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Cardiac · Core12 / 22

Severe symptomatic AS for urgent laparoscopy80-year-old man, 74 kg, with acute cholecystitis for urgent laparoscopic cholecystectomy

Stenotic valve: fixed output, the rate, preload and afterload rules

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Know this first

  • Severe AS: area under 1.0 cm², mean gradient 40 mmHg or more, or Vmax 4.0 m/s or more.
  • Symptomatic patients carry more risk than asymptomatic ones.
  • Keep preload, SVR and sinus rhythm; avoid tachycardia.
  • Phenylephrine is first-line for hypotension across a fixed valve.

The patient

80-year-old man, 74 kg, with acute cholecystitis for urgent laparoscopic cholecystectomy. Severe calcific AS: valve area 0.6 cm², Vmax 4.6 m/s, mean gradient 56 mmHg; exertional angina and one faint; EF 60%. Drugs: amlodipine, atorvastatin. Vitals: BP 132/74, HR 84, SpO2 95%, temperature 38.1°C, RR 18.

The examiner asks

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  1. Consider

    What are your concerns?

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    • An 80-year-old with severe symptomatic AS, for urgent laparoscopic cholecystectomy. Patient
    • At 80, febrile and with a past faint, he is primed for delirium; his kidney function is likely reduced.
    • Urgency: urgent cholecystitis, so hours to days; time to involve the valve team. Stem trigger
    • Active cardiac condition? Yes: area 0.6, gradient 56, Vmax 4.6, angina and a faint. Severe symptomatic AS. Disease
    • Risk score: intraperitoneal surgery, RCRI 1; his valve, not the score, sets his risk.
    • Functional capacity: angina and a faint on exertion, so poor.
    • Decision: valve team today; drainage or balloon valvuloplasty first if possible, else proceed with AS goals.

  2. Prepare

    How do you prepare him?

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    • Heart valve team discussion today, in a centre that does valve interventions. Disease
    • Arterial line before induction, plus two large cannulas.
    • Defibrillator pads on before induction. Crisis
    • Fever with acute cholecystitis: antibiotics now; sepsis only if organ dysfunction appears. Disease
    • Phenylephrine drawn up and noradrenaline running before induction. Crisis

  3. Plan

    What are your goals during the anaesthetic?

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    • Keep preload and SVR up, and keep sinus rhythm. Disease
    • No tachycardia; his thick ventricle is at high risk of ischaemia.
    • Slow induction with etomidate 0.15–0.2 mg/kg; no drug that vasodilates, speeds the heart or depresses it.
    • Ask for low insufflation pressure and slow, gentle repositioning. Surgery
    • HDU or ICU afterwards with arterial monitoring. After surgery

  4. Crisis

    After induction BP is 68/40, HR 98, and V5 shows 2 mm ST depression. What do you do?

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    • Treat immediately: phenylephrine 50–100 mcg, then noradrenaline infusion. (Crisis)
    • Low pressure starves his hypertrophied ventricle and spirals into ischaemia.
    • Fluid bolus to restore his preload.
    • Restoring pressure should slow his heart; nothing that speeds it.
    • Echo if no quick response, to look at filling and LV function.

  5. Crisis

    Pressure recovers, but at insufflation BP falls again to 74/46. What do you do?

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    • Ask the surgeon to deflate the abdomen. (Crisis)
    • Restore pressure with phenylephrine and fluid before re-insufflating.
    • Re-insufflate slowly at the lowest workable pressure.
    • If it recurs, discuss converting to drainage or abandoning.

Fatal mistakes

  • Tolerating hypotension in severe AS.
  • Leaving tachycardia untreated.
  • An induction bolus without vasopressor ready.

Checked against: AHA/ACC 2024 · Miller 10e · Stoelting 8e

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