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Noncardiac surgery in patients with mitral or aortic regurgitation

INTRODUCTION

Significant valvular heart disease is a clinical predictor for increased cardiac risk for patients undergoing noncardiac surgery as noted in the 2014 American College of Cardiology/American Heart Association guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery [1]. The guideline notes that moderate-to-severe or severe mitral regurgitation (MR) or aortic regurgitation (AR) convey increased cardiac risk during noncardiac surgery, though these lesions are generally better tolerated that stenotic valvular disease such as aortic stenosis and mitral stenosis.

The diagnosis of valve disease may have been previously established or a cardiac murmur may be auscultated during the preoperative examination. The quality, intensity, timing, and location of the murmur help distinguish a pathologic from a functional murmur but are of limited utility for evaluation of the severity or functional consequences of valve regurgitation. If valvular heart disease is suspected due to symptoms, a murmur auscultated on physical exam, or incidental findings on chest imaging or non-invasive imaging, then an echocardiogram is appropriate and findings should be correlated clinically with symptoms and evaluation [2]. (See "Auscultation of cardiac murmurs" and "Physiologic and pharmacologic maneuvers in the differential diagnosis of heart murmurs and sounds".)

The following perioperative issues are of particular concern in certain subgroups of patients:

For patients who have undergone a prior valve intervention, the type of the noncardiac procedure to be performed (eg, dental) along with the presence of a prosthetic valve (or prosthetic material used in valve repair) will determine whether antimicrobial prophylaxis is indicated for bacterial endocarditis. (See "Antimicrobial prophylaxis for bacterial endocarditis".)

In patients receiving chronic anticoagulant therapy (eg, those anticoagulated for atrial fibrillation or a mechanical prosthetic valve), interruption of anticoagulation prior to noncardiac surgery may be required. (See "Perioperative management of patients receiving anticoagulants" and "Antithrombotic therapy in patients with prosthetic heart valves", section on 'Interruption of warfarin for surgical procedures'.)

         

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Literature review current through: Nov 2014. | This topic last updated: Oct 21, 2014.
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References
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  1. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014.
  2. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
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  8. Lai HC, Lai HC, Lee WL, et al. Impact of chronic advanced aortic regurgitation on the perioperative outcome of noncardiac surgery. Acta Anaesthesiol Scand 2010; 54:580.