Valvular Heart Disease Mitral Stenosis

1
Valvular Heart Disease Mitral Stenosis

• Dr. Chitra Rajeswari
• Dr. Sivakumaran
• Moderator Dr. Shende D

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.co
m
2
Mitral Stenosis

• Anatomy
• Incidence
• Etiology
• Symptoms
• Physical Exam
• Natural history
• Complications
• Preoperative assessment
• Anaesthetic management

3
Anatomy

• Two triangular cusps (leaflet)
• Unequal size
• Anterior or aortic cusp
• Placed in front and right of the atrioventricular
  and aortic orifices
• Posterior or smaller cusp
• Behind and to the left of the opening

4
Incidence

• 10 35 of all cardiac admissions is for ARF
  RHD
• Pure MS occur in 25 cases of RHD
• MS with MR occurs in 40 cases of RHD
• Two-thirds of all patients with MS are females
  (21)
• Most common lesion associated with RHD

5
Etiology

• Primarily a result of rheumatic fever
• ( 99 of MVs _at_ surgery show rheumatic damage )
• Rarely congenital in infants and children
• Roberts et al, Ann Intern Med 1972
• Malignant carcinoid
• Rheumatoid arthritis
• Mucopolysacccharides
• Severe annular calcification

6
Rheumatic fever- Jones criteria

• Major criteria
• Carditis
• Arthritis
• Subcutaneous nodules
• Chorea
• Erythema marginatum

• Minor Criteria
• Clinical
• Fever
• Arthralgia
• P/H rheumatic fever / RHD
• Laboratory
• Acute phase reactants leucocytosis, ESR, CR
  proteins
• Prolonged PR interval

7
RF - Essential criteria

• Evidence for recent streptococcal infection as
  indicated by
• Increased anti streptococcal antibody titers
• Positive throat cultures
• Recent scarlet fever

8
Rheumatic heart disease

• Cause pancarditis long term sequele confined to
  endocardium
• Interval between the RF and the development of MS
  is 2 years
• Asymptomatic for 2 decades
• Symptoms develop in 3- 4 decades

9
Pathological process- RF

• Leaflet thickening and Calcification (15)
• Commisural fussion (30)
• Chordal fusion (15)
• Combination of these
• Results in a funnel shaped mitral apparatus
• This differential distribution has some
  functional implications
• Chord- regurgitation

10
Pathophysiology
11
Pathophysiology
12
Pathophysiology

• Increased pulmonary arteriolar resistance
• Alveolar basement membrane thickening
• Adaptation of neuroreceptors
• Increased lymphatic drainage
• Increased transpulmonary endothelin spillover rate

13
D
PRESSURE
C
PRESSURE
ESV
SV
EDV
B
A
VOLUME
VOLUME
Normal
Mitral stenosis
14
Transmitral gradient

• Flow
• K. pressure gradient
• Cardiac output / diastolic filling time
• LAP LVDP
• If we assume MVA is constant then,
• cardiac output 2
• Diastolic time
• So when cardiac output increases or diastolic
  time decreases gradient is increased to cause
  symptoms

MVA

LAP- LVDP
15
Transmitral gradient

• Gorlins formula
• MVA Flow/ K . pressure gradient
• Gorlin et al, Am Heart J 1951
• Area gt 1.5 cm2 - no symptoms rest
• Symptoms occur when
• ? transmitral flow
• ? diastolic filling period

16
Effect of tachycardia

• Tachycardia shortens diastole proportionately
  more than systole
• Decreases the overall time available for
  transmitral flow
• In order to maintain CO, the flow rate per unit
  time must increase
• Pressure gradient increases by the square of the
  increase in flow rate

17
Gradient / MVA / Flow
18
Symptoms

• Valve area gt 1.5 cm2 usually does not produce
  symptoms at rest
• Dyspnoea in patients with mild MS usually
  precipitated by
• Exercise
• Emotional stress
• Fever, Infection
• Anaemia
• Pregnancy
• Atrial fibrillation with rapid ventricular
  response
• Thyrotoxicosis

19
Symptoms

• Dyspnoea
• PND
• Orthopnea
• Palpitations
• Fatigue
• Chest pain (25 CAD)
• Cough
• Hemoptysis

• Atrial fibrillation
• Systemic embolism
• Pulmonary infection
• Right sided failure
• Hepatic Congestion
• Edema
• Ortners syndrome

