Aortic stenosis and elective knee replacement

[Planktonmd]

---

Members do not see this ad.

Ok, this forum is in desperate need of some clinical content so let's see if we can stimulate some thinking:
This is a case i did last week, nothing fancy but many important teaching points:
75 Y/O lady coming for total knee replacement.
PMH is significant for Aortic stenosis diagnosed 5 years ago by some unknown cardiologist with no records available.
She was "cleared for surgery" by some family practitioner, but she does not have a regular primary physician.
She says that she is sedentary, and does not walk too much because of knee pain and back pain.
She does not have dyspnea at rest, no chest pain and no history of syncope.
She had her other knee done 4 months ago under GA and post op continuous femoral nerve block, and it seems she did fine.
CXR shows moderate cardiomegaly and mild pulmonary congestion.
EKG shows LVH.
BP = 160/90, HR= 110 BPM regular.
She is requesting GA because the partner who anesthetized her 4 months ago for the other knee told her that spinal is contraindicated because of her aortic stenosis.
What's the plan??
How do you approach this case??

 

[dhb]

Ok, this forum is in desperate need of some clinical content so let's see if we can stimulate some thinking:
This is a case i did last week, nothing fancy but many important teaching points:
75 Y/O lady coming for total knee replacement.
PMH is significant for Aortic stenosis diagnosed 5 years ago by some unknown cardiologist with no records available.
She was "cleared for surgery" by some family practitioner, but she does not have a regular primary physician.
She says that she is sedentary, and does not walk too much because of knee pain and back pain.
She does not have dyspnea at rest, no chest pain and no history of syncope.
She had her other knee done 4 months ago under GA and post op continuous femoral nerve block, and it seems she did fine.
CXR shows moderate cardiomegaly and mild pulmonary congestion.
EKG shows LVH.
BP = 160/90, HR= 110 BPM regular.
She is requesting GA because the partner who anesthetized her 4 months ago for the other knee told her that spinal is contraindicated because of her aortic stenosis.
What's the plan??
How do you approach this case??

Avoid hypotension hypoxia tachycardia 😀

Aggressive: do the case: Ao stenosis asymptomatic although physical activity limited GA + fem block (i guess some would thrown in a sciatic block, don't know if it's superior to just a fem block)

Defensive: get echo and forward to cardiac surgery if needed.

 

[pushthesux]

Epidural/MAC

Would feel comfortable with GA as backup since she passed that test a few months ago.

Probable art line.

 

[Planktonmd]

Epidural/MAC

Would feel comfortable with GA as backup since she passed that test a few months ago.

Probable art line.

Is a spinal really contraindicated?

 

[huktonfonix]

Now as a purely elective case with virtually no info about the aortic stenosis, its a cancellation with further workup. This is not legally defensible if something goes wrong. The fact that the surgeon didnt see fit to send her to see a cardiologist isn't my issue, they had plenty of time between the replacements. Now, if the case was a trauma/fracture and needed to be repaired, options exist for GA, epidural, CSE with lower dose spinal/epidural supplement, continuous spinal, I would be hesitant to do a full dose spinal without knowing more info about the AS. Since she's sedentary her symptoms (CHF, angina, syncope) may not be present and just because they got lucky a few months back doesnt mean that you will get lucky again.

Now assuming you decided to do the case and really wanted a spinal, I would do a continuous spinal with slow dosing to effect, or have a phenylephrine drip ready to counter the effects of a regular spinal although I dont think the risk/benefit really justifies a spinal in this case.

 

[Planktonmd]

Now as a purely elective case with virtually no info about the aortic stenosis, its a cancellation with further workup. This is not legally defensible if something goes wrong. The fact that the surgeon didnt see fit to send her to see a cardiologist isn't my issue, they had plenty of time between the replacements. Now, if the case was a trauma/fracture and needed to be repaired, options exist for GA, epidural, CSE with lower dose spinal/epidural supplement, continuous spinal, I would be hesitant to do a full dose spinal without knowing more info about the AS. Since she's sedentary her symptoms (CHF, angina, syncope) may not be present and just because they got lucky a few months back doesnt mean that you will get lucky again.

Now assuming you decided to do the case and really wanted a spinal, I would do a continuous spinal with slow dosing to effect, or have a phenylephrine drip ready to counter the effects of a regular spinal although I dont think the risk/benefit really justifies a spinal in this case.

