An 82-year-old man presents with an isolated intracapsular fracture of his right neck of femur. He is alert and orientated, and states that he felt dizzy and lost consciousness briefly when he stood up. He has a history of ischaemic heart disease and he takes furosemide for ankle oedema.
He has a soft mid-systolic murmur that is heard loudest over the second left intercostal space radiating to the carotid area. The second heart sound is muffled. He cannot leave his house unaided due to angina. He requires informal carer support to complete his activities of daily living due to breathlessness. His ECG shows the typical electrical criteria for left ventricular hypertrophy, but no acute changes.
He has been booked onto the planned orthopaedic trauma list this afternoon.
What is the most appropriate course of action?
(Please select 1 option)
Cancel surgery, and arrange a transthoracic echocardiogram within five days
Cancel surgery, and perform aortic valve replacement prior to hip fixation
Cancel surgery, manage the fracture conservatively with analgesics and traction
Perform surgery as planned, under a spinal anaesthetic
Perform surgery as planned, under general anaesthesia with invasive monitoring
Explanation:
This patient has clinical evidence of critical aortic stenosis (AS) with evidence of heart failure and left ventricular hypertrophy. He has presented with a mechanism suggesting cardiogenic syncope. He is therefore likely to have a relatively fixed cardiac output state and will be at extremely high risk of morbidity and mortality in the perioperative period. A spinal anaesthetic will be a risky procedure due to profound, uncontrolled and irreversible autonomic blockade. A cardiostable general anaesthetic with appropriate invasive monitoring is more titratable and will be a safer option in these circumstances.
The patient’s outcome is likely to be significantly worse if surgery is delayed. Although delay may be acceptable to amend immediately correctable conditions such as major electrolyte disturbances, arrhythmias and sepsis, it is not acceptable to delay surgery to await echocardiography1. Echocardiography will give useful information, but surgery should not be delayed because of it; it is better to proceed assuming critical AS with an anaesthetic technique tailored towards this.
If surgery is cancelled altogether, the outcome is likely to be grave, and analgesic techniques are less effective than surgery at relieving pain from proximal femoral fractures. There is no place to await the prolonged recovery from major cardiac surgery to replace the aortic valve prior to fixation of the fracture.
Although a transthoracic echocardiogram (TTE) will give useful information on LV function, in this case it will result in a significant delay to surgery. There is enough clinical evidence to manage this patient as if they have critical aortic stenosis with LVSD and LVH until proven otherwise.
Aortic valve replacement will result in a considerable delay to lifesaving hip fracture fixation surgery. There is evidence of both LVH and LV dysfunction, which suggests that there is already end organ damage that may not be reversible even if the valve is replaced.
The mortality with conservative management of proximal femoral fractures approaches 100% in some series. Even as a semi-palliative measure, surgery is more effective than other analgesic techniques1.
Subarachnoid block is likely to result in uncontrolled, irreversible vasodilatation which will drop coronary perfusion and require an increased workload of a heart that probably exists in a relatively fixed cardiac output state, therefore risking a vicious cycle leading to cardiac arrest.
Therefore, performing surgery as planned, under general anaesthesia with invasive monitoring is the least risky option as it allows titrated control of vasodilation and a cardiostable technique can be employed to ensure stability.