Among patients who undergo noncardiac surgery, preexisting cardiac disease increases the risk of perioperative morbidity and mortality.1 Specifically, aortic stenosis (AS), which has an estimated 2% prevalence among persons older than 65 years,2,3 is an important risk factor for perioperative cardiac complications in patients who undergo noncardiac surgery, because a valve area <1.0 cm2 typically results in hemodynamic obstruction.4,5 Angina, dyspnea, and syncope are all symptoms that suggest advanced AS, and it is recommended that patients with these symptoms consider valve replacement before undergoing other elective noncardiac procedures.5 The decision to proceed with a noncardiac case in a patient with severe or critical AS is complex, especially when surgery is considered desirable by the surgeon, the patient, and the patient’s family.
Presentation of both cases was reviewed by the IRB at the Medical University of South Carolina. Neither the patients nor their families could be contacted for consent (both patients had died), and no other identifying data are presented in this report. Because we could not contact the patients, the IRB waived the requirement for written consent. Two authors were involved with the intraoperative care of the patient in case 1, and the other 2 authors were involved with case 2.
A patient who was older than 90 years required hip hemiarthroplasty after a fall that resulted in a displaced femoral neck fracture. Notable medical history included hypertension, vascular disease, severe chronic obstructive pulmonary disease, coronary disease, and Alzheimer dementia. A transthoracic echocardiogram revealed critical AS (valve area 0.43 cm2; mean gradient 49 mm Hg) with an ejection fraction of 60%. According to past medical records, the patient had been evaluated and deemed not a candidate for either open aortic valve replacement or transcatheter aortic valve replacement. Preoperative vital signs were stable (arterial blood pressure 98/55 mm Hg, heart rate 91 bpm, peripheral capillary oxygen saturation 92% 2L nasal cannula). Both internal medicine and cardiology were consulted on admission and concluded that the patient was in optimal medical condition. In the preoperative holding area, the attending anesthesiologist and attending surgeon held a discussion with the patient and family. Risks, benefits, and alternatives to hemiarthroplasty were discussed. Because of critical AS and poor pulmonary function, the potential for intra- and postoperative cardiopulmonary morbidity and mortality were also reviewed with the patient.
When it was decided to proceed, regional anesthesia with lumbar plexus and sciatic nerve blocks was chosen as the primary plan. After 2 peripheral IV lines and an arterial line were placed, lumbar plexus and sciatic (Labat approach) nerve blocks were performed easily with a landmark-based approach and minimal sedation (37.5 μg IV fentanyl). The patient’s arterial blood pressure was noted to decrease with block onset, and phenylephrine infusion was initiated to maintain optimal hemodynamics. The nonoperated extremity remained sensate and had full motor function, showing that there was no neuraxial spread.
The arthroplasty proceeded uneventfully. Intraoperatively, only a phenylephrine infusion (15–60 μg/min) and 1000-mg IV acetaminophen were administered. The patient was transferred to the intensive care unit postoperatively for monitoring and later to the floor. Recovery was uneventful. While awaiting discharge to a nursing facility on postoperative day (POD) 7, the patient aspirated, resulting in acute respiratory distress and rapid clinical decline. Despite optimal medical management, the decision was made to withdraw care on POD 11 and allow a natural death.
A patient who was older than 80 years requested right hip arthroplasty for osteoarthritis and progressive hip pain. Medical history consisted of AS, coronary artery disease, hypertension, osteopenia, dementia, gastroesophageal reflux disease, partial blindness, and a coronary artery bypass grafting procedure in 1993. Preoperative testing included transthoracic echocardiography, which revealed severe AS (valve area 0.86 cm2, mean gradient 30 mm Hg, peak gradient 52 mm Hg), moderate-to-severe tricuspid regurgitation, increased right ventricular systolic pressure (39.17 mm Hg), normal left ventricular size, and ejection fraction 50% to 55%. Exercise tolerance was <4 metabolic equivalents. Interestingly, the patient’s cardiologist stated that the patient was a potential transcatheter aortic valve replacement candidate but did not suggest that hip surgery be postponed.