So, this patient is NPO, in the holding area, you are a private practice anesthesiologist and the orthopedic surgeon is the same guy who did surgery on this patient under the care of one of your partners 4 months ago uneventfully.
You will tell him that you are canceling the case because the patient has Aortic Stenosis?
What if he asks you what is different about this surgery since nothing has changed in the patient's symptoms during the past 4 months?
Was your partner wrong in doing the case 4 months ago?

 

[huktonfonix]

yup. I dont think my partner should have done the case 4 months ago. case gets cancelled pending further workup. Especially early on in private practice, I feel its better to be conservative in this case. lucky doesnt equal good. Now is it likely that she has critical AS? No. Is it possible. Yes.

 

[Planktonmd]

yup. I dont think my partner should have done the case 4 months ago. case gets cancelled pending further workup. Especially early on in private practice, I feel its better to be conservative in this case. lucky doesnt equal good. Now is it likely that she has critical AS? No. Is it possible. Yes.

So, you think that early in private practice you should have a low threshold for canceling cases?
What would you expect the "further workup" to show that would make this surgery contraindicated?

 

[isoman2000]

I am going to assume you cannot see an old anesthetic record.
1. The patient may or may not have had a GA, many think the deep sedation for a colonoscopy is "going to sleep" they often just do not know.
2. The surgeon may not know what anesthetic the patient had, I do not know how many times they ask LMA, or tube? Oh it was spinal? or Oh they got a block? It is not what they do all the time all they may really know is that the patient was quiet and still. Maybe this surgeon knows maybe not.
3. Is a spinal contraindicated? No but it is not the safest thing to do, nor is GA, you can do them you could be lucky or who knows it could be your day to crap out.
4. Three in one and Sciatic SHOULD give surgical level anesthesia to the entire leg, so if you are gonna go that would be my choice.
Questions though, why is her HR so damn high at rest? Wouldn't this decrease her coronary perfusion? As pointed out she is not particularly active so she may be asymptomatic at rest but not under stress, and to maintain her pressure I do not think her HR has much higher to go. Why the pulmonary congestion? Is it due to her high heart rate? Does she have murmur?
I would do it but only with PNB and sedation, if the surgeon or patient just HAD to have SAB then off for a cardiology consult to see what she really has.

 

[Planktonmd]

I am going to assume you cannot see an old anesthetic record.
1. The patient may or may not have had a GA, many think the deep sedation for a colonoscopy is "going to sleep" they often just do not know.
2. The surgeon may not know what anesthetic the patient had, I do not know how many times they ask LMA, or tube? Oh it was spinal? or Oh they got a block? It is not what they do all the time all they may really know is that the patient was quiet and still. Maybe this surgeon knows maybe not.
3. Is a spinal contraindicated? No but it is not the safest thing to do, nor is GA, you can do them you could be lucky or who knows it could be your day to crap out.
4. Three in one and Sciatic SHOULD give surgical level anesthesia to the entire leg, so if you are gonna go that would be my choice.
Questions though, why is her HR so damn high at rest? Wouldn't this decrease her coronary perfusion? As pointed out she is not particularly active so she may be asymptomatic at rest but not under stress, and to maintain her pressure I do not think her HR has much higher to go. Why the pulmonary congestion? Is it due to her high heart rate? Does she have murmur?
I would do it but only with PNB and sedation, if the surgeon or patient just HAD to have SAB then off for a cardiology consult to see what she really has.

Previous anesthetic record is available and shows uneventful GA with LMA and femoral nerve catheter.
So it is safe to do this case under PNB but not under GA or Neuraxial anesthesia?
If the plan should be GA or neuraxial then you will only do it if a cardiologist said it's OK to go?

 

[isoman2000]

LMA and femoral previous surgery? Is she the same now as she was then? same tachycardia, same infiltrates? I would still do PNB safer by far.

 

[Planktonmd]

If a cardiologist after an exam says
1. no AS or
2. No significant AS
then yes I could accomodate the surgeon if he just HAS to have SAB, but if any doubt it is my way, yes we can do the surgery but this is the way I am going to do it. I mean I am performing the anesthetic right?

Exactly, this is how you should view this case from a nurse anesthesia point of view but we are trying to address the real decision making process involved in a case like this from an anesthesiologist consultant point of view.

 

[Planktonmd]

LMA and femoral previous surgery? Is she the same now as she was then? same tachycardia, same infiltrates? I would still do PNB safer by far.

Why is a PNB safer by far?

