Anaesthetic management of severe aortic stenosis in a geriatric patient undergoing dynamic hip screw fixation

Aruna Manaswini Murugesan

Junior Consultant – Department of Anaesthesiology, Kauvery Hospital, Cantonment, Trichy

Abstract

We report a 78-year-old male with severe aortic stenosis (AS), defined by an aortic valve area of 0.7 cm² and a mean pressure gradient of 45 mmHg, who underwent dynamic hip screw (DHS) fixation under epidural and spinal anaesthesia. Anaesthetic management in such high-risk cardiac patients undergoing non-cardiac surgery is challenging due to the risks of hypotension, myocardial ischemia, and sudden cardiac arrest. A carefully titrated low-dose regional anaesthetic technique, coupled with vigilant hemodynamic monitoring, contributed to a successful perioperative outcome.

Keywords

Aortic stenosis; regional anaesthesia; spinal-epidural; geriatric anaesthesia; dynamic hip screw fixation; high-risk surgery.

Introduction

Severe aortic stenosis is a significant perioperative risk factor, particularly in elderly patients undergoing non-cardiac surgery⁽¹⁾. AS limits the cardiac ability to augment cardiac output in response to anaesthetic-induced vasodilation or blood loss, increasing the risk of hypotension, myocardial ischemia, and perioperative mortality⁽²⁾. Although general anaesthesia is often used in such cases, regional techniques—when appropriately tailored—can be safely employed, particularly for lower limb orthopedic procedures.

Case presentation

A 78-year-old male (62 kg), living with hypertension and diabetes, diagnosed to have severe aortic stenosis, was admitted following a domestic fall resulting in a left hip fracture. His functional capacity was New York Heart Association (NYHA) Class II. Pre-operative echocardiography indicated Aortic valve area to be 0.7 cm², with mean transvalvular gradient of 45 mmHg, Left Ventricular ejection fraction (LVEF) of 55%, concentric left ventricular hypertrophy and no significant mitral or tricuspid valve disease.

Routine blood investigations were within normal limits. Cardiology consultation was obtained and the patient was categorized as high risk based on the Revised Cardiac Risk Index (RCRI).

In the operating theatre, standard monitors were attached, two large-bore (18G) intravenous lines were secured, and an invasive arterial line was established. Vasopressors (phenylephrine and noradrenaline) were prepared and kept ready for immediate use.

With the patient in a sitting position, an epidural catheter was placed at the L2–L3 intervertebral space using an 18G Tuohy needle. Spinal anaesthesia was then administered at the L3–L4 level using a 27G Whitacre needle, with 0.7 mL of 0.5% hyperbaric bupivacaine and 25 mcg of fentanyl.

Continuous ECG, pulse oximetry, and invasive blood pressure monitoring were maintained throughout. Epidural top-ups with 3–5 mL of 0.75% ropivacaine were administered incrementally to achieve and maintain a sensory level at T10, which was reached gradually over 15 min.

The surgical procedure lasted 160 min, with minimal blood loss (~200 mL). Fluid management was meticulously maintained. Blood pressure remained stable throughout, with systolic values between 110–130 mmHg. No episodes of bradycardia, hypotension, or arrhythmias occurred.

Postoperatively, the patient was monitored in the recovery area. Analgesia was maintained via continuous epidural infusion of 0.2% ropivacaine at 5 mL/hr. The patient remained hemodynamically stable and was shifted to the ward on postoperative day (POD) 1. He was discharged uneventfully on POD 7.

Discussion

Severe aortic stenosis poses a significant risk in the perioperative period due to the fixed cardiac output state and vulnerability to changes in preload and afterload. Comprehensive preoperative assessment and meticulous intraoperative management are essential to minimize complications.

In symptomatic patients, aortic valve intervention is generally advised before elective surgery.⁽³⁾ However, in asymptomatic patients, with moderate risk, elective non-cardiac surgeries can be proceeded under close monitoring, as per 2014 ACC/AHA guidelines on valvular heart disease.⁽⁴⁾

Key anaesthetic goals in AS include

Avoiding hypotension and vasodilation
Maintaining sinus rhythm and adequate preload
Preventing tachycardia and myocardial ischemia
Preserving coronary perfusion pressure

While regional anaesthesia is often avoided due to concerns about sympathetic blockade and hypotension, recent studies indicate that it may be associated with a lower incidence of myocardial infarction and deep vein thrombosis compared to general anaesthesia in hip fracture surgery⁽⁵⁾.

In this case, a low-dose spinal anaesthetic combined with a carefully titrated epidural approach allowed gradual sympathetic blockade, minimizing hemodynamic fluctuations. Preemptive vasopressor readiness and strict fluid management further contributed to hemodynamic stability. Phenylephrine increases coronary perfusion pressure without significant chronotropic effects and may also improve left ventricular filling dynamics, possibly by increasing left atrial pressure⁽⁶⁾.

This approach illustrates that with careful planning and execution, regional anaesthesia can be a safe and effective alternative to general anaesthesia in lower limb surgeries, even in patients with severe AS.

Conclusion

This case highlights that with thorough preoperative assessment, appropriate planning, and vigilant intraoperative management, neuraxial anaesthesia can be safely administered in patients with severe aortic stenosis undergoing lower limb orthopedic surgery. Low-dose, titrated regional anaesthesia offers a viable alternative to general anaesthesia in select high-risk patients.

References

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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(22):e77–137.
Task Force for Pre-operative Cardiac Risk Assessment and Peri-operative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC); European Society of Anaesthesiology (ESA). Guidelines for pre-operative cardiac risk assessment and peri-operative cardiac management in non-cardiac surgery. Eur Heart J. 2009;30(22):2769–812.
Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297(16):845–50

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Anaesthetic management of severe aortic stenosis in a geriatric patient undergoing dynamic hip screw fixation