Valvular Heart Disease

Emergency Surgery in Severe Aortic Stenosis

Free air under the diaphragm on upright chest x-ray indicates intraabdominal (hollow viscus) perforation.
Diffuse abdominal tenderness with rebound is consistent with generalized peritonitis, which is a surgical emergency.

The definitive treatment for bowel perforation with peritonitis is emergent exploratory abdominal surgery.
Initial stabilization includes intravenous fluids and broad-spectrum antibiotics, but these measures do not replace surgery.

Severe aortic stenosis is defined by an aortic valve area ≤1.0 cm² (this patient: 0.8 cm²).
Severe aortic stenosis increases perioperative risk, including hypotension, myocardial infarction, heart failure, arrhythmias, and sudden cardiac death.
Patients with moderate-to-severe aortic stenosis may also have increased bleeding risk due to acquired von Willebrand syndrome.

A high-risk cardiac condition (eg, severe aortic stenosis) should not delay emergency, life-saving noncardiac surgery.
In contrast, nonemergency noncardiac surgery should be postponed until the cardiac condition is treated or optimized.

Balloon aortic valvuloplasty may be considered before nonemergency surgery in selected patients but should not delay emergency surgery, especially in asymptomatic severe aortic stenosis.
Stress testing (eg, dobutamine echocardiography) does not alter acute management and should not delay surgery.
Left heart catheterization is useful for preoperative risk stratification in nonemergent settings but should not delay emergency surgery.

Emergency surgery in severe aortic stenosis should proceed with:
- Invasive hemodynamic monitoring
- Maintenance of preload
- Avoidance of hypotension
- Preservation of sinus rhythm

High-risk cardiac conditions require optimization before nonemergency surgery, but never delay emergency, life-saving noncardiac surgery.