Preoperatively, an anesthesiologist in the preoperative clinic obtained a complete history, discussed the level of risk, and facilitated a preoperative cardiology evaluation. An internal medicine physician saw the patient as well and also recommended a cardiologic evaluation. The intraoperative anesthesia team, consisting of a senior anesthesia resident and anesthesia attending, was then notified of the patient’s high-risk status the day before surgery. The morning of surgery, the patient, patient’s family, anesthesia team, and surgical team reviewed the morbidity and mortality risk associated with surgery. The patient and family agreed to proceed with the operation in an effort to help relieve the patient’s hip pain. Intraoperative management consisted of inserting a preinduction arterial line with FloTrac monitoring (FloTrac Sensor; Edwards Lifesciences, Irvine, CA). General endotracheal anesthesia was induced with etomidate and fentanyl and maintained with isoflurane. Intraoperatively, brief episodes of hypotension were treated easily with low doses of IV phenylephrine. The trachea was extubated successfully, and the patient was taken to the intensive care unit for postoperative monitoring. The patient was transferred to the floor on POD 1 and was discharged home on POD 3. A routine follow-up call on POD 6 revealed that the patient was having “pain under her breast.” On the morning of POD 7, the patient was found deceased at home.
The cases presented are similar in that both patients had AS and both patients died: the first from aspiration and the second from a presumed cardiopulmonary event. Case 2, however, was purely elective, whereas case 1 was more urgent, because hip fractures typically require surgery within 48 hours to minimize the risk of mortality.6
A few publications, albeit small and retrospective, have examined outcomes of patients with AS who undergo urgent inpatient hip fracture repair.7,8 However, little objective data have been published to guide the management of these patients; moreover, the evidence is conflicting. Publications have associated AS with increased rates of major complications and adverse cardiac events in patients who undergo hip fracture repair.7,8 However, 1-year mortality has not been associated with AS in such patients, and 30-day mortality varies.7–9 Interestingly, our first patient died of aspiration pneumonia related to her dementia rather than of causes related to AS. The cause of our second patient’s death is unclear, but her symptomatology suggests a cardiopulmonary event, possibly secondary to thrombosis. Although thrombosis may be the result of a heritable thrombophilic state, hypercoagulability is common after joint replacement.10,11
There is even less evidence to guide operative planning for a patient with severe AS who desires elective hip replacement. Ho et al.12 published a small (n = 22) retrospective study in patients who underwent total hip arthroplasty and who had noncritical, asymptomatic AS (valve area 0.9–1.8 cm2). These patients successfully underwent hypotensive epidural anesthesia without any deaths, myocardial infarctions, strokes, or pulmonary embolism during their hospital stay; however, unlike the patients of Ho et al., our patients both had valve areas <1 cm2. Conversely, Torsher et al.13 reported an 11% incidence of postoperative cardiac complications associated with elective noncardiac surgery in patients with severe AS, and Kertai et al.14 associated moderate to severe AS with a 5-fold increase in the risk of perioperative mortality and nonfatal myocardial infarction. However, a recent, large retrospective study (n = 5646) did not associate AS with an increased rate of adverse cardiac events or mortality in patients who underwent elective noncardiac surgery, whereas it did find such an association in patients who underwent emergency surgery.15 Unfortunately, the degrees of AS were not reported.
Published guidance and expert opinion relating to the moral and ethical dilemmas surrounding geriatric surgery are both sparse and dated. The underlying goal for most surgery, especially in the geriatric population, is to improve life expectancy or to improve quality of life (such as the comfort of the patient) without reducing life expectancy. In fact, there are typically 4 factors that surgeons and anesthesiologists consider when deciding whether to take a patient to the operating room: overall quality of life before and after surgery, the patient’s ability to understand and give permission (i.e., provide informed consent), the willingness of the perioperative team to take risks, and economic considerations.16 Although all these merit discussion, quality of life and willingness of the team to take risks deserve special attention.
Gauging overall postprocedural quality of life, especially in geriatric patients with other severe comorbidities, is extremely difficult and can raise ethical and moral questions regarding the utility of surgery. In case 1, the patient had a painful fracture that required urgent surgical intervention. Through discussion with family, it was determined that the patient’s ability to move freely brought her happiness and quality of life. The family expressed that they would rather allow her to die than to be permanently bedbound, and hemiarthroplasty was chosen. Because the patient was hospitalized, the anesthesia and surgical teams caring for the patient had equal and adequate time to evaluate and jointly agree to proceed with the surgery. The risk of mortality was thoroughly discussed by all members of the care team who agreed to proceed knowing the risk.
In case 2, a nonemergent elective procedure was planned to decrease chronic hip pain. Unfortunately, the intraoperative anesthesia team was not assigned until the night before surgery and had not been able to participate in the previous multidisciplinary discussion related to the patient’s care. Although a discussion related to serious potential morbidity and mortality did occur on the morning of surgery with both the intraoperative anesthesia team and the surgical team, the surgeon stated that it would be disruptive and unfair to the patient to repeat this discussion. This case could have been improved for all parties by selecting the anesthesia team earlier in the process. This would have allowed members to participate in multidisciplinary discussion, contribute to decision making, and agree to assume the risks or identify someone else willing to do so.
