mitral stenosis mitral regurgitation

8/19/2019 Mitral Stenosis Mitral Regurgitation

1/66

MITRAL STENOSIS & REGURGITATION

Pathophysiology & Anesthetic

considerations for non-cardiacsurgery

Presenter: Dr Prashant Kumar

University College of Medical Sciences &GTB Hospital, Delhi


2/66

Mitral Stenosis

• Mitral valve is present between LA & LV

• Normal mitral valve orifice area MVA!: "#$cm%

• MVA %'(cm% lea)s to s*mptoms

• Decrease in Mitral valve orifice area lea)in+ to chronic & fi,e)mechanical obstruction to LV fillin+ is terme) as MS'


3/66

-auses

• .heumatic /eart )isease

• SL0

• -arcinoi) s*n)rome

• Active 1nfective 0n)ocar)itis• Left atrial m*,oma

• -on+enital mitral stenosis

• Massive Annular -alcification


4/66

.heumatic mitral stenosis

• More common in females %23r) of all pts!

• S*mptoms occur two )eca)es after onset of .heumatic fever

• A+e of presentation

4 0arlier in %5s#35s4 Now in "5s#(5s slower pro+ression!

• 1solate) MS in "56 cases of ./D

4 .emainin+ $56 cases associate) with other valvular )iseases#

M.2A.


5/66

Patho#ph*siolo+*

• 1mmunolo+ical )isor)er initiate) b* 7roup A beta hemol*ticstreptococcus'

• Antibo)ies pro)uce) a+ainst streptococcal cell wall proteins & su+arsreact with connective tissues & heart8 result in rheumatic fever an)

s*mptoms li9e4 -ar)itis

4 Arthritis

4 Subcutaneous no)ules

4 -horea4 0r*thema mar+inatum


6/66

• -hronic car)iac & valvular inflammation lea)s to car)iac & valvularpatholo+*

• Valvular patholo+*.heumatic fever involvin+ mitral valves

Valve leaflet thic9enin+ an) fusion of commissures

1ncrease) ri+i)it* of valve leaflets

hic9enin+; fusion an) contracture of chor)ae & papillar* hea)s

Leaflet calcification lon+ stan)in+ MS!

Pro+ressive re)uction in mitral valve orifice area

Mitral Stenosis


7/66

Mechanical obstruction to left ventricular )iastolic fillin+

A)aptative < in LAP to maintain LV fillin+

#########################################################################

LA enlar+ement < in pulmonar* venous pressure = < in pulmonar* arterial pressure>

Atrial fibrillation ransu)ation of flui) into pulmonar* interstitial spacehrombus formation

S*stemic thrombo#embolism ?e) pulmonar* compliance ########= Pulmonar* arterial h*pertroph* Pulmonar* /N!

.V h*pertroph* an) )ilatation

.V failure


8/66


9/66

Effect of MS on left ventricle

Pressure gradient

between LA & LV


10/66

0ffect of heart rate

• Gorlin formula

Valve area C ransvalvular flow rate ml2s!

K , P7D2%

P7: ransvalvular pressure +ra)ient; mm/+!K is a h*)raulic#pressure constant C3E!

• ach*car)ia shortens )iastole more proportionatel* than s*stole

• Decreases the overall time for transmitral flow;

•1n or)er to maintain -B; the flow rate per unit time must increase• Pressure +ra)ient increase proportionate to sFuare of flow rate

