Year: 2026 | Month: January | Volume: 16 | Issue: 1 | Pages: 227-242
DOI: https://doi.org/10.52403/ijhsr.20260127
Perioperative Management of An Elderly with Coronary Artery Disease and Aortic Stenosis Undergoing Emergency ORIF for Intertrochanteric Fracture. Report of A Rare Case and Systematic Mini Review
Vishnu Datt1*, Sakshi Dhingra2*, Diksha Datt2***, Shreya Khatri2*, Simran Yadav2*, Sansar Sharma3**, Priyanka Dahiya2*, Priyanka Kaushik2*, Rahul Singla2*,
Bharti Yadav4*, KS Goel5****
1Professor & HOD, 2MD student, 3Professor & Dean, 4Senior Resident, 5Professor and HOD,
*Department of Anaesthesiology and Intensive Care, **Department of Orthopaedics, ***Department of PSM, ****Department of Surgery,
SGT Medical College and University, Budhera, Gurugram, Haryana, India.
Corresponding Author: Dr. Vishnu Datt
ABSTRACT
Aortic valve stenosis (AS) is the most common form of valvular heart disease in the elderly population and often associated with significant coronary artery disease (CAD), as both conditions have common risk factors. Patients with untreated severe AS with concomitant coronary CAD requiring a noncardiac surgery (NCS) is associated with worse prognosis and higher risk for major adverse cardiovascular events (MACE). Patients with symptomatic severe AS and significant CAD (>70% stenosis of any major epicardial coronary vessel or >50% stenosis of the left main coronary artery) have a higher risk profile because of a greater number of cardiovascular risk factors and comorbidities, which can complicate their management. Furthermore, such patients are at increased risk of perioperative MI during cardiac and non-cardiac surgery. Recent guidelines suggest surgical aortic valve replacement (AVR) or balloon aortic valvotomy (BAV) or transcatheter aortic valve implantation (TAVI) for severe AS and percutaneous coronary artery intervention (PCI) or coronary artery bypass grafting (CABG)for the significant CAD before noncardiac surgery for better outcome. However, mild to moderate asymptomatic AS might proceed with NCS, but strict hemodynamic monitoring is recommended. The unoperated patients of severe AS with CAD requiring NCS should be managed by multidisciplinary approach and focus is to avoid the hypotension/ hypertension, tachycardia to prevent the MI, MACE and mortality. The sinus rhythm and mean arterial pressure (>65 mmHg) should be maintained with the use careful anaesthetic management and using beta- blockers and phenylephrine or norepinephrine or vasopressin. Untreated patients of AS with concomitant CAD requiring emergency lower limb surgery can be managed safely under spinal anaesthesia with the collaboration of multidisciplinary approach including cardiac anaesthetist, cardiologist and surgeon. The aggressive hemodynamic monitoring such as ECG, CVP/ PAC, arterial catheter, and TEE and arterial blood gas analysis in selected patients is most crucial for early detections of hemodynamic deterioration, and their appropriate management with fluid and vasoactive agents administration, and use of beta-blockers or calcium channel blockers to control the tachycardia or even use of mechanical circulatory support such as intra- aortic balloon counter pulsations(IABP). We describe a successful perioperative management of a challenging case of a 75 yrs- female, weighing 80Kg, a known post-PTCA coronary artery disease with symptomatic severe aortic stenosis, who developed left intertrochanteric fracture and required open reduction and internal fixation (ORIF) with plating. The emergency surgery was performed under spinal anaesthesia with heavy bupivacaine (0.5%),2 ml with fentanyl (25 mcg) used in L4-5 space after obtaining an informed consent from the relatives along with permission for the publication. A review of literature on the CAD with severe symptomatic aortic stenosis requiring emergency non-cardiac surgery will be discussed
Key words: Aortic stenosis, coronary artery disease, echocardiography, multidisciplinary team, non-cardiac surgery, spinal anaesthesia .