Comparison of general anesthesia and spinal anesthesia in patients with moderate to severe aortic stenosis undergoing surgery for hip fracture: a retrospective cohort study

Q: What are the key findings of this study?

Spinal anesthesia reduced intraoperative hypotension (MAP <65 mmHg AUT) compared with general anesthesia in patients with moderate-to-severe aortic stenosis (β = -390 mmHg·min, p = 0.04).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Moderate to severe aortic stenosis undergoing hip fracture surgery (n=103). Intervention: Spinal anesthesia vs. General anesthesia. Primary outcome: Intraoperative hypotension, quantified as the area under the threshold (AUT) for mean arterial pressure below 65 mmHg (mmHg·min) (β = -390 mmHg·min (unadjusted MD -270 mmHg·min), 95% CI -760 to -24, p=0.04).

Q: What does this research mean for the field?

In patients with moderate to severe aortic stenosis undergoing hip fracture surgery, spinal anesthesia is associated with significantly less intraoperative hypotension and lower vasopressor requirements than general anesthesia, with comparable postoperative complication rates. Novelty: ClaimNovelty.CONTRADICTORY. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

Tomoyo Takahashi; Nobuko Fujita; Yuki Yonekura; K Miyasaka; Seiki Abe

doi:10.1186/s13019-026-04766-7

October 31, 2026Journal of Cardiothoracic SurgeryOpen Access

Comparison of general anesthesia and spinal anesthesia in patients with moderate to severe aortic stenosis undergoing surgery for hip fracture: a retrospective cohort study

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Key result

Spinal anesthesia is linked to less intraoperative hypotension than general anesthesia in severe aortic stenosis.

β = -390 mmHg·min (unadjusted MD -270 mmHg·min)
95% CI -760 to -24
P=0.04
n=103

Why the study?

Spinal anesthesia has historically been considered relatively contraindicated in patients with moderate to severe aortic stenosis undergoing hip fracture surgery, yet clear evidence supporting this assumption and data comparing spinal with general anesthesia were limited.

Does spinal anesthesia reduce intraoperative hypotension compared with general anesthesia in patients with moderate to severe aortic stenosis undergoing hip fracture surgery?

Key Points

To compare intraoperative hypotension, vasopressor requirements, and postoperative outcomes between spinal anesthesia and general anesthesia in patients with moderate to severe aortic stenosis undergoing hip fracture surgery.
Single-center retrospective observational cohort study analyzing 103 patients with moderate (n=69) or severe (n=34) aortic stenosis undergoing hip fracture surgery.
Patients were grouped by anesthetic technique: general anesthesia (n=76) versus spinal anesthesia (n=27, primarily receiving isobaric 0.5% bupivacaine).
The primary outcome was intraoperative hypotension, evaluated as the area under the threshold (AUT) for mean arterial pressure <65 mmHg, alongside secondary vasopressor, pain, and complication endpoints.
In multivariable analysis, spinal anesthesia was independently associated with a lower AUT for mean arterial pressure <65 mmHg (β = -390 mmHg·min, 95% CI, -760 to -24; p = 0.04) and reduced phenylephrine requirements (β = -1.6 mg, 95% CI, -2.7 to -0.45; p < 0.01).
No statistically significant differences occurred between groups in 30-day mortality (OR 0.60, 95% CI, 0.03 to 11; p = 0.72) or complications such as acute kidney injury (OR 0.81, 95% CI, 0.27 to 2.5; p = 0.71), delirium (OR 0.52, 95% CI, 0.19 to 1.4; p = 0.21), and heart failure (OR 1.4, 95% CI, 0.41 to 5.1; p = 0.57).
Time to first postoperative analgesic request was longer in the spinal anesthesia group (log-rank p = 0.04; adjusted HR = 0.45, 95% CI, 0.21 to 0.94; p = 0.03), while numeric rating scale pain scores did not differ significantly over time (β = -0.20, 95% CI, -1.10 to 0.69; p = 0.66).

Study Design

Type

Cohort (n=103)

Multicenter

No

Structured PICO

Does spinal anesthesia reduce intraoperative hypotension compared with general anesthesia in patients with moderate to severe aortic stenosis undergoing hip fracture surgery?

P

Population

103 older adults (mean age ~88 years, 88.3% female) with moderate to severe aortic stenosis undergoing hip fracture surgery at a single center in Japan, followed for 30 days.

E

Exposure

Spinal anesthesia (SA), predominantly using intrathecal 0.5% bupivacaine (85% isobaric, 15% hyperbaric) at a mean dose of 2.8 (0.33) mL, injected mostly at the L3/4 interspace (85%, with 3.7% at L2/3 and 11% at L4/5), with nerve block used adjunctively in 11.1% of patients.