Overall, we believe that a strategy to discuss patient options and potentially refuse care for very high-risk patients should include certain points. First, the urgency of surgery needs to be considered. Second, the patient’s expected postoperative quality of life should be discussed, including the patient’s perceived benefits of the procedure. Third, because the perioperative team must agree to take the risk, it should be involved in creating the patient’s perioperative plan. Fourth, all providers should have a nonthreatening avenue to express hesitation or refusal of care for elective cases in which there is a high risk of morbidity and mortality.
With the population rapidly increasing in age and medical technology rapidly developing, it is imperative that our national societies and leading experts in geriatric care start guiding perioperative physicians in the moral and ethical questions of geriatric surgery. Although the American Society of Anesthesiologists has published guidelines for ethical practice, our role as consulting physicians leaves us with ethical duties to the patient, surgeons, and other medical colleagues, and the health care facility where we practice, which can potentially conflict because of increasing production pressure and attention to cost containment with regard to workforce, time, and overall resources.
1. Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ. 2005;173:627–34
2. Stewart BF, Siscovick D, Lind BK, Gardin JM, Gottdiener JS, Smith VE, Kitzman DW, Otto CM. Clinical factors associated with calcific aortic valve disease. Cardiovascular Health Study. J Am Coll Cardiol. 1997;29:630–4
3. Lindroos M, Kupari M, Heikkilä J, Tilvis R. Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. J Am Coll Cardiol. 1993;21:1220–5
4. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O’Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B, Slater EE. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297:845–50
5. Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, Fleisher LA, Froehlich JB, Gusberg RJ, Leppo JA, Ryan T, Schlant RC, Winters WL Jr, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Jacobs AK, Hiratzka LF, Russell RO, Smith SC JrAmerican College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). . ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation. 2002;105:1257–67
6. Perez JV, Warwick DJ, Case CP, Bannister GC. Death after proximal femoral fracture—an autopsy study. Injury. 1995;26:237–40
7. Adunsky A, Kaplan A, Arad M, Mizrahi EH, Gottlieb S. Aortic stenosis in elderly hip fractured patients. Arch Gerontol Geriatr. 2008;46:401–8
8. Leibowitz D, Rivkin G, Schiffman J, Rott D, Weiss AT, Mattan Y, Kandel L. Effect of severe aortic stenosis on the outcome in elderly patients undergoing repair of hip fracture. Gerontology. 2009;55:303–6
9. McBrien ME, Heyburn G, Stevenson M, McDonald S, Johnston NJ, Elliott JR, Beringer TR. Previously undiagnosed aortic stenosis revealed by auscultation in the hip fracture population—echocardiographic findings, management and outcome. Anaesthesia. 2009;64:863–70
10. Zhou X, Qian W, Li J, Zhang P, Yang Z, Chen W, Wu L. Who are at risk for thromboembolism after arthroplasty? A systematic review and meta-analysis. Thromb Res. 2013;132:531–6
11. Salvati EA, Della Valle AG, Westrich GH, Rana AJ, Specht L, Weksler BB, Wang P, Glueck CJ. The John Charnley Award: heritable thrombophilia and development of thromboembolic disease after total hip arthroplasty. Clin Orthop Relat Res. 2005;441:40–55
12. Ho MC, Beathe JC, Sharrock NE. Hypotensive epidural anesthesia in patients with aortic stenosis undergoing total hip replacement. Reg Anesth Pain Med. 2008;33:129–33
13. Torsher LC, Shub C, Rettke SR, Brown DL. Risk of patients with severe aortic stenosis undergoing noncardiac surgery. Am J Cardiol. 1998;81:448–52
14. Kertai MD, Bountioukos M, Boersma E, Bax JJ, Thomson IR, Sozzi F, Klein J, Roelandt JR, Poldermans D. Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery. Am J Med. 2004;116:8–13
15. Andersson C, Jørgensen ME, Martinsson A, Hansen PW, Gustav Smith J, Jensen PF, Gislason GH, Køber L, Torp-Pedersen C. Noncardiac surgery in patients with aortic stenosis: a contemporary study on outcomes in a matched sample from the Danish health care system. Clin Cardiol. 2014;37:680–6
16. Reiss R. Moral and ethical issues in geriatric surgery. J Med Ethics. 1980;6:71–7