 

[isoman2000]

No sympathectomy fewer risks with patient with AS.

 

[Planktonmd]

No sympathectomy fewer risks with patient with AS.

So, if you are going to do this under PNB you don't care about the severity of her aortic stenosis?
Would you be concerned about the post op phase and the need for physical therapy and if she is going to tolerate that?
What are you going to do about the heart rate of 110 BPM ?
By the way the congestion on the CXR is perihilar.

 

[huktonfonix]

Resting tachycardia of unknown origin, LVH, aortic stenosis of unknown degree, surgical stress. Thats a lot of factors potentially increasing myocardial oxygen demand. Can her supply compensate for this? I dont know the answer, and frankly cannot make an appropriate guess given her limited functional capacity. The only information I have is that she made it through a previous surgery. Was she having ST changes during the past surgery? Did they use a 5 lead ekg and check for ST changes? Does she have some autonomic instability causing the resting tachycardia, is she hypovolemic, or just nervous preop? The evidence isnt the strongest for perioperative B blockade in this situation (assuming she isnt already on one), although it may be useful for her to improve supply/demand.

In answer to the prior question, a preop cardiac workup may show severe/critical aortic stenosis which may be amenable to AVR/valvuloplasty. She may have made it through the first TKR with critical AS and may also make it through this one also, but without knowing the extent of AS and poor functional capacity, I wouldnt risk it again. Lucky doesnt mean right.

 

[bubalus]

I'd do a preop TTE, shoot gradients across the AV and LVOT. Look at diastolic function and particularly filling pressures, and take a look at the intraventricular septum while I'm there. Pulmonary congestion may be related to elevated filling pressures which would make me postpone the case until those can be decreased. If filling pressures are normal, no problem with spinal. She might even like the afterload reduction. However, LVH on EKG may be a hint that her filling pressures may be up. With cardiomegaly on CXR, there's a reasonable chance she's got concentric and eccentric hypertrophy. Definately needs a preop echo. I don't care who has cleared her. Her family practitioner isn't doing the case and probably doesn't know jack.

If she is truly asymptomatic after further questioning, there is some data that stressing these patients can help unmask symptoms and give more prognostic data about their function and progression of disease, so in her case, a stress echo may not be a bad idea. She's got a bum knee, so dobutamine for her. However, if she's symptomatic, stressing her is class III recommendation. And if she's symptomatic, I'd suggest replacing the valve before doing the knee.

If she's got critical AS, valvuloplasty isn't going to work. Her valve will be too calcified and ossified (yes, it really is ossification, not merely calcification). With critical AS, AVR is the answer. With severe AS, AVR may not be the answer. It's not valve area that determines whether you replace the valve. It's symptoms, though there are a few circumstances where AVR may be reasonable in the absence of symptoms.

 

[SleepIsGood]

I think the 'academic' answer is to get an echo and full cardiac workup. this is elective, and it really doesnt matter what the previous anesthesiologist did, this is your call.

However, if I were in PP and had a good relationship with the surgeon AND was confident in my regional abilities....

I would do a continuous fem block and a sciatic/popliteal block. This lady is 'older' so titrated midazolam and propofol incrementally...and bada boom.

 

[periopdoc]

I think the physiological concerns are pretty evident (Aortic stenosis of undefined severity, evidence of CHF on EKG and CXR, unexplained tacchycardia etc) and we are all appropriately concerned about her ability to tolerate perioperative stress at this point in time despite a successful GA 4 months ago.

I want to address the aspect of professional relationships and maintaining them in a group that you are new to. (my CA-3 perspective) and I would like to hear some of our seniors critique my approach.

First and foremost, I do not want to say anything critical, to the patient or the surgeon, of the decision my partner made to proceed with surgery 4 months ago. If I have concerns regarding that decision, I would privately discuss them with him at a later time. I might even learn a thing or two from him/her if I approach that interaction the right way.

Second, I do not want to proceed with this elective case without further cardiac workup. I want to know if the aortic stenosis is critical and needs to be repaired prior to surgery, or alternately is mild and is a non-issue. Granted it is most likely somewhere in between and the test will have little impact on my ultimate anesthetic plan. I would also like a stress echo to evaluate for systolic and diastolic dysfunction and ischemic potential. But I said i would not get into my physiological concerns.

Third, I do not want to immediately garner the reputation with Ortho stud that I am the new anesthesia dick who always cancels cases that more senior partners will do without thinking. It only takes one case to make a reputation for yourself.

