SESSION TYPE: Arrhythmia and Coronary Artery Disease
PRESENTED ON: Monday, October 22, 2012 at 11:15 AM - 12:30 PM
PURPOSE: Preoperative management of patients with aortic stenosis (AS) who need non-cardiac surgery (NCS) remains controversial, especially when patients are asymptomatic or NCS needs to be performed before definitive treatment for AS. We sought to determine the impact of AS on the post-operative outcomes after NCS.
METHODS: Patients undergoing NCS with moderate/severe AS were identified using the surgical/echocardiographic databases at the Cleveland Clinic. Severe AS was defined as aortic valve area<1.0 cm2 and mean transvalvular gradient>40 mm-Hg. Moderate AS was defined as aortic valve area 1.0-1.5 cm2. Using propensity score analysis, we obtained 4 matched controls (patient undergoing NCS without AS) for each case. The propensity score matching utilized age, gender and six revised cardiac risk index criteria. Primary outcome was defines as 30-day mortality or post-operative myocardial infarction.
RESULTS: We identified 139 patients with severe AS and 495 patients with moderate AS. 2536 controls were chosen using propensity-score matching. Primary outcome occurred in 12 patients(8.6%) with severe AS, which was significantly higher than incidence in corresponding control population (3.1%, p=0.003). When stratified by presence of symptoms, the incidence of primary outcome was 7.8% and 10.2% in the asymptomatic and symptomatic severe AS patients respectively. Among the moderate AS patients, the primary outcome occurred in 19 patients(3.8%), which was significantly higher than that observed in the corresponding control population(2.0%, p=0.01). A large majority of patients with severe AS with primary outcome(7 of 12 patients) had evidence of intraoperative hypotension, with mean blood pressure<65 mm-Hg or need for vasopressors. In addition, high-risk surgery, symptomatic severe AS, and pre-existing coronary artery disease were significant predictors of primary outcome in patients with AS.
CONCLUSIONS: Presence of AS adversely affects post-operative outcomes among patients undergoing NCS, evidenced by a higher incidence of 30-day mortality and postoperative MI after NCS.
CLINICAL IMPLICATIONS: Meticulous avoidance of intra-operative/post-operative hypotension may help mitigate the risk of adverse outcome in patients with AS undergoing NCS. Use of swan-ganz catheter to guide fluid therapy must be considered in these patients.
DISCLOSURE: The following authors have nothing to disclose: Shikhar Agarwal, Anitha Rajamanickam, Navkaranbir Bajaj, Thadeo Catacutan, Brian Griffin, Lars Svensson, Abdel Anabtawi, E. Tuzcu, Samir Kapadia
No Product/Research Disclosure InformationCleveland Clinic, Cleveland, OH