The Patient With Aortic Stenosis

Abstract

A 55-year-old-woman presented with a pancreatic head mass requiring a pancreaticoduodenectomy. Her medical history was significant for aortic stenosis, chronic obstructive pulmonary disease, and daily tobacco use. Daily medications included albuterol inhalers, aspirin, furosemide, and enalapril. She denied dyspnea, angina, or syncope and was not in any apparent distress. Her blood pressure measured 135/78 mm Hg, pulse was 70 beats per minute, and she was breathing approximately 16 times a minute.The lung fields were clear bilaterally except for occasional wheezing. Cardiac examination revealed a grade III/VI systolic murmur that could be heard best in the right second intercostal space and it radiated to the neck. The patient had strong pulses, and there was no evidence of cyanosis or peripheral edema. Chest x-ray revealed a somewhat enlarged cardiac silhouette with slightly hyperinflated lungs. An echocardiogram revealed aortic stenosis, trace aortic insufficiency, and left ventricular hypertrophy. The gradient across the aortic valve was estimated to be 90 mm Hg.Pulmonary and peripheral artery catheters and a thoracic epidural catheter were placed preoperatively. She tolerated the surgical procedure well. The epidural catheter was removed on postoperative day 4 and she was discharged home 4 days later.Aortic stenosis (AS) is the most common valvular lesion among patients in the United States, affecting approximately 5 of every 10,000 people. It affects 21% to 26% of adults over 65 years of age. Eighty percent of adults with symptomatic AS are male. One percent to 2% of the population has a bicuspid aortic valve that is prone to stenosis. 1 Aortic sclerosis also progresses with age, causing narrowing of the orifice, and as the population ages, the prevalence of AS consequently increases. For adults over 85 years of age, the prevalence of aortic sclerosis and stenosis is 48% and 4%, respectively. 2 The clinical predictors associated with coronary atherosclerosis are similar to those associated with AS and include advanced age, male sex, 21

Do radial arterial pressure curves have diagnostic validity for identify severe aortic stenosis?

“…It exhibits few clinical symptoms such as angina, syncope, dyspnea, or other symptoms of heart failure until the valve area is severely reduced. Because patients with AS are at significant risk with regard to perioperative morbidity and mortality, the diagnosis of AS and proper anesthetic management, such as the maintenance of normovolemia and sinus rhythm and the avoidance of hypotension and tachycardia, are essential [3]. The importance of preanesthetic evaluation cannot be overemphasized.…”

“…Knowledge about the diagnostic validity of radial arterial pressure curves for identify severe AS is important, because it may lead to prompt echocardiographic examination for AS or, at least, recognition of this possibility may change anesthetic management and reduce perioperative morbidity [3].…”