Adverse outcomes after noncardiac surgery in patients with aortic stenosis

Ying-Hsuan Tai,Chun-Chieh Yeh,Chuen-Chau Chang,Chien-Chang Liao,Yih-Giun Cherng,Ta-Liang Chen

doi:10.1038/s41598-021-98507-6

Abstract

Whether aortic stenosis (AS) increases perioperative risk in noncardiac surgery remains controversial. Limited information is available regarding adequate anesthetic techniques for patients with AS. Using the reimbursement claims data of Taiwan’s National Health Insurance, we performed propensity score matching analyses to evaluate the risk of adverse outcomes in patients with or without AS undergoing noncardiac surgery between 2008 and 2013. We also compared the perioperative risk of AS patients undergoing general anesthesia or neuraxial anesthesia. Multivariable logistic regressions were applied to calculate the adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for postoperative mortality and major complications. The matching procedure generated 9741 matched pairs for analyses. AS was significantly associated with 30-day in-hospital mortality (aOR 1.31, 95% CI 1.03–1.67), acute renal failure (aOR 1.42, 95% CI 1.12–1.79), pneumonia (aOR 1.16, 95% CI 1.02–1.33), stroke (aOR 1.14, 95% CI 1.01–1.29), and intensive care unit stay (aOR 1.38, 95% CI 1.27–1.49). Compared with neuraxial anesthesia, general anesthesia was associated with increased risks of acute myocardial infarction (aOR 3.06, 95% CI 1.22–7.67), pneumonia (aOR 1.80, 95% CI 1.32–2.46), acute renal failure (aOR 1.82, 95% CI 1.11–2.98), and intensive care (aOR 4.05, 95% CI 3.23–5.09). The findings were generally consistent across subgroups. AS was an independent risk factor for adverse events after noncardiac surgery. In addition, general anesthesia was associated with greater postoperative complications in AS patients compared to neuraxial anesthesia. This real-world evidence suggests that neuraxial anesthesia should not be contraindicated in patients with AS.

Highlights

Neuraxial anesthesia has long been regarded as a contraindication for patients with Aortic stenosis (AS) due to its sympatholytic effect, potentially causing precipitous falls in vascular resistance and thereafter reduced cardiac output and coronary perfusion[18]; the concern related to neuraxial anesthesia use in AS patients is borne of a theoretical risk rather than clinical evidence[19,20]
A history of AS was associated with an increased risk of intensive care after noncardiac surgery
Compared with AS patients who underwent neuraxial anesthesia (Table 4), those who underwent general anesthesia had higher risks of postoperative acute myocardial infarction, acute renal failure, pneumonia, and septicemia

Summary

Introduction

Neuraxial anesthesia has long been regarded as a contraindication for patients with AS due to its sympatholytic effect, potentially causing precipitous falls in vascular resistance and thereafter reduced cardiac output and coronary perfusion[18]; the concern related to neuraxial anesthesia use in AS patients is borne of a theoretical risk rather than clinical evidence[19,20]. A few case reports have described neuraxial anesthesia use in AS patients[21,22,23], and no large-scale study comparing the perioperative risk of AS patients undergoing general or neuraxial anesthesia has been reported. Based on previous e vidence[6,7,8,9,10,11,12,13,14,15,16,17,21,22,23,24,25,26], we hypothesized that AS is independently associated with higher risks of adverse outcomes and general anesthesia carries a higher perioperative risk compared to neuraxial anesthesia for AS patients undergoing noncardiac surgery

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Conclusion