Use of femoral-femoral cardiopulmonary bypass for urgent aortic valve replacement in a patient with critical aortic stenosis and left ventricular dysfunction

Abstract

THE ONSET OF congestive heart failure in patients with aortic stenosis (AS) indicates a poor prognosis. In some of these patients, left ventricular function may be depressed so that the transvalvular pressure gradient may be low. The mortality after aortic valve replacement (AVR) in such patients has been reported to be 33%1 to 75%.2 Adverse hemodynamic changes (severe hypotension or hypertension) during induction of general anesthesia and until cardiopulmonary bypass (CPB) is established may contribute to this increased mortality. Hemodynamic changes are generally poorly tolerated by these patients, and the myocardium is susceptible to ischemic injury. It is difficult to resuscitate these patients in the event of cardiac arrest. Intraoperative hypotension should be aggressively treated in patients with AS with -agonists with the objective of restoring the perfusion pressure.3 Such an approach may jeopardize the already ischemic myocardium, however. Although hemodynamic effects of anesthetic agents in these sick patients are not well reported, most anesthetic agents (intravenous or inhalation) are likely to cause some degree of hypotension. There is a tendency among anesthesiologists to restrict the doses of induction agents. Such a practice may expose the patients to the risk of excessive sympathetic response during intubation, which can also be deleterious. The risk of exposing these high-risk patients to adverse hemodynamic changes during induction of general anesthesia can be avoided by instituting femoral-femoral CPB under local anesthesia before induction of general anesthesia. The authors report a patient suffering from critical AS (valve area, 0.4 cm2) who presented with severe congestive heart failure (New York Heart Association [NYHA] functional class IV) and underwent urgent AVR. Femoral-femoral CPB was electively instituted in this patient before induction of general anesthesia. The hemodynamic details and management of this patient are described.