Anesthetic Management for Patients with Aortic Stenosis

Preoperative Considerations

Anesthetic techniques and agents should be tailored to individual patient needs, with careful hemodynamic monitoring to maintain stable cardiac output and avoid rapid hemodynamic changes, as recommended by the American College of Cardiology 1
Invasive monitoring, including arterial line and transesophageal echocardiography (TEE), is essential for patients with significant aortic stenosis, unless contraindicated 1
Regional anesthesia is contraindicated in patients on anticoagulants or antiplatelet therapy due to the risk of neuraxial hematoma 1

General anesthesia is often preferred for patients with severe aortic stenosis, particularly for major surgeries, with induction using etomidate or carefully titrated propofol with opioids to blunt sympathetic response 1
Maintenance of anesthesia can be achieved with a balanced technique using volatile agents at low to moderate concentrations supplemented with opioids 1

Conscious sedation is associated with fewer requirements for inotropes/vasopressors, shorter hospital stays, and earlier mobilization for TAVR patients, but should only be used in highly experienced centers using the transfemoral approach 2
Conscious sedation is contraindicated in patients requiring TEE guidance, those with borderline vascular access, cognitive barriers, inability to lie flat, chronic pain, or morbid obesity 2

The risk of adverse events increases with the severity of aortic stenosis, with very severe AS (Vmax ≥5 m/sec or mean gradient ≥60 mmHg) having the highest risk, and is also increased by reduced LVEF (<50%), symptomatic patients, and volume overload or depletion 3, 2
Patients with aortic stenosis depend on adequate preload to maintain cardiac output across the stenotic valve, and volume status should be carefully managed to avoid pulmonary edema and hypovolemia, as recommended by the American College of Cardiology 2
Evaluation for signs of hypovolemia and consideration of echocardiographic evaluation of ventricular filling are important before fluid administration, and monitoring during fluid administration should include blood pressure response, heart rate, pulmonary artery pressures if available, and signs of pulmonary congestion 2
The American College of Cardiology recommends starting with small boluses (250-500 mL) and administering slowly with continuous hemodynamic monitoring, and medications for patients with aortic stenosis and hypertension should be started at low doses and gradually titrated 2, 4
Inotropic support may be preferable to excessive fluid administration in patients showing signs of volume overload, and should be considered if hypotension persists despite careful fluid administration 4