Balloon aortic valvuloplasty in a 94‐year‐old lady with fractured neck of femur

Fractured neck of femur is a common cause of morbidity, mortality and use of health care resources in the elderly. A higher mortality is seen with increasing age and in those with co-morbidity [1, 2]. Aortic stenosis is a major predictor of peri-operative cardiac events and is associated with upto a five-fold increased risk [3, 4]. Critical aortic stenosis is seen in >5% of those aged over 85 years of age [5]. We wish to present a case of a 94-year-old lady who presented with a left-sided fractured neck of femur following a mechanical fall. She lived in a residential home, was mobile with a frame and was self-caring for activities of daily living. She suffered significant co-morbidity including paroxysmal atrial fibrillation, ischaemic heart disease, hypertension, mild chronic obstructive pulmonary disease and partial seizures. Despite this she described no cardio-respiratory symptoms limiting her current level of functioning (including angina or syncope). Clinical examination elicited a loud, harsh ejection systolic murmur over the aortic area of the precordium radiating to the carotid arteries. Cardio-respiratory examination was otherwise normal. 12-lead ECG demonstrated sinus rhythm with evidence of left ventricular strain. Chest x-ray showed clear lung fields without cardiomegaly. A routine blood screen at admission was normal except for a normocytic anaemia (Hb 7.2 g.dl−1). Two units of blood were transfused within 24 h of admission. Surgery was planned for the next available trauma list 36 h following admission. This delay provided the opportunity to perform a trans-thoracic echocardiogram. This demonstrated severe aortic stenosis with a maximum gradient of 110 mm Hg. A valve area was not documented. There was no aortic regurgitation evident. Overall left ventricular systolic function was good. In view of the severity of her aortic stenosis she was discussed with a consultant cardiologist. Unexpectedly, the cardiologist decided that in view of the extremely high peri-operative cardiac risk associated with this degree of aortic stenosis he would attempt a balloon aortic valvuloplasty. The lady proceeded to undergo cardiac catheterisation via the right femoral artery and a successful balloon dilatation of her aortic valve that afternoon. Coronary arteries were found to be normal and her aortic gradient post-procedure was reduced to 50 mmHg. There was no significant resultant aortic regurgitation. She did not require formal anti-coagulation following the procedure. The following morning she underwent an uneventful dynamic hip screw under combined spinal-epidural. She remained stable for the first 24 h postoperatively on the High Dependency Unit and was discharged back to the trauma ward. On the third postoperative day she developed atrial fibrillation with rapid ventricular rate and acute pulmonary oedema. She was treated with standard medical therapy of digoxin, nitrates and diuretics. Her condition improved over the following 48 h with her return to sinus rhythm and resolution of her pulmonary oedema. Troponin T was not raised during this episode. Over the following 3 weeks she proceeded to make a slow but continued recovery from her operation back to her previous level of functioning. She suffered no further cardio-respiratory sequelae. She was discharged back to her residential home on the 31st day of her admission. Aortic valvuloplasty is a method of reducing short-term mortality in the elderly population, although it is not without risk of serious morbidity and may not improve long-term survival [6, 7]. The successful balloon aortic valvuloplasty in this lady significantly reduced her peri-operative cardiac risk and we feel was a major factor in her surviving this hospital admission. With an ever increasing elderly population, anaesthetists are likely to face similar candidates for surgery more commonly in the future. When faced with similar circumstances, early discussion with a consultant cardiologist should take place. Age and proposed surgery should not be a bar to considering aggressive intervention even if this means transfer of the patient to the local cardiac centre. It has been proposed recently that balloon aortic valvuloplasty strategies should be revisited in light of improved knowledge and refined transcatheter device developments [8]. It may provide the means to reduce peri-operative morbidty and mortality in this extremely high risk group.