CASE REPORT
Nagoya J. Med. Sci. 85. 167–170, 2023
doi:10.18999/nagjms.85.1.167

Successful perioperative management of simultaneoustranscatheter aortic valve implantation andhip fracture surgery: a case report
Kochi Yamane, Tadashi Aoyama, Yohei Aoki, Hironori Momohara
and Mikio Nonogaki
Department of Anesthesia and Intensive Care Medicine, Municipal Yokkaichi Hospital, Yokkaichi, JapanABSTRACT
A 90-year-old woman with severe aortic stenosis experienced hospital readmission for chronic heart
failure exacerbations many times and was admitted to our hospital for undergoing transcatheter aortic valve
implantation. Thereafter, she fell in the ward and fractured her femoral trochanter, requiring early hip
fracture surgery. We proposed that we should perform simultaneous transcatheter aortic valve implantationand hip fracture surgery to cardiologist and orthopedist from anesthetic and perioperative management perspective. We considered that it was difficult to maintain cardiovascular function without cardiac intervention
during hip fracture surgery and starting rehabilitation as early as possible was important. General anesthesia
was induced without any complications, and the tracheal tube was removed after the successive surgeries.
On postoperative day 1, bedside rehabilitation was started, and on postoperative day 3, she was transferredfrom the intensive care unit to the general ward. On postoperative day 32, she was transferred to anotherhospital. Anesthesiologist should play an important role for decision making in not only intraoperative but
perioperative management for critical case, we should communicate with other departments. The successful
perioperative management of simultaneous transcatheter aortic valve implantation and hip fracture surgery
enabled to start rehabilitation early and prevented further patient hospitalization.
Keywords: transcatheter aortic valve implantation, aortic stenosis, simultaneous surgery, hip fracture
surgery
Abbreviations:
TAVI: transcatheter aortic valve implantation
AS: aortic stenosis
This is an Open Access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International
License. To view the details of this license, please visit (http://creativecommons.org/licenses/by-nc-nd/4.0/).

INTRODUCTION
Few cases of simultaneous transcatheter aortic valve implantation (TAVI) and non-cardiac
surgery have been reported. Anesthesiologist should play important role in not only intraoperative
Received: October 27, 2021; accepted: March 7, 2022
Corresponding Author: Kochi Yamane, MD
Department of Anesthesia and Intensive Care Medicine, Municipal Yokkaichi Hospital,
2-2-37, Shibata, Yokkaichi 510-8567, Japan
Tel: +81-59-354-1111, Fax: +81-59-352-1565, E-mail: yama-anesth@med.nagoya-u.ac.jp
167

Kochi Yamane et albut perioperative management cooperating with multidiscipline departments. We report here a caseof successful perioperative management of simultaneous emergency TAVI and hip fracture surgery.

CASE PRESENTATION
A 90-year-old woman (height, 152 cm; weight, 44 kg) who experienced hospital readmission
for chronic heart failure exacerbations many times visited our hospital with dyspnea. She had
a medical history of severe aortic stenosis (AS), hypertension, diabetes mellitus, and chronic
kidney disease and had undergone percutaneous coronary intervention with drug-eluting stentplacement for angina pectoris. She had been administered an oral antiplatelet drug (Aspirin
100mg/day). Transthoracic echocardiography revealed no asynergy, a peak velocity of 372 cm/s, amean pressure gradient of 32 mmHg, a maximum pressure gradient of 55 mmHg, and an aortic
valve area of 0.65 cm2. Based on transthoracic echocardiography findings and her symptom, she
was diagnosed with chronic heart failure exacerbation due to AS. After admission, undergoing
non-invasive positive pressure ventilation and diuretics gradually improved her symptoms. Severe
symptomatic AS was as an indication for TAVI; then, elective TAVI was scheduled for AStreatment.
After admission day 11, the patient fell and broke her femoral trochanter. Hip fracture surgery
was need as early as possible. Because the patient had taken an oral antiplatelet drug, spinal
anesthesia was not suitable and general anesthesia was applied. We considered that it was difficult
to maintain cardiovascular function without cardiac intervention during hip fracture surgery andstarting rehabilitation as early as possible was important. From anesthetic and perioperative management perspective, we proposed that we should perform simultaneous emergency TAVI and hip
fracture surgery to cardiologist and orthopedist. We started general anesthesia, using remifentanil(0.15 μg/kg/min), midazolam (1 mg), and rocuronium (30 mg), with infusing norepinephrine(0.035 μg/kg/min) for anesthesia induction. Maintaining intraoperative anesthesia, we infusedremifentanil (0.15–0.2 μg/kg/min) with desflurane (2%) and norepinephrine (0.02–0.035 μg/kg/min). For anesthetic management, we inserted an arterial catheter and a central venous catheter.
For intraoperative monitoring, we used transesophageal echocardiography, Bispectral indexTM(Nihon Kohden, Tokyo, Japan), and SomasensorTM (Covideien, Japan, Tokyo). First, TAVI wasperformed under heparinization. After reversal of heparinization, trochanteric fracture surgery
was performed. The tracheal tube was successfully removed in the operating room, and thepatient’s respiratory condition and hemodynamics were stable. She was admitted to the intensive
care unit, and her general condition was stable, except for hemiparesis and visual disorder. Two
weeks after the operation, transthoracic echocardiography revealed trivial perivalvular leakage
around the prosthetic valve, no asynergy, and an ejection fraction of 58%. On postoperative
day 1, rehabilitation was started by the bedside. On postoperative day 2, she was moved in awheelchair, and on postoperative day 3, she was transferred from the intensive care unit to thegeneral ward. She had a right visual disorder and could stand up with help. On postoperative
day 32, she was transferred to another hospital for rehabilitation.

