Perioperative Management of Patients with Prosthetic Heart Valves?A Narrative Review

Worldwide, about 13% of the 200,000 annual recipients of prosthetic heart valves (PHV) present for various surgical procedures. Also, more and more females are opting for pregnancies after having PHV. All patients with PHV present unique challenges for the anesthesiologists, surgeons and obstetricians (in case of deliveries). They have to deal with the perioperative management of anticoagulation and a host of other issues involved. We reviewed the English language medical literature relevant to the different aspects of perioperative management of patients with PHV, particularly the guidelines of reputed societies that appeared in the last 20 years. Regression of cardiac pathophysiology following valve replacement is variable both in extent and timeline. The extent to which reverse remodeling occurs depends on the perioperative status of the heart. We discussed the perioperative assessment of patients with PHV, including focused history and relevant investigations with the inferences drawn. We examined the need for prophylaxis against infective endocarditis and management of anticoagulation in such patients in the perioperative period and the guidelines of reputed societies. We also reviewed the conduct of anesthesia, including general and regional anesthesia (neuraxial and peripheral nerve/plexus blocks) in such patients. Finally, we discussed the management of delivery in this group of high?risk patients. From the discussion of different aspects of perioperative management of patients with PHV, we hope to guide in formulating the comprehensive plan of management of safe anesthesia in such patients.

Interventional treatments for cancer pain due to bone metastasis

More than 30% of patients with cancer do not receive adequate pain-control treatment. Metastatic bone lesion-induced pain is one of the most common causes of cancer pain. Although cancer pain is reasonably well controlled using the World Health Organization analgesic ladder in most cases, metastatic bone lesion-induced pain generally does not respond well to traditional treatments. Interventional treatments are considered only when traditional treatments are ineffective or increasing the opioids dosage is impossible because of severe complications. In these cases, interventional treatments, such as peripheral nerve block, neuraxial block, vertebral augmentation, percutaneous cementoplasty, radiofrequency ablation, and cryoablation, can be considered. Fortunately, nerve block techniques show significant effects in many cases. The recent development of the intrathecal pump makes drug delivery safer and continuous for patients, without the need for replacement, until the end. Vertebral augmentation is a very useful pain-relieving method for metastatic spinal lesion pain. Vertebral augmentation and percutaneous cementoplasty provide stability and reinforcement to the weight-bearing bones and spine, thereby improving the quality of life of patients. Percutaneous radiofrequency ablation and cryoablation are applicable to painful metastatic spinal and bone lesions; when performed together with vertebral augmentation or percutaneous cementoplasty, the results are even better. If interventional treatments are appropriately performed at the proper time, they can have a synergistic effect and lower the rate of side effects compared to traditional treatments; thus, increasing the quality of life of patients with cancer and restoring their dignity until the end.