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Noncardiac surgery in patients with mitral or aortic regurgitation


Severe valvular disease is a high-risk clinical predictor as identified in the 2007 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for perioperative cardiovascular evaluation for noncardiac surgery [1]. While severe aortic stenosis and symptomatic mitral stenosis were identified as salient examples of severe valvular disease, the guidelines also note that further evaluation may be required in patients with severe symptomatic mitral regurgitation (MR) or aortic regurgitation (AR).

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 a systolic murmur Grade 3 or greater or any diastolic murmur is present on preoperative examination, an echocardiogram is appropriate. The findings also should be correlated clinically with symptoms. (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:

The type of the procedure performed 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 with mitral regurgitation and atrial fibrillation or with 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: Sep 2014. | This topic last updated: Oct 2, 2012.
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  1. Fleisher LA, Beckman JA, Brown KA, et al. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American college of cardiology foundation/American heart association task force on practice guidelines. Circulation 2009; 120:e169.
  2. Desjardins VA, Enriquez-Sarano M, Tajik AJ, et al. Intensity of murmurs correlates with severity of valvular regurgitation. Am J Med 1996; 100:149.
  3. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
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