Shoot From the Hip? Surgery With Aortic Stenosis COPYRIGHT © 2015, ALL RIGHTS RESERVED From the Publishers of

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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? Copyright © 2015

Surgical Repair Timing of Elderly Hip Fracture Meta-analysis of observational studies If surgery later that hours Copyright © 2015 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 ? Copyright © 2015

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

*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: DOI: /eurheartj/ehu044

Aortic Stenosis and Non Cardiac Surgery 2014 Postop MI Postop CHF Risk highest with: Copyright © 2015 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) ; DOI: /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): doi: /jama

Pearls from the Guys Copyright © 2015 Hip fracture should be fixed within 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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