20
General examination

• Mitral facies
• Pink purple patches on the cheeks, cyanotic
  skin changes from low cardiac output
• Pulse low volume pulse
• Blood pressure

21
Examination

• Inspection
• Engorged vein in neck
• Palpation
• Tapping apex beat
• Palpable S1
• Parasternal haeve
• Palpable S2
• Diastolic thrill

• Auscultation
• S1 is short, sharp , accentuated (loud, snapping)
  
• S2 audible
• Opening snap after S2
• A2 to OS interval inversely proportional to
  severity
• Diastolic rumble length proportional to
  severity
• In severe MS with low flow- S1, OS rumble may
  be inaudible

22
Murmur in MS

• Low pitched
• Mid diastolic
• Rumbling
• Presystolic accentuation
• Mitral area
• No radiation

• Best audible
• Bell of the stethscope
• Left lateral
• Height of expiration
• After mild exercise

23
Common Murmurs

• Systolic Murmurs
• Aortic stenosis
• Mitral insufficiency
• Mitral valve prolapse
• Tricuspid insufficiency
• Diastolic Murmurs
• Aortic insufficiency
• Mitral stenosis

S1 S2
S1
24
Differential diagnosis

• Carey coombs murmur
• Austin flint murmur
• Left atrial myxoma
• Ball valve thrombus
• Tricuspid stenosis
• Conducted murmur of AI
• Functional

25
Features of PHT

• Palpation
• Parasternal haeve
• Palpable S2

• Auscultation
• ESM over pulmonary area
• PSM which increases on inspiration heard along
  the left sternal border -Functional TR
• Graham Steell murmur pulmonary Regurgitation

26
Complications

• Atrial dysrhythmias
• Systemic embolization (10-25)
• Risk of embolization is related to age, presence
  of atrial fibrillation, previous embolic events
• Congestive heart failure
• Pulmonary infarcts (result of severe CHF)
• Hemoptysis
• Massive 20 to ruptured bronchial veins (pulm
  HTN)
• Streaking/pink froth pulmonary edema, or
  infection
• Endocarditis
• Pulmonary infections

27
Atrial fibrillation

• 30- 40 of patients with symptomatic MS develop
  AF
• Structural changes due to pressure and volume
  over load alter the electrophysiological
  properties of left atrium
• Rheumatic process itself may lead to fibrosis of
  the internodal and interatrial tracts and damage
  the nodes

28
Atrial fibrillation

• Common in older patients
• Poor prognosis
• 10 year survival rate of 25 (with AF), 46 (with
  sinus rhythm)
• Risk of arterial embolization (stroke) is
  significantly increased

29
Natural History- untreated MS

• Progressive, lifelong disease
• Usually slow stable in the early years
• Progressive acceleration in the later years
• 20-40 year latency from rheumatic fever to
  symptom onset in developed countries
• After symptoms-- additional 10 years before
  disabling symptoms

30
Natural history

• In North America and Europe it has a milder
  delayed course with the decline in incidence of
  rheumatic fever
• In some other geographic areas it progresses
  rapidly causing severe symptomatic MS in early
  20s

31
Survival rate

• 10 year survival rate
• Untreated patients 50- 60
• Minimally symptomatic gt 80
• Significant symptoms 0- 15
• With symptomatic MS, 20 patients die within one
  year 50 die within 10 years
• Once severe pulmonary hypertension develops mean
  survival drops to less than 3 years

32
Causes of mortality

• Untreated MS

Progressive pulmonary and systemic congestion 60- 70
Systemic embolism 20- 30
Pulmonary embolism 10
Infection 1- 5
33
ECG
Axis RAD RVH
P wave Broad bifid in V1, I, II LAE
P wave Inverted P in III LAE
P wave Absent Atrial fibrillation
QRS Tall R in V1 RVH
RR interval Varying Atrial fibrillation
34
Chest x-ray
Straightening of left heart border Prominent pulmonary artery and LA appendage
Double shadow behind the heart Shadow within shadow Left atrial enlargement
Splayed carina LA enlargement
Calcification Mitral valve calcification
35
Chest x-ray
Kerley B lines Dense, short, horizontal lines in costophrenic angles Interalveolar septal thickening
Kerley C lines Reticular pattern throughout the lungs
Kerley A lines Straight, dense lines upto 4 cm towards hilum Distended lymphatics
36
Chest x-ray
Pulmonary hemosiderosis Bilateral patchy alveolar infiltrates
Barium swallow in RAO view Sickling of barium filled esophagus due to compression by enlarged LA
37
Chest x-ray
38
ECHO

