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CARDIAC VALVE STENOSIS REMAINS AN ABSOLUTE CONTRAINDICATION TO SPINAL ANAESTHESIA: CON
Author(s):
Rex, S.*
Affiliations:
University Hospitals Leuven, Anesthesiology, Leuven, Belgium
ESRA Academy. Rex S. Sep 15, 2017; 195873; esra7-0504 Topic: SAFETY AND COMPLICATIONS OF REGIONAL ANAESTHESIA (RA)
Steffen Rex
Steffen Rex

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Abstract
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After viewing this presentation the participant will be able to:

- Discuss how hemodynamic side effects of spinal anaesthesia can be mitigated
- Identify side effects of general anesthesia for patients with severe aortic stenosis

In Western countries, stenosis of the aortic valve is the most frequently encountered cardiac valve stenosis, with severe aortic stenosis being prevalent in about 2-3% of patients older than 65 years.(1)

In the anesthesiologic management of patients with aortic stenosis, the avoidance/immediate treatment of a decrease in venous return and hypotension is the primordial goal to prevent hemodynamic deterioration.(2) Prolonged hypotension can rapidly lead to a vicious circle of subendocardial ischemia, low output, and further hypotension. Due to its sympathicolytic effects, (“high”) spinal anesthesia is known to decrease mean arterial blood pressure, systemic vascular resistance and left ventricular filling (as a consequence of venodilation).(3) As these hemodynamic side effects can be detrimental in patients with aortic stenosis, spinal anesthesia has been traditionally considered to be contra-indicated in these patients.(4)

However, it remains to be proven whether general anesthesia is definitely safer in this vulnerable patient population. The majority of iv-narcotics used for induction of general anesthesia do also significantly affect cardiac afterload, preload and contractility. Instead of banning spinal anesthesia in patients with cardiac valve stenosis, anesthesiologists should focus on the safe conduct of spinal anesthesia by employing techniques suited to minimize arterial hypotension, i.e., low-dose spinal anesthesia and (for longer procedures) the use of spinal catheters allowing the repetitive administration of small doses of the local anesthetic. Low-dose spinal anesthesia titrated via a catheter has been repeatedly demonstrated to be hemodynamically superior in comparison with single-dose spinal anesthesia or general anesthesia, even in elderly and cardiac risk patients. (5,6) Also in parturients with complex congenital heart disease, central neuraxial blocks have been safely used.(7)

In conclusion, the choice of the technique (regional vs. general anesthesia) in patients with cardiac valve stenosis remains irrelevant as long as the anesthesiologist prevents the occurrence of hypotension. This is confirmed by a recent survey from the UK investigating more than 10,000 patients undergoing hip fracture surgery. In these patients, mortality was not linked to anesthesia technique, but clearly (and solely) associated with (even minor) falls in blood pressure.(8)

References:
1.     Otto CM, Prendergast B. Aortic-valve stenosis--from patients at risk to severe valve obstruction. N Engl J Med. 2014 Aug   21;371(8):744–56.
2.     Rex S. Anesthesia for transcatheter aortic valve implantation: an update. Curr Opin Anaesthesiol. 2013 Aug;26(4):456–66.
3.     Rooke GA, Freund PR, Jacobson AF. Hemodynamic response and change in organ blood volume during spinal anesthesia in elderly men with cardiac disease. Anesth Analg. 1997 Jul;85(1):99–105.
4.     Canobbio MM, Warnes CA, Aboulhosn J, Connolly HM, Khanna A, Koos BJ, et al. Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2017 Jan 12. 5.     Favarel-Garrigues JF, Sztark F, Petitjean ME, Thicoïpé M, Lassié P, Dabadie P. Hemodynamic effects of spinal anesthesia in the elderly: single dose versus titration through a catheter. Anesth Analg. 1996 Feb;82(2):312–6.
6.     Biboulet P, Jourdan A, Van Haevre V, Morau D, Bernard N, Bringuier S, et al. Hemodynamic Profile of Target-Controlled Spinal Anesthesia Compared With 2 Target-Controlled General Anesthesia Techniques in Elderly Patients With Cardiac Comorbidities. Reg Anesth Pain Med. 2012;37(4):433–40.
7.     Langesaeter E, Dragsund M, Rosseland LA. Regional anaesthesia for a Caesarean section in women with cardiac disease: a prospective study. Acta Anaesthesiol Scand. 2010 Jan;54(1):46–54.
8.     White SM, Moppett IK, Griffiths R, Johansen A, Wakeman R, Boulton C, et al. Secondary analysis of outcomes after 11,085 hip fracture operations from the prospective UK Anaesthesia Sprint Audit of Practice (ASAP-2). Anaesthesia. 2016 May;71(5):506–14

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