Aortic stenosis and perioperative risk with noncardiac surgery

Summary by Kenneth Phi MD, 12.28.22
https://pubmed.ncbi.nlm.nih.gov/25614427/

The authors proposed the following alternative to the 2014 AHA/ACC criteria for assessing surgical risk with AS with emphasis on mean gradient as opposed to AVA and the use of stress echocardiography to assess increase in valve gradient during exercise.


Take Home Messages:

Patients are at an increased risk for cardiac events during non-cardiac surgery if they have the following:

  • Mean gradient >45-50 mmHg and/or valve area AVA <0.8 cm2

  • Left ventricular systolic dysfunction

  • Symptomatic AS

  • Associated significant mitral regurgitation or other valvular disease

  • ≥18 mm Hg increase in the mean gradient during exercise

  • Significant coronary artery disease 

If a patient satisfies any of these criteria they are deemed as "increased risk" and thus are recommended for aortic valve replacement before non-cardiac surgery if possible. They also recommend cardiology consultation for further investigation and testing (cardiac cath, cardiac mri etc.) to assess obstructive burden if a patient has concurrent CAD. 


The summary of revised recommendations:

Conclusion: Aortic stenosis remains a co-morbidity that increases surgical risk in patients undergoing non-cardiac surgery. The classification of "severe AS" can be difficult to predict increased peri-operative risk based on AHA/ACC criteria. Emphasis on mean gradient in conjunction with other factors such as presence of symptoms and left heart function are better predictors of severe valvular pathology that may warrant replacement prior to undergoing non-urgent non-cardiac surgery.