• 2D and Doppler ECHO is the diagnostic tool of
  choice
• Dilated left atrium
• Restricted diastolic opening of the MV leaflets
• Doming of the anterior leaflet
• Immobility of the posterior leaflet
• Planimetry of the orifice in short- axis view

39
ECHO

• Morphology of MV
• Leaflet mobility and flexibility
• Leaflet thickness
• Calcification
• Subvalvular fusion
• Appearance of commissures
• Doppler
• Mean transmitral gradient
• MV area by Half time method
• Pulmonary artery systolic pressure

40
Echocardiography- class I

• Diagnosis of Mitral Stenosis, Mean gradient,
  mitral valve area, pulmonary artery pressure
• Concomitant valve lesion
• Valve morphology
• Left atrial thrombus
• TEE when trans thoracic ECHO provides suboptimal
  data

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Echocardiography- class IIa

• ECHO is reasonable in the re-evaluation of
  asymptomatic patients with MS and stable clinical
  findings to assess pulmonary pressure

Severe MS every year
Moderate MS 1- 2 years
Mild every 3- 5 years
42
Cardiac catheterisation

• Indications - Class I
• Assessment of severity
• When noninvasive tests are inconclusive
• Discrepancy between the non invasive and clinical
  symptoms
• To evaluate the severity of MR when there is
  discrepancy between Doppler derived mean gradient
  and valve area

43
Cardiac catheterisation

• Uses
• Trans mitral pressure gradient
• Mitral valve area
• Left ventricular function
• Right sided pressures

44
Normal mitral valve

• MVA gt 4 cm2 (4- 6 cm2)
• Diastolic mitral valve flow of 150- 200 ml/ sec/
  diastole
• Diastolic transvalvular pressure gradient of less
  than 2 mmHg

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Classification
Mild Moderate Severe
Mean gradient (mm Hg) lt 5 5- 10 gt 10
Pulmonary artery systolic pressure (mm Hg) lt 30 30- 50 gt 50
Valve area (cm2) gt 1.5 1.0- 1.5 lt 1.0
ACC AHA Guidelines 2006
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Classification

• A2- OS interval
• Longer duration of diastolic rumble
• Loud P2
• Right ventricular heave

Timing (sec) Severity
gt 0.12 Normal
gt 0.10 Mild
0.08- 0.09 Moderate
0.07- 0.08 Mod severe
lt 0.06 Severe
47
Classification

• Pressure half time

Normal 30- 60 ms
Abnormal 90- 140 ms
Gray area 60- 90 ms
Mild MS 90- 150 ms
Moderate MS 150- 219 ms
Severe MS gt220 ms
48
Initial evaluation

• History
• Physical examination
• CXR
• ECG
• 2D ECHO/ Doppler

49
Asymptomatic
Mild MS Valve area gt 1.5 cm2
Moderate to severe MS MVA lt 1.5 cm2
Valve morphology Favorable for PMBV?
Yearly follow up With history, exam CXR, ECG
No
Yes
PASP gt 50 mm Hg?
No
Yes
Class I
Exercise
Poor exercise tolerance, PASP gt60 mmHg, PAWP gt 25
mmHg
Consider PMBV
Class I
No
Yes
Exclude LA clot 3 to 4 MR
Yes
No
New onset AF
Class IIb
50
NYHA Class II
Moderate or Severe stenosis MVA lt 1.5 cm2
Mild stenosis MVA gt 1.5 cm2
Exercise
Valve morphology Favorable for PMBV
PASP gt 60 mmHg PAWP gt 25 mmHg MVG gt 15 mmHg
No
Yes
Yes
No
Valve morphology Favorable for PMBV
Severe PH PAP gt 60 mmHg
Yes
No
Yes
No
Consider Commisurotomy Or MVR
6- month Follow up
Yearly Follow up
6- month Follow up
Consider PMBV
51
NYHA Class III- IV
Moderate or Severe stenosis MVA lt 1.5 cm2
Mild stenosis MVA gt 1.5 cm2
Exercise
Valve morphology Favorable for PMBV
PASP gt 60 mmHg PAWP gt 25 mmHg MVG gt 15 mmHg
No
Yes
No
Yes
High risk Surgical candidate
Consider PMBV
Yes
No
Look for Other causes
MVR
52
Medical therapy