•


11/66

0ffect of Atrial fibrillation in MS

• 1ncrease) chances of thrombus formation & s*stemic thrombo#

embolism

• Normall* effective atrial contraction is important in LV )iastolic fillin+

4 1n presence of A4 Loss of effective atrial contraction

4


12/66

Dia+nosis

• -linical presentation

4 D*spnea; fati+ue; orthopnea; PND; cou+h; hemopt*sis;'

4 56 patients have an+inal t*pe chest pain not attributable to -AD

4 S*stemic thromboembolism first s*mptom in %56 cases!'

• Ph*sical e,amination

4 Low volume pulse

4 Si+n & S*mptoms of ri+ht si)e) heart failure # en+or+e) nec9

veins; enlar+e) ten)er liver


13/66

4 Mitral facies

GPin9 purple patches on the chee9s; c*anotic s9in chan+es from

low car)iac outputH• -ar)iac auscultation

4 Bpenin+ snap

4 .umblin+ )iastolic murmur best hear) at ape, ra)iatin+ to the

a,illa

4 Lou) S%: pulmonar* h*pertension


14/66

• 0-7

4 Iroa) notche) P wave left atrial

enlar+ement!

4 Atrial fibrillation


15/66

• -hest J#ra*

4 Normal to


16/66

• 0chocar)io+raph*

4 Anatom*2sie of mitral valve & its appen)a+es

4 severit* of MS area of orifice!

4 Sie & function of ventricles

4 0stimation of pulmonar* arter* pressure

• -ar)iac catheteriation an) invasive measurement

4 Are almost never necessar*

4 .eserve) for situations 0-/B sub#optimal2conflict with clinicalpresentation


17/66

Severit* of MS

Mil) Mo)erate SevereMean valve gradientmmHg

$ $#5 5

MVA cm '$#%'( '5#'( '5

LA! re"t

E#erci"e

N

<

<


18/66

7ui)elines

'S%mtomatic MS (rogre""ive d%"noea on e#ertion)e#ertional re*"%ncoe) +eart failure, i" an active cardiaccondition & t "+ould undergo evaluation & treatment -eforenon cardiac "urger%.

• Emergenc% "urger%Mild / Moderate MS

• /i+h ris9

• -ontinue me)ication

• Procee) with sur+er*4 Severe MS

• Ver* hi+h ris9 consent• Post# op ventilator* consent


19/66

• !re*oerative Otimi0ation of atient4 Atrial fibrillation

Sinus rh*thm2control of ventricular rate

' Di+o,in emer+ent 1V )i+italiation:# loa)in+ )ose 5'%(m+ iv over( minutes followe) b* 5'm+ ever* hour till response occuror total )ose of 5'(#'5m+' Monitor 0-7; IP; -VP8 /.$5bpm# Stop!

%' --I verapamil2)iltiaem: 5'5(#5'(m+29+ 1V!

3' #bloc9er esmolol: m+ 1V!"' Amio)arone loa)in+: 55m+ 1V; infusion: m+2min 1V for $ hrs'5'(m+2min for ne,t E hrs!

(' -ar)ioversion in hemo)*namic unstable patients


20/66

4 !ulmonar% HTN/Edema/RV1

' B,*+en%' Diuretic

Loop )iuretics

/i+h )ose )eleterious

-ombine with vaso)ilator

3' Di+italis

"' Morphine 5'm+29+!


21/66

!re*oerative Otimi0ation of atient2 !ulmonar% HTN/Edema/RV1 continued3,

(' Vaso)ilators N7!

Pulmonar* vaso)ilation ?PAP!Start from small )ose $'()* +g#gmin%

S20: s*stemic h*potension

$' Nesiriti)e

.ecombinant INP Irain natriuretic pepti)e!Arterial & venous )ilatation

-ontrols )*spnoea in Acute heart failure

' M*ofilament calcium sensitier Levosimen)an!

