Aortic stenosis is a progressive narrowing of the aortic valve that leads to increased resistance against left ventricular ejection. As the heart works harder to overcome this resistance, it undergoes concentric hypertrophy. Over time, this hypertrophy impairs diastolic filling and can result in decreased cardiac output. These physiological and hemodynamic changes in aortic stenosis pose significant risks during anesthesia, where alterations in preload, afterload, heart rate, or contractility can destabilize an already strained cardiovascular system ^1,2.

Patients with aortic stenosis rely on adequate preload to maintain cardiac output, as their stroke volume is essentially fixed. Hypovolemia or vasodilation can quickly lead to a critical drop in perfusion pressure, potentially causing myocardial ischemia or sudden cardiovascular collapse. At the same time, systemic vascular resistance should be preserved or slightly increased to maintain coronary perfusion pressure. Hypovolemia and excessive vasodilation should be avoided during anesthesia in patients with aortic stenosis, which often requires invasive monitoring and cautious fluid administration ^3–5.

Induction of anesthesia is a particularly vulnerable phase for patients with aortic stenosis. Some research suggests that remimazolam could be used as an induction agent with timely bolus vasopressors ^6,7. However, research on the effects of various induction agents on these patients is still ongoing.

Maintaining sinus rhythm is essential in patients with aortic stenosis, in particular when ventricular compliance is reduced due to hypertrophy. Heart rate should be maintained within a normal range to optimize diastolic filling and myocardial perfusion. Both bradycardia and tachycardia can be detrimental and should be corrected promptly ^8–10.

Though research remains inconclusive, the use of neuraxial anesthesia is controversial in patients with severe aortic stenosis due to potential impacts on the cardiovascular system. Epidural anesthesia may possibly be safer if administered slowly and incrementally with careful hemodynamic monitoring. Further large-scale, randomized studies are warranted to establish definitive guidelines and enhance perioperative clinical outcomes for patients ^11–13.

Continuous invasive monitoring is essential during surgery. Arterial lines should be placed pre-induction for real-time blood pressure monitoring. Central venous access may be indicated for volume status assessment and vasoactive drug administration. In high-risk cases, intraoperative transesophageal echocardiography provides valuable real-time insight into cardiac function. Postoperatively, patients require close observation in a monitored setting to detect and treat any hemodynamic instability early ^14–17.

Anesthesia for patients with aortic stenosis demands precise planning and vigilance. Understanding the unique hemodynamic challenges, choosing appropriate agents and techniques, and maintaining close monitoring throughout the perioperative period are key to minimizing risk and ensuring patient safety.

References

1. Aortic valve stenosis – Symptoms and causes. Mayo Clinic https://www.mayoclinic.org/diseases-conditions/aortic-stenosis/symptoms-causes/syc-20353139.

2. Aortic Stenosis – Symptoms and Causes | Penn Medicine. https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/aortic-valve-stenosis.

3. Pujari, S. H. & Agasthi, P. Aortic Stenosis. in StatPearls (StatPearls Publishing, Treasure Island (FL), 2025).

4. The Crashing Patient with Critical Aortic Stenosis. https://www.emra.org/emresident/article/the-crashing-patient-with-critical-aortic-stenosis.

5. Diehl, O. Anesthetic Considerations for Patients with Aortic Stenosis. Nursing Student Class Projects (Formerly MSN) (2022).

6. Kim, B. R. et al. Remimazolam for General Anesthesia in a Patient with Severe Aortic Stenosis Undergoing High-Risk Surgery: A Case Report. Medicina (Kaunas) 58, 1372 (2022). DOI: 10.3390/medicina58101372

7. Nakanishi, T. et al. Remimazolam for induction of anesthesia in elderly patients with severe aortic stenosis: a prospective, observational pilot study. BMC Anesthesiol 21, 306 (2021). DOI: 10.1186/s12871-021-01530-3

8. Vukasovic, J. L., Florenzano, F., Adriazola, P. & Escobar, E. Heart rate variability in severe aortic stenosis. J Heart Valve Dis 8, 143–148 (1999).

9. Intraoperative hemodynamic management of aortic or mitral valve disease in adults – UpToDate. https://www.uptodate.com/contents/intraoperative-hemodynamic-management-of-aortic-or-mitral-valve-disease-in-adults.

10. Brown, J. & Morgan-Hughes, N. J. Aortic stenosis and non-cardiac surgery. Continuing Education in Anaesthesia, Critical Care and Pain 5, 1–4 (2005). DOI: 0.1093/bjaceaccp/mki00

11. Irving, M. & Nielson, P.T. Neuraxial Blockade in Patients with Significant Aortic Stenosis: A Mini-Review of Literature. World Journal of Clinical Case Reports and Case Series (2024).

12. Prasad, A., Ghosh, A. & Nag, T. Regional anaesthesia in a patient with aortic stenosis for bladder tumour resection. Indian J Anaesth 61, 441–442 (2017). DOI: 10.4103/ija.IJA_109_17

13. Johansson, S. & Lind, M. N. Central regional anaesthesia in patients with aortic stenosis – a systematic review. Dan Med J 64, A5407 (2017).

14. Elsherbiny, M., Abdelwahab, Y., Nagy, K., Mannaa, A. & Hassabelnaby, Y. Role of Intraoperative Transesophageal Echocardiography in Cardiac Surgery: an Observational Study. Open Access Maced J Med Sci 7, 2480–2483 (2019). DOI: 10.3889/oamjms.2019.712

15. Herrera, R. A., Smith, M. M., Mauermann, W. J., Nkomo, V. T. & Luis, S. A. Perioperative management of aortic stenosis in patients undergoing non-cardiac surgery. Front Cardiovasc Med 10, 1145290 (2023). DOI: 10.3389/fcvm.2023.1145290

16. Rohatgi, N., Smilowitz, N. R. & Reejhsinghani, R. Perioperative Considerations for Patients with Severe Aortic Stenosis Undergoing Elective Noncardiac Surgery. The American Journal of Medicine 136, 960–962 (2023). DOI: 10.1016/j.amjmed.2023.05.017

17. MD, D. L. T. Intraoperative Monitoring (IOM). News-Medical https://www.news-medical.net/health/Intraoperative-Monitoring-(IOM).aspx (2017).