• Prophylaxis against rheumatic fever
• Avoidance of unusual physical stress
• Rate control in AF
• Digoxin
• Beta blockers
• Calcium channel blockers
• Evidence of pulmonary congestion
• Salt restricted diet
• Diuretics/ Digoxin for LHF/RHF
• Anticoagulation in AF
• Endocarditis prophylaxis

53
Agent Dose Mode Duration
Primary prevention of rheumatic fever Primary prevention of rheumatic fever Primary prevention of rheumatic fever Primary prevention of rheumatic fever
Benzathine penicillin G lt 27 kg 6 lakh U gt 27 kg 12 lakh U IM Once
Penicillin V Child 250 mg Adults 500 mg 2-3 times a day Orally 10 days
Secondary prevention of rheumatic fever Secondary prevention of rheumatic fever Secondary prevention of rheumatic fever Secondary prevention of rheumatic fever
Benzathine penicillin G 1.2 lakh U every 4 weeks Every 3 weeks in carditis IM
Penicillin V 250 mg BD oral
AHA guidelines 1995
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• Duration of secondary prophylaxis

Category Duration
RF, With carditis, With residual heart disease 10 years since last episode or Atleast until 40 yrs or Sometime Lifelong
RF, With carditis, No residual heart disease 10 yrs or Until age 21 yrs Whichever is longer
RF, Without carditis 5 years or Until age 21 yrs Whichever is longer
AHA guidelines 1995
55
Medical therapy- general

• Digitalis does not benefit patients with MS in
  sinus rhythm unless there is LV or RV dysfunction
• Beiser et al
• N Engl J Med 1968

56
Anticoagulation- indications

• Class I
• MS with AF
• MS with prior embolic event even in sinus rhythm
• MS with left atrial thrombus
• Class IIb
• Symptomatic severe MS with LA dimension gt 55 mm
  by ECHO
• Levine et al
• Chest 1995

57
IE prophylaxis

• Prosthetic cardiac valve
• Previous IE
• Congenital heart disease
• Unrepaired CHD
• Completely repaired CHD
• Residual CHD after repair
• Cardiac transplantation with valvulopathy

AHA guidelines 2007
58
Management

• PBMV (percutaneous balloon mitral valvotomy)
• Closed surgical commissurotomy
• Transatrial approach
• Transventricular approach

• Open commissurotomy
• Direct inspection of MV apparatus
• Division of commissures
• Splitting of fused chordae
• Debridement of calcium deposits
• Mitral Valve Replacement
• Mechanical
• Bioprosthetic

59
Candidates for PBMV

• Mobile noncalcified leaflets
• No commisisural calcification
• Little subvalvular fusion

• Wilkins score
• ECHO findings
• 4 grades each in
• Mobility
• Subvalvular thickening
• Valve thickening
• Calcification

60
Percutaneous Balloon Mitral Valvotomy

• Class I
• Symptomatic moderate to severe MS with,
• Favorable valve morphology
• Absence of LA thrombus, MR
• Asymptomatic moderate or severe MS
• Favorable valve morphology
• PASP gt 50 mmHg at rest
• PASP gt 60 mmHg with exercise
• Absence of LA clot, MR

61
PBMV

• Emerged in late 1980s
• 1 or more large balloons are inflated across the
  MV
• Hourglass shaped balloon (inoue balloon)
• Opening of the commissures that were fused by the
  rheumatic process
• This decreases the transmitral gradient and
  increases MVA
• Higher success rate
• Lower complication rate

62

• Complication PBMV
• Severe MR 2- 10
• Residual atrial septal defect 5- 12
• Perforation of left ventricle 0.5- 4
• Embolic events 0.5 -3
• Pericardial tamponade 5
• Myocardial infarction 0.3- 0.5
• Mortality 1- 2
• Outcome
• Event free survival 80-95 over 3- 7 years
• Less complications than closed valvotomy