So, I think like an ortho stud for a minute. What scares that crap out of ortho stud and will get HIM to delay the case. I approach it something like this.

Call Dr. Ortho Stud from preop... "Dr OS I am seeing LOL in NAD and I am concerned because she is showing signs of worsening CONGESTIVE HEART FAILURE on EKG, CXR, and physical exam. I am concerned that this may cause her some problems on the floor tonight with all of the postoperative fluid shifts and may very well PROLONG HER STAY WITH US. I am also concerned that these issues may impair her ability to tolerate an anesthetic load as well as she did 4 months ago. What do you think?"

Now I suspect this works better if you have a long working relationship. Two months ago I was working with one of our neurosurgeons who NEVER cancels scheduled cases and I had very similar concerns to this case. I said "Dr. NS I am concerned that she has worsening CHF because of increase dyspnea and evidence of LV strain on EKG and exam." Without saying a word to me, he turned and walked over to the patient and said, "I think we need to sort out your heart issues before we operate" and walked off. This was the fruit of a focused effort to cultivate a working relationship with this guy who's personality is obvious from the above interaction.

I think that calling and getting his opinion establishes collegiality and a desire on my part to work with him rather than simply calling up and saying, "hey dude I am delaying this case because of blah blah blah." I think that putting the ball in his court by bringing up issues that he will have to deal with postoperatively will have the desired effect without branding me as the dick.

Thoughts?

pod

-of course you have to ask yourself, "What will be my response if he says damn the chf, operate."

 

[Planktonmd]

I'd do a preop TTE, shoot gradients across the AV and LVOT. Look at diastolic function and particularly filling pressures, and take a look at the intraventricular septum while I'm there. Pulmonary congestion may be related to elevated filling pressures which would make me postpone the case until those can be decreased. If filling pressures are normal, no problem with spinal. She might even like the afterload reduction. However, LVH on EKG may be a hint that her filling pressures may be up. With cardiomegaly on CXR, there's a reasonable chance she's got concentric and eccentric hypertrophy. Definately needs a preop echo. I don't care who has cleared her. Her family practitioner isn't doing the case and probably doesn't know jack.

If she is truly asymptomatic after further questioning, there is some data that stressing these patients can help unmask symptoms and give more prognostic data about their function and progression of disease, so in her case, a stress echo may not be a bad idea. She's got a bum knee, so dobutamine for her. However, if she's symptomatic, stressing her is class III recommendation. And if she's symptomatic, I'd suggest replacing the valve before doing the knee.

If she's got critical AS, valvuloplasty isn't going to work. Her valve will be too calcified and ossified (yes, it really is ossification, not merely calcification). With critical AS, AVR is the answer. With severe AS, AVR may not be the answer. It's not valve area that determines whether you replace the valve. It's symptoms, though there are a few circumstances where AVR may be reasonable in the absence of symptoms.

You said that symptoms decide if surgery on the aortic valve is needed, symptoms of critical aortic stenosis are: Angina, syncope and dyspnea.
She does not have any of these symptoms.
The perihilar congestion, cardiomegaly on CXR and the LVH on EKG are not symptoms and they are certainly common and non specific.
So would you agree that this lady most likely does not need AVR before this surgery?

 

[Planktonmd]

I think the physiological concerns are pretty evident (Aortic stenosis of undefined severity, evidence of CHF on EKG and CXR, unexplained tacchycardia etc) and we are all appropriately concerned about her ability to tolerate perioperative stress at this point in time despite a successful GA 4 months ago.

I want to address the aspect of professional relationships and maintaining them in a group that you are new to. (my CA-3 perspective) and I would like to hear some of our seniors critique my approach.

First and foremost, I do not want to say anything critical, to the patient or the surgeon, of the decision my partner made to proceed with surgery 4 months ago. If I have concerns regarding that decision, I would privately discuss them with him at a later time. I might even learn a thing or two from him/her if I approach that interaction the right way.

Second, I do not want to proceed with this elective case without further cardiac workup. I want to know if the aortic stenosis is critical and needs to be repaired prior to surgery, or alternately is mild and is a non-issue. Granted it is most likely somewhere in between and the test will have little impact on my ultimate anesthetic plan. I would also like a stress echo to evaluate for systolic and diastolic dysfunction and ischemic potential. But I said i would not get into my physiological concerns.

