Perioperative Nitroprusside Infusion in a Patient With Severe Aortic Stenosis: Another Component of Afterload Reduction Uncovered

BACKGROUND:

The traditional goals of perioperative management of severe aortic stenosis are based on maintaining a high systemic vascular resistance (SVR) to allow for good coronary perfusion.

CASE REPORT:

An 87-year-old male presented with septic arthritis of a prosthetic knee joint. Arthroplasty, implant removal, and joint washout were planned as surgical intervention. His comorbidities included severe aortic stenosis (peak/mean gradient 109/60 mmHg, aortic valve area of 0.80 cm²), new onset mitral regurgitation secondary to a flail posterior mitral valve leaflet, and a new third-degree conduction block. A nitroprusside infusion was initiated 72 hours preoperatively and continued throughout the intraoperative period and postoperative intensive care stay. This novel use of nitroprusside improved cardiac output and forward flow through the stenotic aortic valve.

CONCLUSIONS:

To our knowledge, the use of nitroprusside infusion during the intraoperative period in patients with severe aortic stenosis undergoing noncardiac surgery has not been described previously. Although contrary to the traditional goal of maintaining a high SVR, this important pharmacological intervention optimizes cardiac indices during the perioperative period in these patients.