Heart valve surgery in a very high-risk population: a preliminary experience in awake patients

Heart valve surgery in high-risk patients is associated with considerable morbidity and mortality. Epidural anesthesia without mechanical ventilation has been proposed to reduce invasiveness. An analysis was conducted in very high-risk heart valve patients of mid-term survival free from complications, and patient satisfaction of regional anesthesia use, without mechanical ventilation.

A prospective follow up study was conducted in 50 patients (24 females, 26 males; mean age 74 +/- 10 years; range: 43-89 years) who underwent heart valve surgery with epidural anesthesia without endotracheal intubation. Preoperatively, all patients were in NYHA class III or IV; eight patients (16%) had undergone a previous cardiac procedure. The median Additive and Logistic EuroSCORE were 14.5 and 52%, respectively. Twenty-seven patients underwent aortic valve replacement, 10 mitral valve replacement, 10 mitral valve repair, two double valve replacement, and one patient ascending aorta replacement. Associated surgical procedures included coronary artery bypass grafting in 12 patients (24%), ascending aorta replacement in three (6%), and left ventricle reshaping in two (4%). Radiofrequency ablation to treat chronic atrial fibrillation (AF) was performed in 15 patients (30%). All patients were prospectively followed up, and a six-month quality of life assessment was performed in all survivors.

Procedures were performed without mechanical ventilation in completely awake and conscious patients. There were two in-hospital and two long-term deaths (8%). Three patients had had previous cardiac surgery (two double valve replacements, two complex mitral valve surgery). Among survivors, 34 (71%) had an uneventful postoperative outcome, except for AF in nine cases. Eight patients required revision for bleeding; two of these were redo cases. The most consistent postoperative complication was acute renal failure in 16 patients, five of whom had previous chronic renal failure. Three patients required mechanical ventilatory support, and none had a cerebrovascular accident. Patients were discharged home after a mean of 10 +/- 5 days (including ICU stay; median 9 h). At follow up, all patients were in NYHA class I/II, and all survivors expressed their satisfaction with epidural anesthesia.

Heart valve surgery while on cardiopulmonary bypass is feasible and safe using epidural anesthesia. By maintaining autonomic ventilation, a low mid-term morbidity and mortality was observed in patients in whom there was an unacceptable operative risk.