Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Noncardiac surgery in patients with aortic stenosis

Prashant Vaishnava, MD
Kim A Eagle, MD, MACC
Section Editor
Catherine M Otto, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


Risk models have identified severe aortic stenosis (AS) as a major clinical predictor of adverse outcomes [1]. Population studies from the United States and Europe have reported AS in approximately 1 to 2 percent of individuals 65 to 75 years old with prevalence increasing to 3 to 8 percent in individuals ≥75 years old [2-6]. In the Helsinki Aging study, nearly 3 percent of the individuals between 75 and 86 years of age had critical AS [3]. Patients with AS frequently have concurrent cardiovascular disease with approximately half of patients with AS aged 50 years and older having concomitant coronary heart disease [7,8]. (See "Clinical manifestations and diagnosis of aortic stenosis in adults" and "Evaluation of cardiac risk prior to noncardiac surgery" and "Valvular heart disease in elderly adults", section on 'Underlying atherosclerosis'.)

The presence of valvular disease has potentially important implications for perioperative management as well as perioperative risk. The perioperative considerations in patients with native aortic valve stenosis who are undergoing noncardiac surgery will be reviewed here. The perioperative management of patients with aortic regurgitation, mitral valve disease, and prosthetic heart valves is discussed elsewhere. (See "Noncardiac surgery in patients with mitral or aortic regurgitation" and "Medical management and indications for intervention for mitral stenosis" and "Overview of the management of patients with prosthetic heart valves" and "Antithrombotic therapy for prosthetic heart valves: Indications".)


Aortic stenosis (AS) results in fixed obstruction to left ventricular (LV) emptying. The stenotic process is usually gradual in onset and progression, giving the heart ample opportunity to adapt. The LV myocardium hypertrophies over time, resulting in the generation of greater pressure during systole, which forces blood past the fixed mechanical obstruction. As a result, the cardiac output and LV end-diastolic volume are maintained and patients can remain asymptomatic for a prolonged period of time, even with severe AS. (See "Clinical manifestations and diagnosis of aortic stenosis in adults" and "Natural history, epidemiology, and prognosis of aortic stenosis".)

However, the chronic pressure overload state that results in the compensatory concentric LV hypertrophy also reduces the compliance of the left ventricle. As a result, diastolic dysfunction develops over time, the end diastolic pressure of the LV increases, and patients eventually develop symptoms of chest pain or dyspnea. The concentric hypertrophy also reduces coronary flow reserve, rendering the patient more susceptible to ischemia in situations of increased myocardial oxygen demand, even in the absence of obstructive coronary artery disease [9]. In addition, due to fixed obstruction of the LV outflow tract, decreases in systemic vascular resistance can result in relative systemic hypotension and subsequent ischemia from reduced coronary perfusion. An additional potential cause of hypotension in patients with AS is elevated LV pressures causing mechanoreceptor stimulation and reflex bradycardia and/or systemic vasodilation. (See "Clinical manifestations and diagnosis of aortic stenosis in adults".)