Third, I do not want to immediately garner the reputation with Ortho stud that I am the new anesthesia dick who always cancels cases that more senior partners will do without thinking. It only takes one case to make a reputation for yourself.

So, I think like an ortho stud for a minute. What scares that crap out of ortho stud and will get HIM to delay the case. I approach it something like this.

Call Dr. Ortho Stud from preop... "Dr OS I am seeing LOL in NAD and I am concerned because she is showing signs of worsening CONGESTIVE HEART FAILURE on EKG, CXR, and physical exam. I am concerned that this may cause her some problems on the floor tonight with all of the postoperative fluid shifts and may very well PROLONG HER STAY WITH US. I am also concerned that these issues may impair her ability to tolerate an anesthetic load as well as she did 4 months ago. What do you think?"

Now I suspect this works better if you have a long working relationship. Two months ago I was working with one of our neurosurgeons who NEVER cancels scheduled cases and I had very similar concerns to this case. I said "Dr. NS I am concerned that she has worsening CHF because of increase dyspnea and evidence of LV strain on EKG and exam." Without saying a word to me, he turned and walked over to the patient and said, "I think we need to sort out your heart issues before we operate" and walked off. This was the fruit of a focused effort to cultivate a working relationship with this guy who's personality is obvious from the above interaction.

I think that calling and getting his opinion establishes collegiality and a desire on my part to work with him rather than simply calling up and saying, "hey dude I am delaying this case because of blah blah blah." I think that putting the ball in his court by bringing up issues that he will have to deal with postoperatively will have the desired effect without branding me as the dick.

Thoughts?

pod

-of course you have to ask yourself, "What will be my response if he says damn the chf, operate."

Excellent points.
The art of avoiding conflict while doing the right thing is very important in private practice.
And you never want to accuse one of your partners of making a wrong decision even if you think so, it will damage the image of the whole group.
👍

 

[amyl]

i have seen surgical blocks with mepivicaine for shoulders, can the same be done with a femoral nerve catheter and then switch the solution to ropi on POD1 for ambulation. then weak propofol drip would probably be okay in PP even without defining whats up with the AS, right? 'course i would rather know whats up with the AS but realize that isn't reality in PP. i like periop docs approach... just because it was okay a few months ago pushing a ? change in symptoms or cxr makes that irrelevant. nice way to save your partners face, your butt, patient perception...

 

[isoman2000]

I care about the severity of the AS, she is in failure, the PNB will decrease her pain and the resultant tachycardia or other cardiovascular changes. Her HR is elevated due to heartfailure. by using PNB I avoid the problems associated withn a GA or SAB get the case done keep ortho happy and protect the patient.
Treatment for her AS will be between her and her cardiologist family doc surgeon whoever. It is not anything I can do anything about at this time.

 

[2ndyear]

This is an all too common happening where I work. Cardiology notes that are done at places outside our system that never make it to the chart, stress tests done the day before surgery and the patient shows up at 7 am, no records. Office closed until 8. What do we do?

In this case ideally we want to know how bad the AS is. Since I don't do echo it seems reasonable to delay the case until a bedside TTE can be done. This is purely elective. Of course this results in a mad surgeon who will likely scream, yell, and carry on like a 2 year old. The fact that a partner did the case recently doesn't help. In an ideal world this shouldn't matter, but I don't live in one. From the ortho guys standpoint he did everything right. He sent the patient for 'clearance' and got it. The case was done uneventfully recently. In the real world this has to play into the decision making at least a little bit.

I think the patient has to be involved in the decision making to a large degree. Tell her that there is a very real risk of a bad outcome. There is a chance that she could die. If she agrees to proceed, she or her family still can and will sue you for a bad outcome, but I'd still sleep better knowing that I had the discussion.

I would do the case. I think that the recent general anesthetic and total knee rehab are pretty good indicators of her degree of AS. Preop single shot femoral block and careful induction, LMA placement. I don't trust my combined fem/sciatic blocks to cover tourniquet pain and I'd rather not convert to GA in the middle of things.

Now who would have done the initial case? Same patient, shows up and says she has 'history of AS', no echo, apparently asymptomatic, limited exercise tolerance by ortho problems, and 'cleared' by primary care?

 

[sevo85288]

Echo. Cards consult.

 

[August_Bier]

I care about the severity of the AS, she is in failure, the PNB will decrease her pain and the resultant tachycardia or other cardiovascular changes. Her HR is elevated due to heartfailure. by using PNB I avoid the problems associated withn a GA or SAB get the case done keep ortho happy and protect the patient.
Treatment for her AS will be between her and her cardiologist family doc surgeon whoever. It is not anything I can do anything about at this time.

