Aortic Stenosis Management in Patients With Acute Hip Fracture

Abstract

The treatment of severe aortic stenosis (SAS) has evolved rapidly with the advent of minimally invasive structural heart interventions. Transcatheter aortic valve replacement has allowed patients to undergo definitive SAS treatment achieving faster recovery rates compared to valve surgery. Not infrequently, patients are admitted/diagnosed with SAS after a fall associated with a hip fracture (HFx). While urgent orthopedic surgery is key to reduce disability and mortality, untreated SAS increases the perioperative risk and precludes physical recovery. There is no consensus on what the best strategy is either hip correction under hemodynamic monitoring followed by valve replacement or preoperative balloon aortic valvuloplasty to allow HFx surgery followed by valve replacement. However, preoperative minimalist transcatheter aortic valve replacement may represent an attractive strategy for selected patients. We provide a management pathway that emphasizes an early multidisciplinary approach to optimize time for hip surgery to improve orthopedic and cardiovascular outcomes in patients presenting with HFx-SAS.

Keywords: HOS; SAVR; TAVR; aortic stenosis; balloon aortic valvuloplasty; hip fracture; hip fracture surgery; management; minimalist transcatheter aortic valve replacement; non cardiac surgery; protocol; transcatheter aortic valve replacement; treatment algorithm.

Graphical abstract

Figure 1

Inter-Relationship Between Severe Aortic Stenosis and Hip Fracture SAS and HFx share common pathological mechanisms, comorbidities and often coexist leading to worse clinical outcomes. AS = aortic stenosis; CAD = coronary artery disease; HFx = hip fracture; PAD = peripheral artery disease; SAS = severe aortic stenosis.

Figure 2

Use of Transthoracic Echocardiography in the Setting of Acute Hip Fracture The detection of a SAS in the perioperative setting has important clinical implications. ^aThe use of POCUS may help clinicians to expedite the diagnosis of SAS. ^bKnown or suspected heart failure, ischemic heart disease or abnormal ECG. ^cTTE may be still obtained if readily available, as about ⁓10% of patients with SAS and HFx will remain undiagnosed. AS = aortic stenosis; ECG = electrocardiogram; HFx = hip fracture; HOS = hip orthopedic surgery; POCUS = point-of-care ultrasound; SAS = severe aortic stenosis; TTE = transthoracic echocardiogram.

Figure 3

Pathophysiology of Severe Aortic Stenosis in the Setting of Noncardiac Surgery Patients with severe LV outflow obstruction due to SAS are particularly susceptible to sudden hypotension during the anesthetic period, rapid fluid shifts and tachyarrhythmias precipitating a vicious circle of reduced coronary perfusion, myocardial ischemia, impaired ventricular function, and worsening hypotension that may fail to respond to vasopressor treatment. CCP = coronary perfusion pressure; DT = diastolic time; LV = left ventricular; MVO₂ = myocardial oxygen consumption; PVR = peripheral vascular resistance; SAS = severe aortic stenosis.

Figure 4

Triage and Management Pathways for Patients With Severe Aortic Stenosis and Hip Fracture ^aDue to the high prevalence of cognitive dysfunction, comorbidities and low functional capacity, the assessment of symptoms of SAS is not always accurate. ^bPatients undergoing HOS with an uncorrected SAS should have invasive monitoring (eg, A-line, Swan-Ganz catheter). ^cPatients need close follow-up to verify if criteria for AVR are met. ^dA collaborative structure for fast track preoperative minimalist TAVR-HOS protocol (Group 1) needs to be readily available. ^eBAV is generally discouraged in the presence of moderate or severe AR. AR = aortic regurgitation; AS = aortic stenosis; BAV = balloon aortic valvuloplasty; CABG = coronary artery bypass graft; COPD = chronic obstructive pulmonary disease; HFx = hip fracture; HOS = hip orthopedic surgery; LVEF = left ventricular ejection fraction; LVOT = left ventricular outflow tract; PAD = peripheral artery disease; SAS = severe aortic stenosis; SAVR = surgical aortic valve replacement; STS = Society of Thoracic Surgeons; TAVR = transcatheter aortic valve replacement.

Central Illustration

Severe Aortic Stenosis Management Options in the Setting of Acute Hip Fracture A dedicated time-sensitive protocol and a TAVR collaborative multidisciplinary structure is key for the management of these patients. This structure needs to be mounted in advance to rapidly detect inclusion/exclusion criteria, so the risks of delaying HOS can be minimized, and the potential benefits of the intervention enhanced. ADLs = activities of the daily living; AS = aortic stenosis; BAV = balloon aortic valvuloplasty; HOS = hip orthopedic surgery; MACE = major adverse cardiac events; MI = myocardial infarction; SAVR = surgical aortic valve replacement; TAVR = transcatheter aortic valve replacement; TTE = transthoracic echocardiogram; TTS = time to surgery.

Figure 5

Proposed Time-Sensitive Protocol for Patients With Hip Fracture and Severe Aortic Stenosis Depending on resource availability, patients may need to be transferred to complete TAVR work-up at the TAVR-capable facility. We adapted^, and identified pre-, intra- and post-procedural issues that may exclude a patient from either entering a fast track minimalist TAVR-HOS protocol or completing it on time. These issues can be treated and favor an expedited surgery (eg, active fixation TVP for new conduction disturbances). BAV = balloon aortic valvuloplasty; CT = computed tomography; ED = emergency department; GFR = glomerular filtration rate; HOS = hip orthopedic surgery; IC = interventional cardiologist; IM = internal medicine; SHD = structural heart disease specialist; STS = Society of Thoracic Surgeons; SW = social worker; TAVR = transcatheter aortic valve replacement; TEE = transesophageal echocardiogram; TTE = transthoracic echocardiogram; TVP = transvenous pacing.