Aortic stenosis
Stem
A 79-year-old woman, 62 kg, is scheduled for elective laparoscopic cholecystectomy. A systolic murmur prompted an echocardiogram last month: aortic valve area 0.8 cm2, mean gradient 46 mmHg, peak jet velocity 4.3 m/s, ejection fraction 60%. She walks a mile daily and denies chest pain, fainting or breathlessness. Blood pressure is 142/78, heart rate 70 in sinus rhythm.
Question
How will you prepare for and conduct her anesthetic?
Ideal answer
HeadlineSevere asymptomatic aortic stenosis, preserved ventricle, so she proceeds: I keep a stiff, hypertrophied ventricle full, slow and well perfused.
- Ask again about syncope, angina and dyspnea, because symptomatic severe stenosis has short survival and warrants valve discussion first.1
- Arterial line and defibrillator pads before induction,1 because resuscitation across a stenotic valve rarely works and the draped chest is hard to reach.
- Etomidate or slow propofol, phenylephrine or norepinephrine running: any fall gets phenylephrine immediately: coronary perfusion of that thick ventricle depends on diastolic pressure.
- Heart rate between 60 and 80, sinus rhythm, for diastolic time and the atrial kick; new atrial fibrillation or tachycardia is an emergency.
- General anesthesia, not single-shot spinal, because sudden sympathectomy drops preload and afterload the fixed valve cannot offset; a carefully titrated epidural if regional is needed.
Watch for: ST segments in V5 and II from induction.
Breaking down the answer
- Proceed or refer — symptomatic severe stenosis, or low-flow low-gradient with poor ventricular function, goes to the heart team for valve replacement first; balloon valvuloplasty is only a case-by-case bridge (restenosis, complications).1 Stems hide it behind "a murmur in the chart."
- Which valve — surgical replacement is preferred under 65, transfemoral TAVR over 80, and either after shared decision-making between 65 and 80.2
- Why the line goes in awake — the window for treating hypotension is seconds; waiting for a cuff cycle costs coronary perfusion.
- Why not ephedrine — its tachycardia shortens diastolic filling time for a ventricle that depends on it; phenylephrine adds no chronotropy, and norepinephrine comes second when it is not enough.
- Sinus rhythm matters — the non-compliant ventricle depends on the atrial contribution for up to 40% of filling;1 new atrial fibrillation with hypotension is an indication for synchronized cardioversion, not rate control.
- Why not a spinal — sudden sympathectomy drops preload and afterload together, and the fixed obstruction cannot raise stroke volume. Classic teaching, not trial evidence: neuraxial has been used safely in asymptomatic severe stenosis, arterial line first, slow small increments, hypotension treated immediately with norepinephrine.1
- Monitoring for big cases — subendocardial ischemia occurs with normal coronaries (high wall tension, short diastolic time). With large fluid shifts, TEE shows filling and function in real time; a PA catheter overestimates filling pressures in a stiff ventricle, so I interpret the wedge accordingly.
Follow-up question
Twenty minutes after insufflation, her pressure falls to 70/40 and the monitor shows atrial fibrillation at 130.
What do you do?
Follow-up answer
HeadlineAtrial fibrillation with hypotension starts the spiral: lost atrial kick, tachycardia, short diastole, a hypoperfused ventricle, more arrhythmia. I say it aloud.
I ask the surgeon to desufflate and tell the room we may cardiovert. 100% oxygen, phenylephrine 100–200 mcg boluses while the pads charge, and synchronized cardioversion at 120–200 J biphasic if the pressure does not recover within a minute.3 Then I correct the trigger: volume, potassium, magnesium, depth of anesthesia, surgical stimulus. If pulseless, compressions and epinephrine, telling the team that compressions generate little flow across the valve, so early defibrillation and rapid return of a perfusing rhythm are the only things that work. Once stable, I reassess whether to finish the operation.
Pitfalls that cost points
- Giving a fluid bolus alone when the problem is afterload.
- Confusing aortic stenosis with hypertrophic cardiomyopathy management; both want a full, slow ventricle, but only HCM is worsened by inotropes.
- Forgetting that mitral regurgitation and aortic stenosis want opposite afterloads if both are present.
Rapid-fire
Q: Why is bradycardia also dangerous? A: Stroke volume is fixed, so cardiac output is rate-dependent; below about 50 the output falls even though diastole is long.
Q: Why is nitroglycerin a poor choice for angina here? A: It drops preload and diastolic pressure, which lowers coronary perfusion of the hypertrophied ventricle and worsens the ischemia.
Q: What are the classic symptom-to-survival figures? A: Angina about 5 years, syncope about 3 years, heart failure about 2 years without valve replacement; contemporary summaries put average survival at only 1–3 years after symptom onset.4
Q: Does TAVR change the anesthetic plan afterward? A: The obstruction is gone, so I manage an elderly patient with the underlying ventricular disease, continue antiplatelet therapy, and check for a new conduction block or pacemaker.
Numbers to know
| Item | Value |
|---|---|
| Severe stenosis | Valve area ≤1.0 cm2, mean gradient ≥40 mmHg, jet velocity ≥4 m/s2 |
| Very severe stenosis | Jet velocity ≥5 m/s2 |
| Heart rate target | 60–80, sinus rhythm |
| Normal valve area | 2.5–3.5 cm2 |
| Cardioversion for unstable AF | 120–200 J biphasic, synchronized3 |
| Atrial contribution to filling | Up to 40%1 |
Links
- Preoperative cardiac evaluation for non-cardiac surgery, Hypertrophic obstructive cardiomyopathy, Spinal anesthesia: dosing, spread, hypotension, ACLS adapted to the operating room, Intraoperative cardiac arrest: care after return of circulation, Vasopressors and inotropes: choosing and titrating
- Atlas: Basic valvular lesions on 2D and color; The 11 TEE views
- ACC/AHA 2020 guideline for the management of valvular heart disease
Sources
- 1.Anesthesia for aortic valve stenosis: Anesthesiological management of patients with aortic valve stenosis during noncardiac surgery · Die Anaesthesiologie (PubMed Central), 2024 · pmc.ncbi.nlm.nih.govBillig S et al., German-language review; atrial contribution up to 40%, arterial line and pads before induction, neuraxial evidence.
- 2.2020 ACC/AHA Heart Valve Disease Guideline: Key Perspectives, Part 1 · American College of Cardiology, 2020 · acc.orgSummary of Otto CM et al., 2020 ACC/AHA valvular guideline (stage D1-D3 definitions, AVR indications, SAVR vs TAVI by age).
- 3.Direct-Current (DC) Cardioversion-Defibrillation · Merck Manual Professional Edition · merckmanuals.com
- 4.Aortic Stenosis · StatPearls, 2023 · statpearls.com
Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.