63
Post PBMV

• Symptomatic improvement occurs immediately
• Decrease in LA pressure, PAP and pulmonary
  vascular resistance
• Improved cardiac output
• Gradual reduction in pulmonary hypertension over
  months has been demonstrated

64
Mitral Valve Repair

• Indications - Class I
• Moderate or severe MS with NYHA III-IV symptoms
• When percutaneous mitral balloon valvotomy is not
  available
• PBMV contraindicated because of left atrial
  thrombus, MR
• Valve morphology not favorable
• Moderate or severe MS with
• Moderate to severe MR

• Complications
• Valve thrombosis
• Valve dehiscence
• Valve infection
• Embolic events

65
MVRwhen?

• Significant calcification
• Fibrosis
• Subvalvular fusion of MV apparatus
• Commissurotomy or PBMV is less likely to be
  sucessful and MV replacement will be necessary

66
Preop assessmentlook for

• Severity of MS
• Pulmonary hypertension
• Atrial fibrillation
• Cardiac failure
• Associated other valvular diseases
• On anticoagulants, digoxin, diuretics
• Other medical disorders

67
ACC/AHA guidelines

• Severe valvular heart disease major clinical
  predictor delay/ cancel elective non cardiac
  surgery consider echo, cardiac cath followed by
  valve surgery
• Preoperative surgical correction of mitral valve
  disease is not indicated before noncardiac
  surgery, unless the valve condition should be
  corrected to prolong survival prevent
  complications , unrelated to the proposed non
  cardiac surgery
• Eagle et al ACC/AHA 2002

68
Anaesthetic considerations

• Control the heart rate to low end of normal,
  avoid tachycardia
• Preserve / restore sinus rhythm
• Maintain adequate intra vascular volume
• Avoid marked increase in central blood volume
• Prevent systemic vasodilatation
• Avoid increase in PVR hypothermia, hypercarbia,
  hypoxia, acidosis

69
Cardiac grid
Preload Maintain adequate preload
After load (SVR) N
PVR Avoid increase
Contractility N
Heart rate Avoid tachycardia
Rhythm Maintain sinus
70
Premedication

• Sedatives should be used cautiously
• diazepam 0.1 0.15 mg/kg PO/IM
• morphine 0.1 0.2 mg/kg IM
• Respiratory depression hypercarbia
  PVR
• IE prophylaxis ?
• Anticholinergics cause tachycardia
• Glycopyrrolate preferred
• Digoxin, beta blockers, diuretics
• Anticoagulants

71
Digoxin

• If the patient is on digoxin to control the
  ventricular rate response due to AF, continue
  digoxin in the preoperative period
• Patients with chronic heart failure, who were
  randomised to digoxin withdrawal had an increased
  likelihood of acute exacerbation
• Adams et al J Am Coll Cardiol 1997

72
Digoxin

• Perioperative discontinuation of digoxin remains
  controversial
• Digoxin was associated with increased risk in
  urgent emergent surgical patients
• Sear et al BJA 2001
• Given that rate, rhythm control, positive
  inotropy can be achieved with other drugs, the
  authors tend to discontinue in elderly surgical
  patients
• Groban et al, Anesth Analg
  2006

73
Digoxin

• Continue diuretics on the day of surgery
• For a minor surgery, continue anticoagulant
  therapy
• For a major surgery, discontinue warfarin 3- 5
  days before substitute heparin
• Kurup et al ACNA 2006

74
Anticoagulants minor surgery

• Conclusions of the meta analysis were that most
  patients can undergo dental procedures,
  arthrocentesis, cataract diagnostic endoscopy
  without alteration of anticoagulant regimen
• Baker et al Med J Aust 2004

75
On warfarin Do initial INR
INR 2- 3
INR gt 3
Stop 4 days Before planned surgery
Decrease the dose Of warfarin
INR 2 Day before surgery
Low risk
High risk
Post op
Pre op
Post op
Pre op
No need
Heparin
Heparin
Till INR gt 2 after warfarin therapy
76
Anticoagulants emergency surgery

• To temporarily reverse the effect of warfarin
• FFP 15 ml/ kg
• Vitamin K1 0.5- 2 mg IV
• 10 mg IM then 5 mg 4 hourly
• To reverse heparin
• Protamine 1 mg for every 100 U of heparin

