Non-cardiac surgery in patients with severe aortic stenosis: time to revise the guidelines?: Figure 1

This editorial refers to ‘Perioperative risk of major non-cardiac surgery in patients with severe aortic stenosis: a reappraisal in contemporary practice’[†][1], by T. Tashiro et al. , on page 2372. Many patients undergoing major non-cardiac surgery have a high risk of perioperative cardiovascular complications. Several studies have identified variables that are associated with this increased perioperative cardiovascular risk,1–3 including arrhythmias, heart failure, recent myocardial infarction, and ischaemic heart disease. Aortic stenosis (AS) is not always included in cardiac risk prediction models, because it is regularly underdiagnosed and therefore also under-represented in databases and the resulting risk assessment tools. Nevertheless, severe AS is the most prevalent valvular heart disease in the elderly,4 many of whom regularly require non-cardiac surgery. Patients with AS have an obstruction in the outflow tract that gradually results in left ventricular myocardium hypertrophy. Initially, the cardiac output and left ventricular end-diastolic volumes are preserved, permitting patients to stay asymptomatic. Eventually, however, the concentric left ventricular hypertrophy and reduced compliance of the myocardium leads to diastolic dysfunction. At that point, patients develop symptoms of dyspnoea or chest pain due to the increased diastolic pressure of the left ventricle. In addition, the AS causes systemic hypotension and … [1]: #fn-2