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Education in Heart
Valvular heart diseases
Valve disease and non-cardiac surgery
  1. John B Chambers
  1. Cardiology Department, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
  1. Correspondence to Professor John B Chambers, Cardiology Department, Guys and St Thomas' NHS Foundation Trust, London SE1 9RT, UK; john.chambers{at}gstt.nhs.uk

https://doi.org/10.1136/heartjnl-2017-312455

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    Learning objectives

    • To understand the principles of assessment by type of non-cardiac surgery, the Revised Cardiac Index Risk score, the grade of valve disease and functional capacity.

    • To understand that adverse events at non-cardiac surgery result from associated coronary disease and the haemodynamic effects of the valve disease.

    • To understand the precautions necessary during and after non-cardiac surgery and when invasive intervention is indicated in severe aortic stenosis or mitral stenosis.

    Introduction

    Valve disease is a major concern in patients having non-cardiac surgery. First, it is common (table 1)1–4 particularly in the elderly who may also have other comorbidities. The adult population prevalence of moderate or severe disease is 2.5% and this rises to >13% in people aged ≥75.1 Second, valve disease is often asymptomatic and may be detected for the first time during preoperative assessment for non-cardiac surgery. In the OxVALVE community study,3 moderate or severe valve disease was known in 4.9% people aged >65 and was newly detected by screening in a further 6.4%. Third, valve disease, particularly aortic stenosis (AS), may be associated with coronary disease which contributes to the perioperative risk.5 Fourth, recognised competencies in heart valve disease6 7 are not universal in all disciplines caring for patients having non-cardiac surgery. Finally, the evidence base is small. A combination of these factors leads to anxiety over the presence of valve disease although this is often misplaced.

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    Table 1

    Prevalence (%) of moderate or severe valve disease

    This article discusses the assessment and perioperative management of patients with heart valve disease including replacement valves.

    An approach to valve disease

    If emergency life-saving surgery is needed, this should proceed immediately (figure 1).8–11 If severe valve disease is known or suspected from the history or the presence of a significant murmur, additional precautions should be taken in perioperative care (box 1).

    Figure 1

    An approach to valve disease. …

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    Footnotes

    • Contributors JC is the sole author.

    • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent Not required.

    • Provenance and peer review Commissioned; externally peer reviewed.