Key points for anesthetic and hemodynamic management of aortic stenosis during cardiac surgery

Hemodynamic goals	Avoid	Monitor	Intervention
Sinus rhythm	Avoid atrial fibrillation or other SVT	5-lead ECG	Manage new-onset atrial fibrillation or other SVT: Control HR. Cardioversion for SVT with hemodynamic compromise.
Normal HR (60 to 80 bpm)	Avoid tachycardia Avoid severe bradycardia Avoid junctional rhythm	5-lead ECG Pulse oximetry with visible waveform	Design an anesthetic that maintains a relatively slow HR (eg, an opioid-based technique). Prevent tachycardia by ensuring adequate depth of anesthesia and analgesia. Manage tachycardia related to hypotension with a vasoconstrictor (eg, phenylephrine, norepinephrine) and fluid administration. Slow HR with beta blockers if necessary.
Maintain afterload	Avoid hypotension	Intra-arterial BP	Administer a vasoconstrictor (eg, phenylephrine, norepinephrine) to manage hypotension. Consider preemptive administration of a low-dose infusion of a vasoconstrictor (eg, phenylephrine, norepinephrine) during induction.
Maintain preload	Avoid hypovolemia	Assess clinical response to fluid boluses	Maintain intravascular volume status. Rapid resuscitation for hemorrhage.
Maintain contractility	Avoid doses of drugs that cause significant myocardial depression	Hemodynamics	If inotropic support needed, norepinephrine is preferred.

SVT: supraventricular tachycardia; ECG: electrocardiogram; HR: heart rate; bpm: beats per minute; BP: blood pressure.

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