Aortic stenosis is one of the most prevalent valvular heart diseases, particularly in elderly populations, and it presents unique perioperative challenges. The condition involves progressive narrowing of the aortic valve, resulting in fixed left ventricular outflow obstruction 1. Since cardiac output cannot easily increase in response to physiological stress, patients with aortic stenosis are vulnerable to hypotension, myocardial ischemia, and sudden hemodynamic collapse during anesthesia. Effective anesthesia risk stratification of patients with aortic stenosis before non-cardiac surgery is therefore essential to minimize complications and guide clinical decision-making.
The first step in risk stratification for anesthesia management is determining the severity of aortic stenosis, typically using transthoracic echocardiography. Key parameters include aortic valve area, mean transvalvular gradient, and peak jet velocity. In addition to valve metrics, left ventricular function and degree of hypertrophy should be evaluated. Higher severity significantly increases perioperative risk, especially when associated with left ventricular dysfunction 2,3.
Symptomatology plays a critical role in perioperative risk prediction as well. Patients with angina, syncope, or heart failure have markedly higher morbidity and mortality during non-cardiac surgery. Symptomatic status often reflects reduced cardiac reserve and impaired coronary perfusion. In contrast, asymptomatic patients with preserved ventricular function may tolerate surgery better, although they still require careful intraoperative management. Distinguishing between symptomatic and asymptomatic disease is therefore critical to anesthesia planning 4–6.
The urgency and invasiveness of the non-cardiac surgery significantly influence overall risk, as elective surgeries allow time for patient optimization, including consideration of valve intervention to treat severe aortic stenosis prior to the procedure. High-risk surgeries, such as major vascular operations, impose greater hemodynamic stress compared to minor or intermediate-risk procedures. Emergency surgeries present the highest risk, as there is no opportunity for preoperative cardiac optimization or multidisciplinary planning 7–9.
Guidelines emphasize a team-based approach involving anesthesiologists, cardiologists, and surgeons. Risk stratification places patients with severe symptomatic aortic stenosis in the highest risk category, and elective non-cardiac surgery is typically postponed until valve intervention, such as surgical aortic valve replacement or transcatheter aortic valve implantation (TAVI), is completed. For asymptomatic patients or those undergoing urgent surgery, individualized risk-benefit assessment is essential. Shared decision-making helps balance surgical necessity against cardiovascular risk 10,11.
From an anesthetic perspective, maintaining hemodynamic stability is paramount. Key goals include preserving sinus rhythm, avoiding tachycardia, maintaining adequate preload, and preventing sudden decreases in systemic vascular resistance. Both general and regional anesthesia can be used, but invasive monitoring is often warranted in moderate-to-severe AS. Arterial line placement and, in selected cases, advanced cardiac monitoring may help guide real-time management 12–14.
Risk stratification of patients with aortic stenosis undergoing non-cardiac surgery requires a comprehensive evaluation of disease severity, symptom status, functional capacity, and surgical urgency. A structured, multidisciplinary approach allows clinicians to identify high-risk patients and optimize perioperative care.
References
1. Aortic Stenosis Overview | American Heart Association. https://www.heart.org/en/health-topics/heart-valve-problems-and-disease/heart-valve-problems-and-causes/problem-aortic-valve-stenosis.
2. Reddy, Y. N. V. & Nishimura, R. A. Evaluating the severity of aortic stenosis: a re-look at our current ‘gold standard’ measurements. Eur Heart J 39, 2656–2658 (2018). DOI: 10.1093/eurheartj/ehy224
3. Berthelot-Richer, M. et al. Discordant Grading of Aortic Stenosis Severity: Echocardiographic Predictors of Survival Benefit Associated With Aortic Valve Replacement. JACC Cardiovasc Imaging 9, 797–805 (2016). DOI: 10.1016/j.jcmg.2015.09.026
4. Pujari, S. H. & Agasthi, P. Aortic Stenosis. in StatPearls (StatPearls Publishing, Treasure Island (FL), 2025).
5. Aortic valve stenosis – Symptoms and causes. Mayo Clinic https://www.mayoclinic.org/diseases-conditions/aortic-stenosis/symptoms-causes/syc-20353139.
6. What Is Aortic Stenosis? Cleveland Clinic https://my.clevelandclinic.org/health/diseases/23046-aortic-valve-stenosis.
7. Bak, M. et al. Perioperative Risk of Noncardiac Surgery in Patients With Asymptomatic Significant Aortic Stenosis: A 10‐Year Retrospective Study. Journal of the American Heart Association 13, e032675 (2024). DOI: 10.1161/JAHA.123.032675
8. 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
9. Place, A. et al. Peri-operative risk of non-cardiac surgery in patients with aortic stenosis: a systematic review and meta-analysis. Anaesthesia (2025). DOI: 10.1111/anae.70084
10. Kuiper, B. I. et al. Does preoperative multidisciplinary team assessment of high-risk patients improve the safety and outcomes of patients undergoing surgery? BMC Anesthesiol 24, 9 (2024). DOI: 10.1186/s12871-023-02394-5
11. Arnal-Velasco, D. et al. Multidisciplinary, evidence-based, patient-centred perioperative patient safety recommendations: a European consensus study☆. British Journal of Anaesthesia 135, 723–736 (2025). DOI: 10.1016/j.bja.2025.04.047
12. Cruvinel, C. The Anesthetic Challenges of Managing Patients with Aortic Stenosis for Non-cardiac Surgery. Medical Research Archives 13, (2025). DOI: 10.18103/mra.v13i8.6899
13. Chacko, M. & Weinberg, L. Aortic valve stenosis: perioperative anaesthetic implications of surgical replacement and minimally invasive interventions. Continuing Education in Anaesthesia, Critical Care and Pain 12, 295–301 (2012). DOI: 10.1093/bjaceaccp/mks037
14. Jacobs, D. Aortic stenosis. NYSORA https://www.nysora.com/anesthesia/aortic-stenosis/ (2022).