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Anaesthetists as echocardiographers can influence the perioperative management of patients with suspected aortic stenosis

STEINER, L. A.; FILIPOVIC, M.; SKARVAN, K.; SEEBERGER, M. D.

European Journal of Anaesthesiology: July 2000 - Volume 17 - Issue 7 - p 463
Correspondence
Free
SDC

Department of Anesthesia, University of Basel, Kantonsspital, 4031 Basel, Switzerland

Correspondence: L. A. Steiner.

EDITOR:

The use of transoesophageal echocardiography by anaesthetists who have undergone special training in echocardiography is well-established [1]. The following case illustrates a clinical situation in which the use of transthoracic echocardiography by such an anaesthetist efficiently influenced perioperative patient management. An 84-year-old woman was admitted late one evening with a fracture of her left femur requiring treatment by insertion of a dynamic hip-screw. She had a history of coronary artery disease and complained of dyspnoea. Clinical examination revealed a rough systolic murmur with radiation into both carotid arteries. Electrocardiography showed sinus rhythm, frequent premature ventricular contractions and signs of left ventricular hypertrophy, but no signs of a previous myocardial infarction. The chest radiograph showed moderate signs of congestive heart failure, slight cardiac enlargement and calcification of the aortic valve. Severe aortic stenosis was suspected. The anaesthetist in charge was unwilling to proceed with spinal anaesthesia, which was strongly requested by the patient, unless a diagnosis of severe aortic stenosis could be excluded [2]. Because no cardiologist was available to perform echocardiographic assessment of the aortic valve until the next morning, an anaesthetist trained in transthoracic echocardiography performed the diagnostic evaluation. This examination showed moderate aortic stenosis with a peak pressure gradient of 40 mmHg and normal left ventricular function. Surgery was performed that evening using spinal anaesthesia. The perioperative course was uneventful.

The perioperative risk for patients with severe aortic stenosis is relatively high [3] but can be improved if perioperative management is adjusted appropriately [4]. For this reason, and because spinal anaesthesia for patients with severe aortic stenosis is usually not recommended [2], preoperative evaluation of such patients should be mandatory to determine the extent of haemodynamic monitoring and perhaps the anaesthetic technique. Without prompt echocardiographic evaluation, surgery in our patient would have been postponed and the patient's treatment delayed, which could have resulted in a prolonged hospital stay. Preoperative diagnostic echocardiography is traditionally performed by cardiologists. However, if no cardiologist is immediately available, optimal and efficient patient treatment will depend on appropriate training and experience of the echocardiographer rather than on his or her speciality background. If an anaesthetist performs transthoracic echocardiography, s/he should have undergone formal training in a cardiological echocardiography laboratory and needs to work continuously in close co-operation with cardiologists.

L. A. STEINER

M. FILIPOVIC

K. SKARVAN

M. D. SEEBERGER

Department of Anesthesia, University of Basel, Kantonsspital, 4031 Basel, Switzerland

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References

1 Thys DM, Abel M, Bollen BA et al. Practice guidelines for perioperative transesophageal echocardiography: a report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 1996; 84: 986-1006.
2 DeRuyter ML. Aortic stenosis. In: Faust RJ. ed. Anesthesiology Review. New York: Churchill Livingstone, 1994: 369-370.
3 Goldman L, Caldera DL, Nussbaum SR et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977; 297: 845-850.
4 O'Keefe JH Jr, Shub C, Rettke SR. Risk of noncardiac surgical procedures in patients with aortic stenosis. Mayo Clin Proc 1989; 64: 400-405.
© 2000 European Academy of Anaesthesiology