Valvular heart disease is a common cardiovascular disorder, with an estimated prevalence of 2.5% in the United States. The disease is particularly burdensome in adults over 75 years of age, with 13.3% having moderate to severe disease of the aortic or mitral valve. As populations grow older, diagnostic capabilities improve, and health care becomes more accessible, the number of patients with valvular heart disease undergoing both cardiac and non-cardiac surgery will continue to grow. The preoperative assessment and optimization of these patients is a complex task involving multiple specialists, including internists, cardiologists, intensivists, cardiothoracic surgeons, and anesthesiologists. As newer therapeutic options are offered to patients with numerous comorbidities, the preoperative management of these patients will require a sophisticated multimodal approach. The purpose of this chapter is to summarize the preoperative assessment and optimization of patients with valvular heart disease undergoing cardiac and non-cardiac surgery.
TopBackground
The preoperative assessment of patients with valvular heart disease is vital to anesthetic and surgical planning. General principles include a thorough evaluation of the severity of valvular disease, the degree of impaired myocardial function, and associated comorbidities. The preoperative assessment should start with a thorough history and physical. The history should focus on functional capacity, cardiac reserve, symptoms of congestive heart failure, and symptoms of coronary ischemia. On physical exam, congestive heart failure is evidenced by jugular venous distension, peripheral edema, third and fourth heart sounds, crackles, and rales. Every patient should receive an electrocardiogram (EKG) and chest radiograph (CXR) as part of the preoperative workup. A complete transthoracic echocardiogram (TTE) is indicated in all patients with suspected valvular disease, and periodic repeat studies are indicated at intervals dependent on the type and severity of valvular disease. Based on findings in the aforementioned tests, advanced testing can be performed, which may include transesophageal echocardiography (TEE), three dimensional echocardiography, cardiac catherization, stress testing, cardiac magnetic resonance imaging (CMR), and computed tomography (CT).
In 2014 the ACC/AHA published a new classification system for valvular heart disease (VHD). This new system is similar to the staging system for heart failure that was published by the AHA/ACC in 2013, and is based upon four stages of disease progression. Table 1 describes these four stages (Nishimura et al., 2014).
Table 1. Stages of Progression of VHD
| Stage | Definition | Description |
| A | At risk | Patients with risk factors for development of VHD |
| B | Progressive | Patients with progressive VHD (mild-to-moderate severity and asymptomatic |
| C | Asymptomatic severe | Asymptomatic patients who have the criteria for severe VHD:
C1: Asymptomatic patients with severe VHD in whom the left or right ventricle remains compensated
C2: Asymptomatic patients with severe VHD, with decompensation of the left or right ventricle |
| D | Symptomatic severe | Patients who have developed symptoms as a result of VHD |
Table taken from 2014 ACC/AHA Valvular Heart Disease Guidelines (Nishimura et al., 2014).
VHD indicates valvular heart disease.