In Reply The purpose of our review was to provide a broad but succinct overview of perioperative risk assessment and management for general medical readers, and we focused on topics that are supported by data, common in clinical practice, and consistent with current society guideline recommendations.
Symptomatic, severe aortic stenosis was highlighted as a contraindication to noncardiac surgery in our review.1 Aortic stenosis is a complex entity, and paradoxical low-gradient severe aortic stenosis is an emerging phenotype associated with adverse outcomes in nonsurgical cohorts.2 However, data on perioperative outcomes of noncardiac surgery in patients with low-gradient aortic stenosis are limited. In a study evaluating perioperative risks of aortic stenosis in 256 patients, only 35 patients had low-gradient severe aortic stenosis and only 10 patients had the paradoxical low-flow, low-gradient variant.3 The surgical outcomes of these patients have not been reported separately. However, we agree that all patients with a diagnosis of severe aortic stenosis with a valve area less than 1.0 cm2 (regardless of transvalvular gradients) require preoperative expert consultation with a cardiovascular disease specialist prior to noncardiac surgery.
Smilowitz NR, Berger JS. Cardiovascular Risk Assessment for Noncardiac Surgery—Reply. JAMA. 2020;324(20):2106–2107. doi:10.1001/jama.2020.19416
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