HR is high from failure - and that is why I would stay away from betablockers. Her CO is HR dependent.

Would also cancel elective case given presentation in CHF possibly from AS. Treatment and management intra-op could change depending on cause for her CHF - this needs to be sorted out first.

 

[dhb]

ability to tolerate perioperative stress

Can you define this? can you grade this versus other types of activities?

 

[Planktonmd]

This is an all too common happening where I work. Cardiology notes that are done at places outside our system that never make it to the chart, stress tests done the day before surgery and the patient shows up at 7 am, no records. Office closed until 8. What do we do?

In this case ideally we want to know how bad the AS is. Since I don't do echo it seems reasonable to delay the case until a bedside TTE can be done. This is purely elective. Of course this results in a mad surgeon who will likely scream, yell, and carry on like a 2 year old. The fact that a partner did the case recently doesn't help. In an ideal world this shouldn't matter, but I don't live in one. From the ortho guys standpoint he did everything right. He sent the patient for 'clearance' and got it. The case was done uneventfully recently. In the real world this has to play into the decision making at least a little bit.

I think the patient has to be involved in the decision making to a large degree. Tell her that there is a very real risk of a bad outcome. There is a chance that she could die. If she agrees to proceed, she or her family still can and will sue you for a bad outcome, but I'd still sleep better knowing that I had the discussion.

I would do the case. I think that the recent general anesthetic and total knee rehab are pretty good indicators of her degree of AS. Preop single shot femoral block and careful induction, LMA placement. I don't trust my combined fem/sciatic blocks to cover tourniquet pain and I'd rather not convert to GA in the middle of things.

Now who would have done the initial case? Same patient, shows up and says she has 'history of AS', no echo, apparently asymptomatic, limited exercise tolerance by ortho problems, and 'cleared' by primary care?

Excellent.
In private practice things are not always either black or white actually they are always some shade of gray.
Although this patient has an ambiguous cardiac history and many elements are missing from her history we know that she is asymptomatic at rest and she never experienced chest pain or syncope.
There is no signs of acute ischemia or old MI on her EKG.
Her systolic BP is 160 and people with critical aortic stenosis can not have a systolic pressure in that range, they simply can't produce high systolic pressure.
She tolerated GA and knee surgery including rehab.
The CXR is compatible with mild LV failure but it is most likely chronic and asymptomatic (her SPO2 on room air was 98%).
Canceling the case will annoy the surgeon, the OR staff and the patient, it will also imply that your partner was wrong proceeding with surgery 4 moths ago.
So, for those who said let's cancel, is it worth it?

 

[huktonfonix]

everyone keeps mentioning that this patient "went through rehab" and therefore assumes that this substitutes for a stress test.. we dont know this. Perhaps her rehab consisted of a lot of range of motion exercise, but not much that would actually stress her heart. The initial information given stated that she was fairly sedentary secondary to her knee and back pain.

 

[seinfeld]

Couple thougths

1. If its my family member i would want to know the gradient and severity of AS before doing the case. I hope no one is suggesting putting work flow or cash flow in front of patient safety.

2. Any case can be done safely, albeit with higher risk of adverse outcome. Once did an open AAA on a patient with moderate-severe AS, patient made it out of the OR. Just keep the patients physiology (Bp, HR, volume status etc) as close to where they live with at home as possible. This may mean doing PNB's/ Epidural, using ALine, Central line etc.

 

[bubalus]

You said that symptoms decide if surgery on the aortic valve is needed, symptoms of critical aortic stenosis are: Angina, syncope and dyspnea.
She does not have any of these symptoms.
The perihilar congestion, cardiomegaly on CXR and the LVH on EKG are not symptoms and they are certainly common and non specific.
So would you agree that this lady most likely does not need AVR before this surgery?

The ACC guidlines refer to symptoms as "angina, syncope, or heart failure" rather than limiting symptoms of heart failure to dyspnea only. From an AVR point of view, I'd talk to her and make sure that she was truly asymptomatic in my opinion, and then she gets a TTE. If her EF is less than 50%, that's a class I recommendation for AVR. I'd also do a dobutamine stress echo. In some studies, she's got a 1 in 3 chance of showing symptoms on DSE. If she shows symptoms there, I'd strongly consider replacing the valve before the knee.