1no)ilators


22/66

!re*oerative Otimi0ation of atient2 !ulmonar% HTN/Edema/RV1 continued3,

E' 1notropic a+ents

Norepinephrine

Dopamine

Dobutamine

O' 1no)ilators

Amrinone

Milrinone


23/66

• Elective "urger%

4 Mil)2 mo)erate MS

• Procee) with sur+er* after evaluation

• -ontinue me)ications

4 Severe MS

• -ar)iolo+* referral2sur+ical correction

• Patients ta9en in optimie) con)ition


24/66

Management of Anest!esia Anest!etic goals

Heart rate/

rhythm

Sinus r!yt!m, controlventricular rate $-".bpm%

Avoid tac!ycardia

Preload /ormal or increased Avoid under"load

overload

After-load Maintain normal afterload

Avoid suddenincreasereduction inafterload

Contractility 0sually LV systolicfunction: /

Avoid cardio"depressant drugs

Pulmonary HTN/RVdysfunction

/ormal o1ygenation,acid base status

Avoid !ypo1ia,!ypercarbia, acidosis


25/66

Advice

Di+o,in o continue preoperativel*

Diuretic Mornin+ S' electrol*te; K supplementation if reFuire)

Anticoa+ulant

Minor sur+er* -ontinue warfarin

MaQor sur+er* Discontinue warfarin 3#( )a*s beforesur+er* an) substitute heparin


26/66

Pre medication• o )ecrease an,iet* & an* associate) li9elihoo) of a)verse

circulator* responses pro)uce) b* tach*car)ia

• Dru+ to control heart rate• Antibiotics proph*la,is for infective en)ocar)itis is no lon+er

recommen)e)! .ef: MillerHs Anesthesia; th e)ition!

$la"" 4rug 4o"e (mg/5g, Route

IRPs Diaepam 5'#5'( PB; 1M

Loraepam 5'53#5'5$ PB; 1M

Mi)aolam 5'53#5'5 1M

Bpioi)s Morphine 5'% 1M

Meperi)ine '5#'( 1M


27/66

Monitorin+

A"%mtomatic

• Stan)ar) non#invasive

4 0-7;

4 /.

4 N1IP

4 Pulse#o,*metr*

4 -apno+raph

4 emperature

• S%mtomatic t" or

ma6or "urger%

4 Stan)ar) non#invasive

4 Serial AI74 1nvasive monitorin+

• 1IP

• -VP2PA-

• 0chocar)io+raph*0200!

• -ar)iac catheteriation


28/66

1ntra#operative mana+ement

Analge"ia

Induction

Mu"cle rela#ant

Bpioi) Morphine5'm+29+! Preventstach*car)ia

All 1V a+entsetomi)ate 5'3#5'(m+29+!

/. stable Avoi) 9etamine

-ar)iostable li9evecuronium

/. stable;Pancuroniun offsetbra)*car)ia )2topioi)

Avoi) histaminereleasin+ )ru+


29/66

Non*oioid induction agent"

T+ioentone !roofol Etomidate 7etamine 89!

MAP ↓ ↓ T ↑ ↓

/. ↑ ↓ T ↑ ↓

-B ↓ ↓ T ↑ ↓

SV. ↓ ↓ T2? ↑ ↓

PV. T T2? ? < T

contr ? T2 ? T T2< T


30/66

Muscle .ela,ants

!an Vec Roc Atra Miv Sc+

MAP ↑ # ↑ ↓ ↓ ↓

/. ↑ # ↑ ↔ ↔ ↓

-B ↑ # ↑ ↑ ↑ #

SV. # # # ↓ ↓ #/istamine # # # #


31/66

Maintenance N%B Narcotics orvolatile a+ents low

conc!A)eFuate plane ofanesthesia

/.; SV.; PV.;M*ocar)ial

contractilit*maintaine)

Avoi) tach*car)ia

N%B can evo9e PVconstriction

Rever"al SlowNMI2anesthesia

reversal

Avoi) tach*car)ia Prefer+l*cop*rrolate over

atropine

IV 1luid .L2NS2bloo)pro)ucts

-VP +ui)e) 0,cessive: P0

Regional ane"t+e"ia in MS4SAI is best avoi)e)'

