Proximal femur fracture in elderly patients with severe aortic stenosis - anaesthetic considerations and perioperative care

Abstract

Objective: Severe senile aortic stenosis is associated with valve calcification and prevalence rates that increase with age. Similarly, proximal femur fracture also has a high incidence in the elderly population. Concomitance of these pathologies is a major challenge in decision making. Aortic stenosis is associated with the risk of cardiovascular events in the perioperative period, and delays in orthopaedic surgery increase morbidity and mortality. Case Presentation: We report different perioperative and anaesthetic approaches and their respective outcomes in two cases of severe aortic stenosis in elderly patients undergoing surgical procedures for proximal femur fractures. In the first case, an 86-yearold woman initially approached with general anesthesia for hemiarthroplasty. There were many complications in the postoperative period and early hospital readmission after discharge. Eight months later the same patient suffered a periprosthetic fracture and underwent a successful surgical procedure only with peripheral block and sedation despite severe aortic stenosis and older age. In the second case, a 90-year-old woman with a proximal femur fracture was submitted to total hip arthroplasty with spinal anesthesia. Although less instability was expected, there was great difficulty in hemodynamic control in the intraoperative. The patient was observed in a longer postoperative period, being able to finally be discharged for outpatient rehabilitation. Conclusion: Elderly patients with proximal femoral fractures and severe aortic stenosis demand an interdisciplinary medical team where cardiologists, anaesthesiologists and orthopaedists need to make decisions case-by-case. The perioperative care strategy, including anaesthetic-surgical planning, requires extensive knowledge and immense team involvement. We recommend shared deci?sion making that presupposes the involvement of patients and their families.