Noncardiac surgery in patients with mitral or aortic regurgitation
- Michelle V Conde, MD
Michelle V Conde, MD
- Clinical Professor of Medicine
- University of Texas Health Science Center
- San Antonio
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 . 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 . (See "Auscultation of cardiac murmurs in adults" 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 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 for prosthetic heart valves: Management of bleeding and invasive procedures", section on 'Management of antithrombotic therapy for invasive procedures'.)
- 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; 64:e77.
- 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.
- Desjardins VA, Enriquez-Sarano M, Tajik AJ, et al. Intensity of murmurs correlates with severity of valvular regurgitation. Am J Med 1996; 100:149.
- Lai HC, Lai HC, Lee WL, et al. Mitral regurgitation complicates postoperative outcome of noncardiac surgery. Am Heart J 2007; 153:712.
- Bajaj NS, Agarwal S, Rajamanickam A, et al. Impact of severe mitral regurgitation on postoperative outcomes after noncardiac surgery. Am J Med 2013; 126:529.
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- Frogel J, Galusca D. Anesthetic considerations for patients with advanced valvular heart disease undergoing noncardiac surgery. Anesthesiol Clin 2010; 28:67.
- 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.
- CHRONIC MITRAL REGURGITATION
- Features of mitral regurgitation
- Perioperative risk of mitral regurgitation
- Management of patients with MR
- CHRONIC AORTIC REGURGITATION
- Features of aortic regurgitation
- Perioperative risk of aortic regurgitation
- Management of patients with AR
- SUMMARY AND RECOMMENDATIONS