Shoot From the Hip?

Surgery With Aortic Stenosis

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Dear Guys:

Need your help with a tough one.

We just admitted an 82 year old woman with a hip fracture. She lives independently

and despite her age is moderately active. She maintains her apartment and cooks,

cleans, and does her own grocery shopping. She has no medical problems. Today

she tripped on a rug in her apartment and fell. She could not stand and called for

help.

She has been found to have a right intertrochanteric fracture.

Exam:•BP 150/70, HR 80, Respirations 14

•JVP normal

•Lungs clear

•III/VI crescendo-decrescendo murmur heard in the aortic area radiating to carotid

arteries and precordium.

•ECG: NSR, LVH

•Echo: normal LV function (LV EF 60%)

•Aortic valve thickened and calcified with markedly restricted motion. Mean aortic

valve gradient 50 mmHg compatible with critical aortic stenosis.

So the question for you two is: what do we do now? Do we fix her aortic valve

(valvuloplasty, vs TAVR, vs AVR) or do we bite the bullet and fix the hip?

Dear Guys:

Need your help with a tough one.

We just admitted an 82 year old woman with a hip fracture. She lives independently

and despite her age is moderately active. She maintains her apartment and cooks,

cleans, and does her own grocery shopping. She has no medical problems. Today

she tripped on a rug in her apartment and fell. She could not stand and called for

help.

She has been found to have a right intertrochanteric fracture.

Exam:•BP 150/70, HR 80, Respirations 14

•JVP normal

•Lungs clear

•III/VI crescendo-decrescendo murmur heard in the aortic area radiating to carotid

arteries and precordium.

•ECG: NSR, LVH

•Echo: normal LV function (LV EF 60%)

•Aortic valve thickened and calcified with markedly restricted motion. Mean aortic

valve gradient 50 mmHg compatible with critical aortic stenosis.

So the question for you two is: what do we do now? Do we fix her aortic valve

(valvuloplasty, vs TAVR, vs AVR) or do we bite the bullet and fix the hip?

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Surgical Repair Timing of Elderly Hip Fracture

Meta-analysis of observational studiesIf surgery later that 48-72 hours

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• Increased mortality• Increased pneumonia• Increased pressure

sores

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Cause and Effect of Surgical Delay

Most of the risk for mortality is explained by the medical reason for the delay and the not the delay itself

Early surgery for older patients with hip fracture when no medical contraindication

Optimal timing for surgery in those with clinical instability needs to be determined

So is the aortic stenosis a reason to delay the surgery ?

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*Agarwal S. et al. Impact of Aortic Stenosis on Postoperative Outcomes After Noncardiac Surgeries. Circulation: Cardiovascular Quality and Outcomes. 2013; 6: 193-200

*Tashiro T. et al. Perioperative risk of major non-cardiac surgery in patients with severe aortic stenosis: a reappraisal in contemporary practice. European Heart Journal. 2014; 35: 2372-2381. DOI:10.1093/eurheartj/ehu044

Aortic Stenosis and Non Cardiac Surgery 2014

Postop MIPostop CHFRisk highest with:

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• High risk surgery• Severe symptomatic

AS• Co-existing mitral

regurgitation• Pre-existing CAD• Emergency surgery

*Vahanian AV. Et al. Guidelines on the Management of Valvular Heart Disease. European Heart Journal Oct 2012, 33 (19) 2451-2496; DOI: 10.1093/eurheartj/ehs109

*Patorno E. et al. Comparative safety of anesthetic type for hip fracture surgery in adults: retrospective cohort study. BMJ. 2014; 348 :g4022.

*Neuman MD. et al. Anesthesia Technique, Mortality, and Length of Stay After Hip Fracture Surgery. JAMA. 2014;311(24):2508-2517. doi:10.1001/jama.2014.6499.

Pearls from the Guys

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Hip fracture should be fixed within 48-72 hours.The risk of cardiac complication related to noncardiac

surgery for the patient who has severe aortic stenosis is lower than historical teaching.

In the patient with severe aortic stenosis the risk of noncardiac surgery is lower if the patient’s aortic stenosis is asymptomatic.

Overall there is no evidence that regional anesthesia for hip fracture surgery is safer than general. • For the patient with severe AS hypotension is

especially bad. We believe that collaboration with anesthesiology is essential for this patient group.

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