From a TKA point of view, I'd want to know what her filling pressures are. Give me some tissue doppler measurements (E, E' lateral, and E' septal), and I'll tell you specifically what I'd do. A lot can change in 4 months with regard to diastolic function and filling pressures. She may have been fine 4 months ago and not fine now.

I also disagree that she can't have critical AS because her SBP is 160. I've seen patients with critical AS have a BP of 160.

 

[Planktonmd]

The ACC guidlines refer to symptoms as "angina, syncope, or heart failure"

Isn't that what I said?
I didn't think "heart failure" is a symptom, is it?
You said AVR is decided based on symptoms:
If she has no symptoms does she still need an AVR?
Her quality of life does not seem to be affected by her Aortic disease, does she still need an AVR ?

 

[Planktonmd]

From a TKA point of view, I'd want to know what her filling pressures are. Give me some tissue doppler measurements (E, E' lateral, and E' septal), and I'll tell you specifically what I'd do. A lot can change in 4 months with regard to diastolic function and filling pressures. She may have been fine 4 months ago and not fine now.

I also disagree that she can't have critical AS because her SBP is 160. I've seen patients with critical AS have a BP of 160.

So, how is knowing the filling pressures going to influence your anesthetic plan assuming you are not going to tell her to get a new aortic valve before her knee surgery?
And I have to say again that if a patient with critical aortic stenosis that is causing hypoperfusion to the brain (syncope) and to the coronaries (angina), if this patient is unable to produce enough pressure to perfuse the heart or the brain how do you expect him/her to produce a systolic of 160??
If the systolic is 160 I would question the accuracy of the diagnosis.

 

[dhb]

Just keep the patients physiology (Bp, HR, volume status etc) as close to where they live with at home as possible. This may mean doing PNB's/ Epidural, using ALine, Central line etc.

Do you need to know the degree of the AS to do this?

 

[Mman]

If I'm doing the case, I'm going with LP/sciatic blocks. Since there is no such thing as a femoral 3-in-1 block, you need the LP to guarantee surgical anesthesia of the lower extremity.

It'll provide complete anesthesia with practically no hemodynamic change. She could be as awake as she or I want her to be in the OR at that point.

Whether or not this elective case should be done at this point is another question.

 

[Planktonmd]

If I'm doing the case, I'm going with LP/sciatic blocks. Since there is no such thing as a femoral 3-in-1 block, you need the LP to guarantee surgical anesthesia of the lower extremity.

It'll provide complete anesthesia with practically no hemodynamic change. She could be as awake as she or I want her to be in the OR at that point.

Whether or not this elective case should be done at this point is another question.

really?
What if I told you that I have done knee replacement under Sciatic + Femoral blocks many times without any problem?

 

[Mman]

really?
What if I told you that I have done knee replacement under Sciatic + Femoral blocks many times without any problem?

It means that what you miss of the obturator and LFCN you can cover up with a little bit of IV sedation/analgesia if the surgeon is quick on the tourniquet. Three in one block is a myth according to anybody that has looked at it.

 

[Planktonmd]

It means that what you miss of the obturator and LFCN you can cover up with a little bit of IV sedation/analgesia if the surgeon is quick on the tourniquet. Three in one block is a myth according to anybody that has looked at it.

I know that this is what they are teaching you and I know that you have to learn what they teach you, but in medicine nothing is either black or white, everything we do is somewhere in between and I can tell you that I have done TKR numerous times under straight Femoral block + Sciatic block, provided you inject high volume in the femoral (30 cc) and did not need anything else other than 2 mg of Midazolam.
It is good to memorize all these things they tell you but you have to try things a few times before you discredit them.

 

[pd4emergence]

Do the case however you want but I think you should know the severity of this lady's stenosis before you proceed. Get the echo, put her off till later in the day, placate the surgeon however you can and try not to slow him down too much. The other option is to get the partner who orginally did her to do her again. Remember this is a elective procedure.

 

[Planktonmd]

Do the case however you want but I think you should know the severity of this lady's stenosis before you proceed. Get the echo, put her off till later in the day, placate the surgeon however you can and try not to slow him down too much. The other option is to get the partner who orginally did her to do her again. Remember this is a elective procedure.

So, it doesn't matter that she is asymptomatic and never complained of chest pain, dyspnea, or syncope?

 

[pd4emergence]

So, it doesn't matter that she is asymptomatic and never complained of chest pain, dyspnea, or syncope?