4-areful epi)ural anaesthesia in NU/A class an) % patients

47eneral anaesthesia NU/A class 3 an) " patients


32/66

Post#operative

Management

• Monitorin+

• B,*+en

• Pain relief: multimo)al

inclu)in+ neuroa,ial

opioi)s

• 1ntravenous flui)s• Anticoa+ulants

$omlication

• Pulmonar*

con+estion2e)ema

• hrombo#embolism

• /eart failure


33/66

New Uor9 /eart Association functional classification of

patients with heart )isease

-lass 1 As*mptomatic

-lass 11 S*mptoms with or)inar* activit* but comfortable at rest

-lass 111 S*mptoms with minimal activit* but comfortable at rest

-lass 1V S*mptoms at rest


34/66

2ongestive 3eart 4ailure

• Diuretics: loop )iuretics furosemi)e %5#"5m+ 1V!8 S20: /*po9alemia

• Di+o,in:

Intravenou" Oral

Di+italiin+ )ose 5'(#'(m+ 5'(#'(5m+

Maintenance )ose )ail*! 5'%(m+ 5'%(#5'(m+

Bnset (#35 min '(#$hrs

0limination 2% 3#33hr 3#33hr

.oute of elimination .enal .enal

herapeutic plasma concentration level: 5'(#%'5n+2ml


35/66

-linical manifestation of )i+italis to,icit*

4 Plasma level 3n+2ml

4 0,tra -ar)iac: Anore,ia; nausea; vomitin+ & ab)ominal pain -R stimulation!

4 -ar)iac: an* t*pe of atrial or ventricular arrh*thmia; )ela*e) con)uction

throu+h AV unction'

• Atrial tach*car)ia with AV bloc9 is most common arrh*thmia

• Ventricular fibrillation is most freFuentl* cause of )eath'

reatment of )i+italis to,icit*4 Stop further )ose

4 -orrection of h*po9alemia; h*poma+nesemia; arterial h*po,emia

4 Dru+s

• Phen*toin 5'(#'(m+29+ 1V over (min!; li)ocaine #%m+29+ 1V!; atropine

3(#5W+29+ 1V! for car)iac )*sarrh*thmia

• Di+iban) )i+o,in specific antibo)ies; ab portion; 1V preparation "5m+

vial!

4 1nsertion of a temporar* artificial transvenous car)iac pacema9er


36/66

Anticoagulant t!erapy

• Management of !atient" on :arfarin

4 Emergenc% "urger%

4 Discontinue warfarin

4 7ive vitamin K 5'( 4 %'5 m+ 1V4 P ( ml29+ repeat if necessar*

4 Accept for sur+er* if 1N. '(

4 Elective "urger%

4 Stop 3 )a*s preoperativel*

4 monitor 1N. )ail*

4 7ive heparin when 1N. '(


37/66

4 Stop heparin $ hours prior to sur+er*

4 -hec9 1N.

4 Accept for sur+er* if 1N. '(4 .estart heparin post#operativel* as soon as possible

4 Ioth to be +iven for % 4 3 )a*s; stop heparin if 1N. '( 4

%'5'


38/66

• Management of !atient" on Hearin

4 Emergenc% "urger%

• -onsi)er reversal with 1V protamine m+ for ever* 55 1X

of heparin4 Elective Surger%

• Stop heparin $ hours prior to sur+er*

• -hec9 1N.; accept for sur+er* if 1N. '(

• .estart heparin in post#op as soon as possible

1f patient is on LM@/; we rarel* nee) to stop it'


39/66

Summary of MS

• 1s a low & fi,e) car)iac output con)ition

• Stress con)ition li9e pre+nanc*; labour & sepsis; con)ition become

worst# -/; pulmonar* e)ema; A

• Patients ma* be on )iuretics; )i+italis & anticoa+ulant therap*

• Peri#operativel* these patients have to be mana+e) as per me)ications

& +ui)elines

• ach*car)ia has to be avoi)e) at an* cost

• Pulmonar* vasculature resistance has to be re)uce)

• Preloa) & afterloa) both shoul) be maintaine)