DISCUSSION
Hip fractures have a high incidence in the elderly population. Current guidelines recommend
early surgery within 2 days after admission for hip fracture surgery.1 In previous report, apositive effect of early surgery on the mortality rate was observed.2 Early surgery reduce postNagoya J. Med. Sci. 85. 167–170, 2023

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Anesthesia for TAVI and hip surgery

injury mortality and provide effective functional results for the remaining years of life.3 From
this perspective, we should cooperate with orthopedist and multidiscipline departments, in orderto perform hip fracture surgery as early as possible to improve the patient’s quality of life in
the elderly population.
Performing non-cardiac surgery for AS patients is a high risk for major adverse cardiovascular
events in the perioperative period.4,5 Aakash reported that AS was associated with a significantly
increased risk of complications in elderly patients undergoing surgery for hip fracture.6 The
current guidelines recommend that non-cardiac surgery should be postponed for symptomatic
AS patients until after aortic valve surgery.7 In our case, symptomatic severe AS patient need
non-cardiac surgery, we thought performing AS treatment prior to hip surgery was reasonable.
Tashiro et al5 reported that perioperative death rates were lower in AS patients than in historical
reports, and that emergent surgery, rather than AS, was the principal determinant of perioperativemortality. The recommendation of postponing surgical intervention until AS is corrected seems
to be overly conservative and may delay necessary non-cardiac surgery.7 Tashiro et al also
reported that symptomatic patients and patients with Revised Cardiac Risk Index ≧ 2 should
be considered for a reduction in the risk of cardiovascular instability due to severe AS prior
to non-cardiac surgery.5 In our case, symptomatic AS patient that was candidate for surgicaltreatment need emergency hip surgery, there were risk factors for perioperative cardiovascularadverse event. It is important to decide which surgery should be performed prior to the othersurgery communicating with other departments.
Perioperative management of TAVI is challenging, as patients undergoing TAVI have highfrailty and comorbidities. In a previous study, rehabilitation after TAVI and after surgical aortic
valve replacement was assessed using the Functional Independence Measure score that assesses
physical and cognitive disability and evaluate activity of daily living.8 TAVI patients were older
and had high comorbidities; improvement in the Functional Independence Measure score wascomparable in both groups. On the other hand, open thoracic surgery is not reasonable forfrail patients, and it may be difficult to perform hip fracture surgery and surgical aortic valve
replacement simultaneously. Because full heparinization is need for establishing cardiopulmonary
bypass, that may induce more bleeding from fracture site.
If we were applied to general anesthesia for emergency non-cardiac surgery with severe AS, wehad better consider to performing TAVI and non-cardiac surgery simultaneously. This less invasive
simultaneous surgery enables to start rehabilitation and recover early for elderly and frail patient.

CONCLUSIONS
We managed TAVI and hip fracture surgery simultaneously in symptomatic AS patient successfully. Simultaneous and successive surgeries may be one of the choices for patients requiring
early recovery and timely rehabilitation. Anesthesiologist should play an important role fordecision making in not only intraoperative but perioperative management, and it is essential foranesthesiologist to communicate with other departments.

ACKNOWLEDGEMENTS
The authors would like to thank Prof Kimitoshi Nishiwaki, Department for Anesthesiology
Nagoya University Graduate School of Medicine, for professional advice. The authors would liketo thank Editage (www.editage.com) for English language editing too.
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CONFLICT OF INTEREST
The authors declare that they have no competing interests.

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