Peri-operative risk of non-cardiac surgery in patients with aortic stenosis: a systematic review and meta-analysis

Abstract

Introduction: Aortic stenosis is a risk factor for adverse outcomes following non-cardiac surgery; however, existing data regarding peri-operative morbidity and mortality in this patient cohort remain conflicted. This systematic review and meta-analysis aimed to quantify the peri-operative risks in patients with aortic stenosis undergoing non-cardiac surgery. Methods: Following the development of our search strategy, we searched databases for relevant studies. The primary endpoint was all-cause in-hospital or 30-day mortality associated with aortic stenosis in patients undergoing non-cardiac surgery. Secondary endpoints included: myocardial infarction; heart failure; stroke; delirium; venous thromboembolism; and acute kidney injury. Results: Nineteen studies involving 100,486 patients were included. The estimated all-cause mortality was 3.8% (95%CI 3.7–3.9%) for patients with any degree of aortic stenosis and 9.6% (95%CI 7.7–12.1%) for those with severe aortic stenosis. A meta-analysis of 14 comparative studies involving 2,885,254 patients revealed significantly increased mortality in patients with aortic stenosis compared with those without aortic stenosis (relative risk 1.58, 95%CI 1.18–2.12, p < 0.001). Aortic stenosis was also associated with an elevated risk of postoperative myocardial infarction (relative risk 1.79, 95%CI 1.2–2.67, p < 0.001) and heart failure (relative risk 2.06, 95%CI 1.19–3.59, p < 0.001). Discussion: Aortic stenosis in patients undergoing non-cardiac surgery is associated with a three-fold relative increase in the risk of mortality. These results highlight the need for further delineation of which surgical procedures are associated with the greatest risk of poor peri-operative outcomes to guide heightened surveillance protocols, optimised peri-operative management and thresholds for pre-operative intervention.