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RISK FACTORS

Up to 2.9% of adults without known valvular heart disease have moderate to severe valve pathology on screening studies, and some of these patients will be faced with undergoing noncardiac surgery.1 Older patients are more likely to undergo noncardiac surgery and are also more likely to have significant valvular heart disease. In a cohort study of patients over 65 years old undergoing screening echocardiography, newly detected moderate or severe valve disease was uncovered in 6.4%.2 Advanced age and significant coronary artery disease are associated with calcific and degenerative aortic stenosis. Apart from being older, other risk factors for significant valvular heart disease are listed in Table 12-1.

TABLE 12-1Risk Factors for Significant Valvular Heart Disease

VALVULAR HEART DISEASE AND RISK FOR PERIOPERATIVE COMPLICATIONS

Aortic Stenosis

Valvular conditions commonly encountered before noncardiac surgery are significant aortic stenosis, mitral regurgitation, and aortic regurgitation. Other valve abnormalities that may impact outcome in noncardiac surgery are severe mitral stenosis (often accompanied by atrial fibrillation) or severe tricuspid regurgitation especially in the setting of severe pulmonary hypertension. Severe aortic stenosis is defined as an echocardiographic-derived aortic valve area ≤ 1 cm2 or indexed to body surface area ≤ 0.6 cm2/m2, and typically an aortic valve velocity ≥ 4 m/s and mean gradient ≥ 40 mmHg. In general, symptomatic severe aortic stenosis portends a higher perioperative risk than asymptomatic disease.3 The 1977 Goldman Cardiac Risk Index included physical examination-identified significant aortic stenosis as one of the nine variables prospectively predictive of worse postoperative outcomes. In about half of the cases aortic stenosis severity was determined by cardiac auscultation alone.4 However, in the 1999 Revised Cardiac Risk Index (RCRI), critical aortic stenosis was relatively underrepresented and found in only 5 of the 2893 derivation cohort patients (0.2%) and did not correlate with postoperative complications.5 Our contemporary view of the role of aortic stenosis as a risk factor in noncardiac surgery comes from two single-institution tertiary care center reviews, a small prospective observational study, and a large meta-analysis. In a review of 256 patients with severe aortic stenosis who were estimated to be at intermediate or high risk and underwent noncardiac surgery at the Mayo Clinic, aortic stenosis was found to be a risk factor for postoperative heart failure but was not a risk for perioperative mortality.6 In a review of the Cleveland Clinic experience, moderate or severe ...

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