Structural Heart Disease in Surgical Setting

Erwin Mulia

We can simplify the presence of structural heart disease into acquired and congenital heart
disease. Acquired heart disease including primary and secondary valvular heart disease.
When we deal with valvular heart disease in surgical patients, we have to elaborate few
questions to be answered:
• Should we intervene the valvular problem or treat it conservatively first?
• Evaluation for the need of valvular intervention
• Non surgical vs surgical valvular intervention
• Perioperative anticoagulant and or antiplatelet related with prosthetic valve and or
percutaneous coronary intervention (PCI)
• Prophylactic antibiotics
Using the seven stepwise approach which was proposed in 2014 European Society of
Cardiology (ESC)/ European Society of Anaesthesiology (ESA) guidelines on non-cardiac
surgery, we can easily stratify and decide the better management for our non cardiac surgical
patients.1 Evaluation of the need for valvular intervention prior to surgery is important. Non
invasive modality plays major role in this part.2 Elective noncardiac surgery can be
proceeded with elevated risk using appropriate intraoperative and postoperative
hemodynamic monitoring in3:
1. asymptomatic severe aortic regurgitation with normal left ventricular ejection fraction
2. asymptomatic severe mitral regurgitation
3. asymptomatic severe aortic stenosis
4. asymptomatic severe mitral stenosis not favorable for percutaneous mitral balloon
commissurotomy
Presence of significant coronary artery disease should also be evaluated before valvular
intervention.2 Discussion and heart team based decision is essential to decide type of
prosthesis in case of definitive valvular intervention. Prophylaxis against infective
endocarditis should be limited.4
Image 1. Management of Severe Aortic Stenosis in Elective Noncardiac Surgery2

References
1. ESC/ESA Guidelines on Non-cardiac Surgery: Cardiovascular Assessment and
Management. Eur Heart J 2014;35:2383-2431.
2. ESC/EACTS Guidelines for the Management of Valvular Heart Disease. Eur Heart J
2017:1-53.
3. ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of
Patients Undergoing Noncardiac Surgery. Circulation 2014;130:278-333.
4. AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of
Patients with Valvular Heart Disease. Circulation 2017.