Peri-Op Recommendations for Patients with Valvular Heart Disease

From: Circulation
http://circ.ahajournals.org/cgi/content/full/116/17/1971

In symptomatic aortic stenosis, elective noncardiac surgery should generally be postponed or canceled. Such patients require aortic valve replacement before elective but necessary noncardiac surgery. If the aortic stenosis is severe but asymptomatic, the surgery should be postponed or canceled if the valve has not been evaluated within the year. On the other hand, in patients with severe aortic stenosis who refuse cardiac surgery or are otherwise not candidates for aortic valve replacement, noncardiac surgery can be performed with a mortality risk of approximately 10%.27,28 If a patient is not a candidate for valve replacement, percutaneous balloon aortic valvuloplasty may be reasonable as a bridge to surgery in hemodynamically unstable adult patients with aortic stenosis who are at high risk for aortic valve replacement surgery and may be reasonable in adult patients with aortic stenosis in whom aortic valve replacement cannot be performed because of serious comorbid conditions.6,29

Significant mitral stenosis increases the risk of heart failure. However, preoperative surgical correction of mitral valve disease is not indicated before noncardiac surgery, unless the valvular condition should be corrected to prolong survival and prevent complications unrelated to the proposed noncardiac surgery. When the stenosis is severe, the patient may benefit from balloon mitral valvuloplasty or open surgical repair before high-risk surgery.30

In patients with persistent or permanent atrial fibrillation who are at high risk for thromboembolism, preoperative and postoperative therapy with intravenous heparin or subcutaneous low-molecular-weight heparin may be considered to cover periods of subtherapeutic anticoagulation.1,31–33

Patients with a mechanical prosthetic valve are of concern because of the need for endocarditis prophylaxis34 when they undergo surgery that may result in bacteremia and the need for careful anticoagulation management. The Seventh American College of Chest Physicians Consensus Conference on Antithrombotic and Thrombolytic Therapy35 recommends the following: for patients who require minimally invasive procedures (dental work, superficial biopsies), the recommendation is to briefly reduce the international normalized ratio to the low or subtherapeutic range and resume the normal dose of oral anticoagulation immediately after the procedure. Perioperative heparin therapy is recommended for patients in whom the risk of bleeding with oral anticoagulation is high and the risk of thromboembolism without anticoagulation is also high (mechanical valve in the mitral position; Bjork-Shiley valve; recent [ie, less than 1 year] thrombosis or embolus; or 3 or more of the following risk factors: atrial fibrillation, previous embolus at any time, hypercoagulable condition, mechanical prosthesis, and LV ejection fraction less than 30%).36 For patients between these 2 extremes, physicians must assess the risk and benefit of reduced anticoagulation versus perioperative heparin therapy.