77
Monitoring

• All routine EKG, SpO2, NIBP, Temp, ETCO2, Urine
  output
• IBP, PCWP, CVP, TEE
• Mild disease and minor surgery
• Non invasive monitors
• Severe diseases and surgery with huge fluid
  shifts
• Invasive monitor including arterial line, PAC, TEE

78
CVP

• CVP reflects right ventricular filling pressure
  and a reliable guide of left sided filling in
  patients with normal LV function
• In the presence of reduced LV compliance or
  pulmonary hypertension this relationship is less
  predictable and PCWP is used as a index of LV
  filling

79
PAC

• Because of significant PHT, pulmonary artery
  diastolic pressure not an accurate estimate of
  LAP
• PCWP overestimates LV filling pressure because of
  stenotic mitral valve
• Catheters often must be inserted further than
  usual due to dilated pulmonary arteries
• Care should be taken because of the increased
  risk of pulmonary artery rupture

80
Induction- GA

• Intravenous agents anaesthetic goal
• Ketamine avoided
• Etomidate preferred
• Thiopentone / propofol
• Opioid induction
• Fentanyl / morphine
• N2O
• PHT

81

• Inhalational agents
• All decrease blood pressure
• Halothane, enflurane causes ? SV
• Occasionally desflurane ? HR
• Isoflurane, sevoflurane ? SVR

• Muscle relaxants
• Avoid pancuronium
• Reversal glycopyrrolate is preferred

82
Regional anaesthesia

• Fixed cardiac output state may result in profound
  hypotension in spinal
• Epidural anaesthesia- gradual fall in BP
• Combined spinal epidural

83
Anticoagulants Regional

• Post operative LMWH
• Single dose
• First dose after 6- 8 hrs
• Remove catheter after 10 -12 hrs
• Restart 2 hrs after removal
• Double dose
• First dose after 24 hrs
• Remove catheter after 24 hrs
• Restart 2 hrs after removal

• Unfractionated heparin
• Subcut prophylaxis
• No contraindication for regional
• Intraoperative anticoagulation
• 1 hr after needle placement
• Remove catheter after 2- 4 hrs
• LMWH thromboprophylaxis
• 10- 12 hrs after last dose
• LMWH higher dose pre op
• 24 hrs after last dose

ASRA guidelines 2002
84
Pregnancy MS

• Rheumatic MS is the most common clinically
  significant valvular disease in pregnant women
• Prevalence in pregnancy is less than 1
• MS increases the risk of adverse maternal, fetal
  neonatal outcome

85
Pregnancy MS

• Concerns are due to physiological cardiovascular
  changes of pregnancy
• Increased HR
• Increased circulating blood volume
• Increased cardiac output
• Low SVR
• IVC compression abrupt decrease in preload

86
Pregnancy MS

• Hypercoagulable state
• Further abrupt increase in CO during labour
  delivery
• After delivery, surge in preload due to
  autotransfusion of uterine blood into systemic
  circulation due to IVC decompression

87
Maximum risk

• The time of maximum risk for these patients is
  during late pregnancy, labour immediate
  postpartum

88
Risk predictors

• MVA lt 1.5 cm2
• NYHA class more than 2
• LVEF lt 40
• History of prior cardiac events
• Adverse cardiac events with 0, 1 or more than 1
  risk factors were 5, 27 75 respectively
• Overall mortality lt1 in mild MS , 5 15 with
  severe MS/AF
• Silversides et al
• Am J Cardiol 2003

89
Pregnancy mild-moderate MS

• Bed rest
• Avoid supine position
• Penicillin prophylaxis
• Diuretics to relieve pulmonary systemic
  venous congestion, care to avoid vigorous volume
  depletion to protect against uteroplacental
  hypoperfusion

90
Pregnancy mild-moderate MS

• Beta blockers to prevent or treat tachycardia
• Although propranolol has been used for decades,
  some authorities recommend cardioselective agent
  like atenolol or metoprolol to prevent the
  potential deleterious effect of epinephrine
  blockade on uterine myometrial activity
• Bonow et al
• ACC/AHA 2006
• Maternally administered esmolol fetal
  bradycardia hypoxemia
• Losasso et al
• Anesthesiology 1991