It doesn't sound like she really does anything to make herself symptomatic. Regardless, I want to know what her valve is like. I had any old guy with a valve area of 0.7 not too long ago that walked the golf course every day with few symptoms. It was good to know about. It did change the way I approached him from an anesthetic standpoint.

pd4

 

[pgg]

Interesting thread. Especially liked periopdoc's response.

So planktonmd, how'd you end up doing it - or did you delay/cancel?

 

[Planktonmd]

It doesn't sound like she really does anything to make herself symptomatic. Regardless, I want to know what her valve is like. I had any old guy with a valve area of 0.7 not too long ago that walked the golf course every day with few symptoms. It was good to know about. It did change the way I approached him from an anesthetic standpoint.

pd4

It is good to know as much information as possible about the degree of the aortic stenosis but the question is: Do you want to know bad enough that you are willing to cancel the case and annoy several people you work with everyday in the process?
Do you feel that you can't proceed with this case safely without an Echo?

 

[Planktonmd]

Interesting thread. Especially liked periopdoc's response.

So planktonmd, how'd you end up doing it - or did you delay/cancel?

🙂
A line pre-op. Midazolam and 2.5 mg Lopressor preop brought the HR down to 70-80 BPM.
Femoral nerve catheter + GA using LMA.
Uneventful anesthetic and excellent post op course.
This does not mean that it was wrong to delay the case and ask for cardiac workup but there are many ways to do everything in this business and it is important to be flexible as well.

 

[huktonfonix]

CAN I proceed with this case safely? Of course. I treat the guy as if his AVA was 0.5 and proceed as I would if this were an emergency case. SHOULD I do it? No, because this isnt an emergency case and I dont believe this to be in my patients best interest. Also, Im sure there would be a line of expert witnesses willing to hang me out to dry if anything happened to go wrong.

 

[pd4emergence]

Sure you can treat like she has critical aortic stenosis, she would probably do fine and everybody's happy. So why not go this route? The fact is that if she does not do well, I would look back on the case an say that I should have looked at the echo (a non invasive test with no risk). The other issue is informed consent. With an echo, I could tell this lady more in regards to the risk of this anesthetic. If it comes back with an area of 0.5, I tell her she is at a higher risk of complications and she is ok with that, I do the case and she doesn't do well, at least she knew what she was getting into. So yes, I would inconvience the surgeon and the patient to get the echo.

 

[Planktonmd]

CAN I proceed with this case safely? Of course. I treat the guy as if his AVA was 0.5 and proceed as I would if this were an emergency case. SHOULD I do it? No, because this isnt an emergency case and I dont believe this to be in my patients best interest. Also, Im sure there would be a line of expert witnesses willing to hang me out to dry if anything happened to go wrong.

Hey, there will be a line of expert witnesses willing to hang you out to dry no matter what you do.

 

[Planktonmd]

Sure you can treat like she has critical aortic stenosis, she would probably do fine and everybody's happy. So why not go this route? The fact is that if she does not do well, I would look back on the case an say that I should have looked at the echo (a non invasive test with no risk). The other issue is informed consent. With an echo, I could tell this lady more in regards to the risk of this anesthetic. If it comes back with an area of 0.5, I tell her she is at a higher risk of complications and she is ok with that, I do the case and she doesn't do well, at least she knew what she was getting into. So yes, I would inconvience the surgeon and the patient to get the echo.

I think the fear of doing elective surgery on people with aortic stenosis is way over rated and that many of us keep forgetting that the history and physical exam are still valuable tools in evaluating patients in this situation as well as any other situation.
On the other hand I would not criticize anyone for wanting to get more information before proceeding with a case like this one.

 

[OB1🤙]

Tangential CA-1 question- what did you make of her preop HR, and what went into the decision to beta block?

 

[Planktonmd]

Tangential CA-1 question- what did you make of her preop HR, and what went into the decision to beta block?

The tachycardia was probably caused by her anxiety.
Beta blockade in a patient with severe aortic stenosis is tricky because you could very easily put them in heart failure but tachycardia is really bad for these patients and could trigger ischemia.
The fact that her HR was 110 without showing any ST changes was actually reassuring because people with critical aortic stenosis don't tolerate such tachycardia without ischemia.
My goal was to achieve slower heart rate to protect from ischemia without decreasing the cardiac output too much and this is why I gave a small dose of Metoprolol with the preop anxiolytic.