C

Comparator

General anesthesia (GA), chosen at the discretion of the attending anesthesiologist (not randomized or protocolized), with nerve block used adjunctively in 9.2% of patients.

O

Outcome

Intraoperative hypotension, quantified as the area under the threshold (AUT) in mmHg·minutes for mean arterial pressure (MAP) below 65 mmHg between the start and end of anesthesia.surrogate

Main Result

Mean Difference: -390 (95% CI -760–-24)

Absolute Event Rate: 250% vs 520%

p-value: p=0.04

In patients with moderate to severe aortic stenosis undergoing hip fracture surgery, spinal anesthesia was associated with significantly less intraoperative hypotension and lower phenylephrine requirements compared to general anesthesia, without increasing 30-day mortality or postoperative complications.

Limitations

Retrospective single-center design limiting generalizability
Small sample size, particularly in the spinal anesthesia group (n=27), reducing statistical power for rare outcomes like mortality
Residual confounding from unadjusted baseline imbalances (such as preoperative ACE inhibitor use, body weight, and mean pressure gradient)
Subgroup analyses stratified by aortic stenosis severity were limited by very small sample sizes
Temporal heterogeneity over the 10-year study period in anesthetic monitoring practices and vasopressor administration protocols
Retrospective single-center design may limit generalizability
Choice of anesthetic technique was not randomized or protocolized
Underpowered to reliably detect the between-group difference in AUT at 80% power
Fixed MAP threshold of 65 mmHg may underestimate true hemodynamic compromise in patients with severe LV hypertrophy
Small sample sizes within the AS severity subgroups precluded multivariable adjustment in subgroup analyses

Implication

Spinal anesthesia was associated with less hypotension; challenges historical contraindication in aortic stenosis yet leaves open need for randomized confirmation.

Abstract

Patients with moderate to severe aortic stenosis undergoing hip fracture surgery are at high risk for perioperative complications, but data comparing spinal anesthesia and general anesthesia are limited. Historically, spinal anesthesia has been considered relatively contraindicated in patients with aortic stenosis, but there is no clear evidence supporting this assumption. We conducted a single-center retrospective observational study of patients with moderate to severe aortic stenosis undergoing hip fracture surgery. Patients were classified by anesthetic technique (general anesthesia or spinal anesthesia). The primary outcome was intraoperative hypotension, quantified as the area under the threshold, representing the duration and magnitude of mean arterial pressure below 65 mmHg. Secondary outcomes included the ratio of hypotensive time to total anesthesia time, vasopressor requirements, 30-day mortality, postoperative complications, time to first analgesic request, and numeric rating scale pain scores postoperatively. Among 103 patients analyzed (general anesthesia = 76; spinal anesthesia = 27), baseline characteristics were comparable between groups. Spinal anesthesia was associated with lower area under the threshold for mean arterial pressure below 65 mmHg (β = -390 mmHg·min, 95% CI, -760 to -24; p = 0.04) and reduced phenylephrine use (β = -1.6 mg, 95% CI, -2.7 to -0.45; p < 0.01). There were no statistical differences between groups in mortality and postoperative complications (30-day mortality: OR 0.60, 95% CI, 0.03 to 11; p = 0.72; AKI: OR 0.81, 95% CI, 0.27 to 2.5; p = 0.71; delirium: OR 0.52, 95% CI, 0.19 to 1.4; p = 0.21; heart failure: OR 1.4, 95% CI, 0.41 to 5.1; p = 0.57). In patients with moderate to severe aortic stenosis undergoing hip fracture surgery, spinal anesthesia was associated with reduced intraoperative hypotension and vasopressor use compared with general anesthesia. These results suggest that spinal anesthesia may be a feasible alternative to general anesthesia in this patient population, though prospective confirmation is needed.

Discussion

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Cite This Study

Takahashi et al. (2026) conducted a cohort in Moderate to severe aortic stenosis undergoing hip fracture surgery (n=103). Spinal anesthesia vs. General anesthesia was evaluated on Intraoperative hypotension, quantified as the area under the threshold (AUT) for mean arterial pressure below 65 mmHg (mmHg·min) (β = -390 mmHg·min (unadjusted MD -270 mmHg·min), 95% CI -760 to -24, p=0.04). Spinal anesthesia reduced intraoperative hypotension (MAP <65 mmHg AUT) compared with general anesthesia in patients with moderate-to-severe aortic stenosis (β = -390 mmHg·min, p = 0.04).

synapsesocial.com/papers/6ae7d421edffb496294104af https://doi.org/10.1186/s13019-026-04766-7

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Comparison of general anesthesia and spinal anesthesia in patients with moderate to severe aortic stenosis undergoing surgery for hip fracture: a retrospective cohort study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Comparison of general anesthesia and spinal anesthesia in patients with moderate to severe aortic stenosis undergoing surgery for hip fracture: a retrospective cohort study

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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