Portal de Periódicos da CAPES

EMERGENCY PERCUTANEOUS AORTIC BALLOON VALVULOPLASTY IN A NONAGENARIAN

2008; Wiley; Volume: 57; Issue: 1 Linguagem: Inglês

10.1111/j.1532-5415.2009.02066.x

1532-5415

Sanoj Chacko, Mamas A. Mamas, Satheesh Nair, Matthew Luckie, Tahir Hamid, Vaikom S. Mahadevan,

Aortic Disease and Treatment Approaches

To the Editor: A nonagenarian female was admitted after a mechanical fall that resulted in a fracture of the neck of the femur. She was transferred to the tertiary care center for consideration of urgent hip surgery and was assessed for this purpose. She was found to have an ejection systolic murmur. An echocardiogram revealed critical aortic stenosis (AS) with a peak aortic valve gradient of 142 mmHg and a valve area of 0.4 cm2 (Figure 1). The left ventricular function was impaired, with an ejection fraction of 30%. In keeping with a femoral neck fracture, she was noted to be anemic, with hemoglobin of 7 g/dL. She lived in a residential home with preserved mobility and good quality of life. The orthopedic surgeons decided that she required immediate surgical correction of her hip under general anesthesia because of the high risk of mortality should her fracture be left untreated, but in view of her critical AS, the general anesthetic and surgical risk was considered to be high. Therefore, it was decided to perform an emergency percutaneous balloon aortic valvuloplasty (PBAV) to reduce the risk of general anesthesia before her hip surgery. The procedure was performed successfully through the right femoral artery and resulted in significant reduction in the gradient across the aortic valve to 50 mmHg. The patient tolerated the procedure well, and on the following day, she underwent a successful hip surgery under general anesthesia. She made a remarkable recovery and was subsequently discharged home and remained well on follow-up at 3 months. Echocardiogram showing severely calcified aortic valve with critical gradient across the valve. AS produces fixed left ventricular outflow tract obstruction, and the chronic pressure overload state results in concentric left ventricular hypertrophy, reducing the compliance of the left ventricle and coronary reserve. This renders the patient more susceptible to myocardial ischemia during increased oxygen demand. In addition to this, the fixed cardiac output does not allow the decrease in systemic vascular resistance to be compensated for during general anesthesia, resulting in relative systemic hypotension and myocardial ischemia. For this reason, clinical deterioration can occur in asymptomatic patients with AS during increased hemodynamic stress, such as during noncardiac surgery. Despite advances in anesthesia management, the risk of surgery in patients with AS appears to be high. A retrospective cohort study of patients who underwent noncardiac surgery over a 9-year period in the Netherlands found that a composite end point of perioperative mortality and nonfatal myocardial infarction was more common in patients with AS than in those without (14% vs 2%). Severe AS was defined as an aortic valve area of less than 0.7 cm2 or a mean gradient of 50 mmHg or greater.1 Composite end points were more common in the 16 patients with severe AS (31% vs 11%). This patient had severe AS according to these criteria and would have had a high perioperative mortality risk. The presence of AS, even if asymptomatic, can increase the risk of postoperative adverse cardiac events after noncardiac surgery. The 1977 study that led to the initial Goldman cardiac risk index for noncardiac surgical procedures found that the 23 patients with AS faced a 17% risk of cardiac complications and a 13% cardiac mortality rate,2 and this was reported in a further series.3 PBAV was initially used in mid 1980s and since then it has been used as a palliative procedure for patients with severe AS. Severe AS has been identified as an independent, important risk factor for patients undergoing noncardiac surgery.4 Increasing numbers of octogenarians and nonagenarians are presenting with severe AS for consideration of open heart surgery, and physicians are increasingly confronted by the growing dilemma of finding suitable therapy for elderly patients who are often poorly suited for traditional valve replacement surgery.5 While percutaneous aortic valve implantation is developing as an alternative option for patients with severe AS and are at a high surgical risk for aortic valve replacement this is suitable only for a certain cohort of patients and is still experimental. We report a nonagenarian with critical AS who underwent successful percutaneous aortic valvuloplasty prior to emergent noncardiac surgery. PBAV can be performed in patients with severe AS not suitable for cardiac surgery as a palliation and also to reduce risk for noncardiac surgery, regardless of their age. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Author Contributions: The first and the last authors prepared the case report and all other authors helped with images and modifications of the case report. Sponsor's Role: Not applicable.