Therefore, clinical deterioration can occur in patients with asymptomatic AS during the hemodynamic stress associated with noncardiac surgery (as well as other states that require augmentation of cardiac output such as infection, anemia, or pregnancy). The hemodynamic stress of noncardiac surgery is a combination of anesthetic and surgical stress.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Dec 22, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  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; 64:e77.
  2. Stewart BF, Siscovick D, Lind BK, et al. Clinical factors associated with calcific aortic valve disease. Cardiovascular Health Study. J Am Coll Cardiol 1997; 29:630.
  3. Lindroos M, Kupari M, Heikkilä J, Tilvis R. Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. J Am Coll Cardiol 1993; 21:1220.
  4. Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: a population-based study. Lancet 2006; 368:1005.
  5. Iung B, Vahanian A. Epidemiology of valvular heart disease in the adult. Nat Rev Cardiol 2011; 8:162.
  6. Eveborn GW, Schirmer H, Heggelund G, et al. The evolving epidemiology of valvular aortic stenosis. the Tromsø study. Heart 2013; 99:396.
  7. Mullany CJ, Elveback LR, Frye RL, et al. Coronary artery disease and its management: influence on survival in patients undergoing aortic valve replacement. J Am Coll Cardiol 1987; 10:66.
  8. Levinson JR, Akins CW, Buckley MJ, et al. Octogenarians with aortic stenosis. Outcome after aortic valve replacement. Circulation 1989; 80:I49.
  9. Banovic MD, Vujisic-Tesic BD, Kujacic VG, et al. Coronary flow reserve in patients with aortic stenosis and nonobstructed coronary arteries. Acta Cardiol 2011; 66:743.
  10. Etchells E, Bell C, Robb K. Does this patient have an abnormal systolic murmur? JAMA 1997; 277:564.
  11. Etchells E, Glenns V, Shadowitz S, et al. A bedside clinical prediction rule for detecting moderate or severe aortic stenosis. J Gen Intern Med 1998; 13:699.
  12. Munt B, Legget ME, Kraft CD, et al. Physical examination in valvular aortic stenosis: correlation with stenosis severity and prediction of clinical outcome. Am Heart J 1999; 137:298.
  13. 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.
  14. Green SJ, Pizzarello RA, Padmanabhan VT, et al. Relation of angina pectoris to coronary artery disease in aortic valve stenosis. Am J Cardiol 1985; 55:1063.
  15. Chobadi R, Wurzel M, Teplitsky I, et al. Coronary artery disease in patients 35 years of age or older with valvular aortic stenosis. Am J Cardiol 1989; 64:811.
  16. Lombard JT, Selzer A. Valvular aortic stenosis. A clinical and hemodynamic profile of patients. Ann Intern Med 1987; 106:292.
  17. Graboys TB, Cohn PF. The prevalence of angina pectoris and abnormal coronary arteriograms in severe aortic valvular disease. Am Heart J 1977; 93:683.
  18. Samuels B, Kiat H, Friedman JD, Berman DS. Adenosine pharmacologic stress myocardial perfusion tomographic imaging in patients with significant aortic stenosis. Diagnostic efficacy and comparison of clinical, hemodynamic and electrocardiographic variables with 100 age-matched control subjects. J Am Coll Cardiol 1995; 25:99.
  19. Patsilinakos SP, Spanodimos S, Rontoyanni F, et al. Adenosine stress myocardial perfusion tomographic imaging in patients with significant aortic stenosis. J Nucl Cardiol 2004; 11:20.
  20. Demirkol MO, Yaymaci B, Debeş H, et al. Dipyridamole myocardial perfusion tomography in patients with severe aortic stenosis. Cardiology 2002; 97:37.
  21. Kertai MD, Bountioukos M, Boersma E, et al. Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery. Am J Med 2004; 116:8.
  22. Agarwal S, Rajamanickam A, Bajaj NS, et al. Impact of aortic stenosis on postoperative outcomes after noncardiac surgeries. Circ Cardiovasc Qual Outcomes 2013; 6:193.
  23. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977; 297:845.
  24. Goldman L. Aortic stenosis in noncardiac surgery: underappreciated in more ways than one? Am J Med 2004; 116:60.
  25. Zahid M, Sonel AF, Saba S, Good CB. Perioperative risk of noncardiac surgery associated with aortic stenosis. Am J Cardiol 2005; 96:436.
  26. Torsher LC, Shub C, Rettke SR, Brown DL. Risk of patients with severe aortic stenosis undergoing noncardiac surgery. Am J Cardiol 1998; 81:448.
  27. Leibowitz D, Rivkin G, Schiffman J, et al. Effect of severe aortic stenosis on the outcome in elderly patients undergoing repair of hip fracture. Gerontology 2009; 55:303.
  28. Tashiro T, Pislaru SV, Blustin JM, et al. Perioperative risk of major non-cardiac surgery in patients with severe aortic stenosis: a reappraisal in contemporary practice. Eur Heart J 2014; 35:2372.
  29. Calleja AM, Dommaraju S, Gaddam R, et al. Cardiac risk in patients aged >75 years with asymptomatic, severe aortic stenosis undergoing noncardiac surgery. Am J Cardiol 2010; 105:1159.
  30. Vincentelli A, Susen S, Le Tourneau T, et al. Acquired von Willebrand syndrome in aortic stenosis. N Engl J Med 2003; 349:343.
  31. Raymer K, Yang H. Patients with aortic stenosis: cardiac complications in non-cardiac surgery. Can J Anaesth 1998; 45:855.
  32. Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451.
  33. Levine MJ, Berman AD, Safian RD, et al. Palliation of valvular aortic stenosis by balloon valvuloplasty as preoperative preparation for noncardiac surgery. Am J Cardiol 1988; 62:1309.
  34. Roth RB, Palacios IF, Block PC. Percutaneous aortic balloon valvuloplasty: its role in the management of patients with aortic stenosis requiring major noncardiac surgery. J Am Coll Cardiol 1989; 13:1039.
  35. Hayes SN, Holmes DR Jr, Nishimura RA, Reeder GS. Palliative percutaneous aortic balloon valvuloplasty before noncardiac operations and invasive diagnostic procedures. Mayo Clin Proc 1989; 64:753.
  36. Mittnacht AJ, Fanshawe M, Konstadt S. Anesthetic considerations in the patient with valvular heart disease undergoing noncardiac surgery. Semin Cardiothorac Vasc Anesth 2008; 12:33.
  37. Christ M, Sharkova Y, Geldner G, Maisch B. Preoperative and perioperative care for patients with suspected or established aortic stenosis facing noncardiac surgery. Chest 2005; 128:2944.
  38. Goertz AW, Lindner KH, Seefelder C, et al. Effect of phenylephrine bolus administration on global left ventricular function in patients with coronary artery disease and patients with valvular aortic stenosis. Anesthesiology 1993; 78:834.
  39. Goertz AW, Lindner KH, Schütz W, et al. Influence of phenylephrine bolus administration on left ventricular filling dynamics in patients with coronary artery disease and patients with valvular aortic stenosis. Anesthesiology 1994; 81:49.