2026 FSA Podium and Poster Abstracts

Introduction: Severe aortic stenosis (AS) represents one of the most significant cardiovascular risks for patients undergoing non-cardiac surgery. In neurosurgery, the anesthetic challenge is compounded by the need to maintain a narrow hemodynamic window to ensure adequate cerebral perfusion pressure (CPP) while managing the fixed stroke volume and potential for sudden decompensation associated with AS. This report compares two cases of severe AS undergoing neurosurgical procedures: one where the valve was addressed pre-operatively and one where the neurosurgical emergency took precedence.

Case Report 1 (The "Not Fixed" Case): An 82-year-old male with a known history of severe AS (Aortic Valve Area [AVA] 0.82 cm², peak velocity 371 cm/s, mean gradient 32 mmHg, and DVI of 0.22) presented with an L1 Chance fracture following a fall. Despite the cardiovascular risks, the neurosurgical team deemed the spinal instability an emergency requiring immediate T11-L3 instrumentation and fusion. The patient proceeded to the operating room without valvular intervention. Intraoperatively, the patient experienced significant hemodynamic lability, requiring aggressive vasopressor support to maintain Mean Arterial Pressure (MAP). The postoperative course was critical; the patient experienced a cardiac arrest in the postoperative period, requiring full resuscitation. This catastrophic event resulted in a prolonged recovery and poor overall outcome, highlighting the high morbidity and mortality risks of unoptimized severe AS in the setting of major surgical stress.

Case Report 2 (The "Fixed" Case): A 77-year-old male with severe AS (AVA 0.63 cm², mean gradient 45 mmHg) was originally scheduled for resection of a resection of a left sided cystic cerebellopontine angle mass with severe brainstem compression. However, upon identifying the severity of the AS during preoperative evaluation, the neurosurgical procedure was cancelled to prioritize cardiac optimization. A multidisciplinary approach was utilized, and the patient underwent a successful balloon aortic valvuloplasty (BAV), which reduced the mean transvalvular gradient to 30 mmHg and increased the AVA to 0.8 cm². The patient subsequently underwent the neurosurgical procedure one week later. The anesthetic course was notably more stable, with well-managed hemodynamics and a significantly better clinical outcome. The patient was discharged for rehabilitation with a plan for definitive TAVR in 2-3 months.

Discussion: The contrast between these two cases underscores the critical importance of pre-operative hemodynamic optimization in AS. While neurosurgical emergencies often force the anesthesiologist’s hand, the "fixed" case demonstrates that even a "bridge" intervention like BAV can significantly widen the safety margin for non-cardiac surgery. For the anesthesiologist, the reduction in transvalvular gradient allows for more predictable responses to induction agents and surgical stimulation, mitigating the risk of myocardial ischemia, heart failure, or the postoperative cardiac arrest seen in Case 1.

Conclusion: In patients with severe AS requiring neurosurgery, pre-operative valvular intervention (where time permits) is associated with superior hemodynamic stability and clinical outcomes. This comparative study advocates for early multidisciplinary involvement between neurosurgery, cardiology, and anesthesiology to weigh the risks of surgical delay against the benefits of cardiac optimization, emphasizing that even "emergencies" must be balanced against the potential for intraoperative or postoperative catastrophic collapse.