Christ Michael, Sharkova Yulia, Geldner Götz, Maisch Bernhard
Department of Internal Medicine and Cardiology, Philipps University Marburg, Germany.
Chest. 2005 Oct;128(4):2944-53. doi: 10.1378/chest.128.4.2944.
Current medicine has displayed a trend toward less interfering techniques but more invasive surgical approaches in older patients with more comorbidities. In this population, the prevalence of symptomatic cardiac disease including aortic stenosis is increased. More than 25 years have elapsed since severe aortic stenosis was identified as an independent, important risk factor for patients undergoing general anesthesia for noncardiac surgery. Despite impressive advances in anesthesiologic and surgical techniques, morbidity and mortality in patients with severe aortic stenosis remains high. Published study results clearly show that adverse perioperative risk in patients with aortic stenosis depends on the interaction of factors such as the severity of valve disease, concomitant coronary artery disease, and the severity and/or urgency of the surgical procedures. The mainstay of preoperative evaluation remains the obtaining of a comprehensive preoperative medical history and a physical examination, while transthoracic echocardiography is necessary to establish or exclude hemodynamically relevant aortic stenosis in selected patients. Perioperative care is established in patients with asymptomatic aortic stenosis and/or those undergoing low-risk surgery. However, further preoperative testing or aortic valve replacement prior to noncardiac surgery should be discussed individually with the patients awaiting urgent surgical procedures who are at medium or high risk. At this point, decisions should be made in an interdisciplinary manner, including the opinions/wishes of the patient and the patient's family.
当前医学已呈现出一种趋势，即在患有更多合并症的老年患者中，采用干扰性较小的技术，但手术侵入性更强。在这一人群中，包括主动脉瓣狭窄在内的有症状心脏病的患病率有所上升。自严重主动脉瓣狭窄被确定为非心脏手术患者全身麻醉的一个独立且重要的危险因素以来，已经过去了25年多。尽管麻醉和手术技术取得了令人瞩目的进展，但严重主动脉瓣狭窄患者的发病率和死亡率仍然很高。已发表的研究结果清楚地表明，主动脉瓣狭窄患者围手术期的不良风险取决于瓣膜疾病的严重程度、合并冠状动脉疾病以及手术的严重程度和/或紧迫性等因素之间的相互作用。术前评估的主要内容仍然是获取全面的术前病史和进行体格检查，而对于部分患者，经胸超声心动图对于确定或排除血流动力学相关的主动脉瓣狭窄是必要的。对于无症状主动脉瓣狭窄患者和/或接受低风险手术的患者，应建立围手术期护理。然而，对于等待紧急手术的中高风险患者，应与他们单独讨论在非心脏手术前是否进行进一步的术前检查或主动脉瓣置换。此时，应通过跨学科方式做出决策，包括患者及其家属的意见/意愿。