91
Drugs and pregnancy

• Category B animal studies not demonstrated
  fetal risk but no controlled studies in pregnant
  women
• Category C adverse effect in animal studies
  not confirmed in human studies. Drug to be given
  if the potential benefit justify potential risk
  to fetus
• Category D evidence of human fetal risk. Drug
  to be given if the potential benefit justify
  potential risk to fetus
• Category X fetal abnormalities in animals or
  humans. Risk outweighs any possible benefit

92
Drugs pregnancy
drug Side effects Breast feeding risk
Beta blockers Fetal bradycardia IUGR Compatible AcebutololB Labetolol C MetoprololC PropranololC AtenololD
Digoxin Compatible C
93
Drugs pregnancy
Drug Side effects Breast feeding Risk
Diuretics Hypovolemia induced reduced uteroplacental perfusion,fetal hypoglycemia,thrombocytopenia,hyponatremia, hypokalemia,thiazides inhibit labour suppress lactation compatible C
94
Drugs pregnancy
Warfarin Crosses placenta, Embryopathy,CNS abnormality, fetal hemorrhage compatible X
Heparin None reported compatible C
95
Pregnancy severe MS

• Will not tolerate hemodynamic burden of pregnancy
• Consider PBMV before conception
• If not a candidate for PBMV, do commissurotomy
• If valve replacement is indicated, bioprosthetic
  valve is preferred

96
Pregnancy severe MS

• Patients who develop NYHA III IV symptoms
  during pregnancy should undergo PBMV with limited
  fluroscopy (1- 2 min exposure with abdominal
  pelvic shielding) or ECHO guidance
• Rahimtoola et al
• Circulation 2002

97
Goals

• Provide adequate maternal analgesia
• Minimise endogenous catecholamine release
• Prevent tachycardia
• Maintain sinus rhythm
• Maintain optimal preload
• Avoid aortocaval compression
• Avoid acute increase in preload

98
Goals

• Avoid rapid decrease in SVR
• Maintain PCWP near baseline
• Limit maternal valsalva maneuver stress
  associated with maternal expulsive efforts
• Avoid factors which increase PVR
• Cut short the second stage by instrumental
  delivery
• Reserve caessarean for obstetric indications

99
Analgesic anesthetic management

• Intrathecal opioid in the first stage excellent
  analgesia without sympathetic blockade
• During second stage of labour or operative
  delivery, epidural anesthesia and analgesia can
  facilitate gradual increase in venous capacitance
  to accommodate acute increase in venous return
  CO in the immediate postpartum period

100
CSEA in laboring parturients

• Severe MS
• Intrathecal fentanyl 25 mcg
• Followed by diluted epidural bupivacaine 0.125
  fentanyl 2 mcg/ml
• Kee et al
• Anesth Intensive Care 1999

101
Choice of vasopressor

• Phenylephrine rather than ephedrine is the
  preferred vasopressor in MS
• Maintains SVR without causing maternal
  tachycardia
• Oxytocin or methergin
• Methergin contraindicated ? SVR
• oxytocin tachycardia- use infusion
• Obstetric anesthesia
• Chestnut

102
Severe MS emergency CS

• Modified rapid sequence with etomidate
  Succinylcholine
• Esmolol, sufentanil, NTG infusion in the
  induction phase
• Maintained with 100 oxygen, isoflurane, titrated
  doses of sufentanil muscle relaxant
• Hypotension treated with phenylephrine boluses
• Peter et al
• Reg Anaes Pain Med 2004

103
Anticoagulants pregnancy

• Warfarin
• Probably safe in first 6 weeks
• Risk of embryopathy in 6- 12 weeks
• Relatively safe in second and third trimesters of
  pregnancy
• Heparin
• First and third trimester

104
Case report

• Epidural anesthesia with the Trendelenburg
  position for cesarean section with or without a
  cardiac surgical procedure in patients with
  severe mitral stenosis
• 7 patients
• Epidural anaesthesia
• PAC monitoring
• PCWP adjusted by Trendelenberg position
• Ziskind et al
• J Cardiothorac anaesth 1990

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Post operative care

• ICU care
• Continue monitoring
• Pain relief
• Cardiac medications to be started

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Conclusion

• Anaesthesiologists should not expect to deal with
  absolutely normal patients always
• Specific guidelines are available to deal with
  patients having heart diseases
• Choose appropriate techniques drugs
• Maintain haemodynamic goals
• With currently available anaesthetic medications
  and monitoring techniques these patients can be
  successfully managed.

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