A Review of Aortic Stenosis: Risk Assessment, General Management, and Anesthetic Considerations Prior to Dental Care

Aortic stenosis (AS) is a significant cardiac condition that mainly occurs from age-related calcification of the aortic valves as well as congenital bicuspid aortic valve abnormalities or rheumatic heart disease. AS can also occur from congenital defects and other malformations of the associated cardiac structures; however, this generally happens in much younger patients and as such is beyond the general scope of this review. The sequelae from untreated AS progressively worsen over time, leading to a reduced cardiac output. Critical AS with ventricular hypertrophy typically manifests in adults between the ages of 60 to 80 years. Classification of AS is dependent upon transaortic velocities and mean aortic pressure gradients as assessed via transthoracic echocardiograms. Interdisciplinary communication is imperative for the timing of dental procedures, the need for antibiotic prophylaxis, guidance for holding or maintaining anticoagulation therapy, and dental clearances throughout the aortic valve replacement process. Special considerations for dental treatment should be made on a patient-by-patient basis and may vary from one appointment to the next dependent upon the patient’s current physiological status and the planned dental care. Judicious use of local anesthetics containing epinephrine can be helpful to balance increases in catecholamine release in response to pain and surgical stimulation. It is advisable to utilize perioperative monitoring during local anesthetic only cases for patients that are at higher risk for adverse cardiac events. Anesthetic management options such as nitrous oxide, enteral (oral) minimal or moderate sedation, parenteral (intravenous) moderate or deep sedation, or general anesthesia may be used; however, any level of anesthesia should coincide with appropriate perioperative monitoring to ensure cardiac stability and patient safety throughout.