Pre‐operative detection of valvular heart disease by anaesthetists

Abstract

SummaryWe prospectively estimated the prevalence of heart murmurs in 2522 consecutive adult noncardiac surgery patients during pre-operative evaluation. Factors that contribute to the detection of a heart murmur were identified, and echocardiography was used to evaluate to what extent a murmur reflected presence of valvular heart disease. A cardiac murmur was detected in 106 patients (prevalence 4.2%, 95% CI: 3.5-5.1%). Multivariable logistic regression analyses showed that age and general physical impression were independently associated with detecting a murmur (p-values < 0.01). In 83 (79%) of the patients with a murmur, an echocardiographic diagnosis was available: 39% had aortic valve abnormalities, 24% had mitral valve regurgitation, 7% had other valvular heart disease and 30% did not have any abnormality. Thus, 58 of the 83 patients had valvular heart disease (positive predictive value using routine cardiac auscultation for diagnosing VHD: 70%, 95% CI: 59-79%). Murmurs in patients younger than 40 years never reflected valvular heart disease. Pre-operative cardiac auscultation seems only reasonable in patients aged 40 years or older. Subsequent echocardiography in these selected patients is necessary.

The impact of focused transthoracic echocardiography in the pre‐operative clinic

“…A TTE at rest primarily evaluates functional and anatomical abnormalities, is a poor discriminator for active coronary artery disease and is not a substitute for pre-operative stress testing. In addition, a normal TTE study does not rule out all possible cardiac pathology (2) No TOE (2) AS, aortic stenosis; CVP, central venous pressure; HDU, high dependency unit; LV, left ventricular; PHT, pulmonary hypertension; TOE, intra-operative transoesophageal echocardiography. The number in parenthesis refers to the number of patients.…”

The impact of pre‐operative focused transthoracic echocardiography in emergency non‐cardiac surgery patients with known or risk of cardiac disease

“…Successful use of focused TTE by emergency [21], intensive care [22] and trainee physicians [23] has also been demonstrated. The ability to discriminate haemodynamically significant from nonsignificant aortic stenosis is important as it is a significant risk factor for postoperative mortality [6], is relatively common [5], is often poorly assessed clinically [8,9] and may be asymptomatic even if severe [24]. This has been achieved by focused TTE without the use of quantitative Doppler (standard with comprehensive TTE) in this study, and by others [25][26][27][28] by using 2D assessment of cusp separation.…”

“…Accurate pre-operative cardiac assessment is important to devise the most appropriate anaesthetic plan [2]. Aortic stenosis, common in the hip fracture population [5], and pulmonary hypertension are significant risk factors for mortality [6,7], but diagnosis is unreliable without echocardiography [8,9]. In addition, other abnormal haemodynamic states such as hypovolaemia, left ventricular systolic and ⁄ or diastolic failure, right heart failure and vasodilatation (for example, in sepsis) often accompany acute surgical disease, and may contribute to impaired cardiac output and tissue…”

Routine Preoperative Echocardiograms in Select Patients with Adolescent Idiopathic Scoliosis Rarely Show Abnormalities and do not Predict Adverse Cardiovascular Events

“…In comparison with their control populations, they noted mitral valve prolapse to occur at four times the rate in patients with AIS [5,12]. However, prior data has shown no higher perioperative risk with the finding of mitral valve prolapse in asymptomatic patients [25]. Li et al [22] showed a significant decrease in RV ejection fraction in patients with severe scoliosis (major curve angles >80º) using the tricuspid annular plane systolic excursion as a surrogate for ejection fraction.…”