]    
2.
Suntharalingam G, Dob D, Yentis SM. Obstetric epidural analgesia in aortic stenosis: A low-dose technique for labour and instrumental delivery. Int J Obstet Anesth 2001;10:129-34.  Back to cited text no. 2
    
3.
Working Party: Association of Anaesthetists of Great Britain & Ireland, Obstetric Anaesthetists' Association, Regional Anaesthesia UK. Regional anaesthesia and patients with abnormalities of coagulation: The association of anaesthetists of great britain & Ireland the obstetric anaesthetists' association regional anaesthesia UK. Anaesthesia 2013;68:966-72.  Back to cited text no. 3
    
4.
Carstoniu J, Yee I, Halpern S. Epidural anaesthesia for caesarean section in an achondroplastic dwarf. Can J Anaesth 1992;39:708-11.  Back to cited text no. 4
    
5.
Wardall GJ, Frame WT. Extradural anaesthesia for caesarean section in achondroplasia. Br J Anaesth 1990;64:367-70.  Back to cited text no. 5
    
6.
Torsher LC, Shub C, Rettke SR, Brown DL. Risk of patients with severe aortic stenosis undergoing noncardiac surgery. Am J Cardiol 1998;81:448-52.  Back to cited text no. 6
    
7.
Tashiro T, Pislaru SV, Blustin JM, Nkomo VT, Abel MD, Scott CG, et al. Perioperative risk of major non-cardiac surgery in patients with severe aortic stenosis: A reappraisal in contemporary practice. Eur Heart J 2014;35:2372-81.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
Previous article    Next article
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  IN THIS Article
   References
   Article Figures

 Article Access Statistics
    Viewed115    
    Printed0    
    Emailed0    
    PDF Downloaded29    
    Comments [Add]    

Recommend this journal