• NU/A 1 & 11 :# 0pi)ural bloc9 or 7A

• NU/A 111 & 1V :# 7A preferre) over epi)ural bloc9


40/66

Mitral Regurgitation


41/66

• .etro+ra)e flow of bloo) from LV to LA throu+hincompetent mitral valve )urin+ s*stolic phase

$au"e"

4 M. is almost alwa*s O56! associate) with MS in ./D

4 De+enerative processes of leaflets an) chor)alstructures

4 1nfective en)ocar)itis

4 Mitral annular calcification


42/66

• unctional

Structurall* normal leaflets an) chor)aeten)ineae

4 1schemic heart )isease 1schemic M.!

4 1)iopathic )ilate) car)iom*opath*

4 Mitral annular )ilatation


43/66

Pat!op!ysiology of M

Mitral re+ur+itation

S*stolic .etro+ra)e! eQection into LA

Acute -hronic

Volume overloa) in LA & LV ?e) LV afterloa) into LA!


44/66

Acute M

Sudden onset M

Sudden increase in LV preload

En!anced LV contractility 5ed LAP $acute%

$LV si6e: /% $LA si6e: /%

E7ection into LA & 5ed Pulm vascul pressure

systemic circulation

8 cardiac output Pulmonary congestionedema


45/66

2!ronic compensated M

9 Slow development of M

2!ronic LV overloading

Eccentric LV !ypertrop!y LA dilatation

5LV radius, 5ed wall tension Maintenance of LAP

Maintenance of LV systolic function 2!ange in LV compliance

$LVEP maintained%

After load2;: maintained


46/66

ecompensated p!ase

Progressive LV dilatation

Mitral annular dilatation 5ed wall stressafterload

=ncreased regurgitation deteoration in LV syslolic

& diastolic function

5ed LAP

Atrial enlargement Pulmonary congestionedema3>/

Atrial 4ibrillation V dysfunctionfailure


47/66

Pat!op!ysiology of MS wit! M

MS MR

Bbstruction of bloo) flow s*stolic retro+ra)e! eQection into LA

from LA to LV )urin+ )iastole

Volume overloa) in LA Volume overloa) in LV

?e) LV fillin+ < LAP LV )*sfunction

?e) -B

?e) -B LA )ilatation


48/66

M. MS


49/66

Dia+nosis

• -linical presentation

4 ati+ue; )*spnoea; orthopnoea2S*stemic thrombo#embolism

• Ph*sical e,amination

4 Arterial pressure: N2?4 Pulse @ater /ammer pulse# ?DIP; < SIP!

4 Si+ns of .V li9e < VP

4 S*stolic thrill at ape, h*per)*namic circulation!

• -ar)iac auscultation4 /olos*stolic murmur

4 S is absent; soft or burie) in the s*stolic murmur


50/66

• 0-7

4 Non#specific fin)in+s4 Atrial fibrillation

4 LA enlar+ement2LV h*pertroph*

• -hest J#ra*

4 Left heart chamber enlar+ement

4 Pulmonar* con+estion


51/66

• 0chocar)io+raph*

4 Dia+nosis2mechanism2severit* of M.2MS

4 1mpact on car)iac chamber sie; pressure & function4 Pulmonar* arter* pressure

4 Presence of thrombus

• -ar)iac catheteriation with left ventriculo+raph*4 invasive

4 .eserve) for pts in whom 0-/B is sub#optimal


52/66

Severit% of MR

.e+ur+itant Mild Moderate Severe

Volume 35#"5ml "5#$5ml $5ml

raction 5#356 35#(56 ((6

Brifice area 5'% 5'3#5'" 5'"


53/66

Management of Anest!esia

!ro-lem" to -e anticiated:

• Pulmonar* con+estion2 e)ema

• Atrial fibrillation2 thrombo#embolism

• LV )*sfunction: ? -B• Acute ↑ in afterloa) followin+ 0 intubation & sur+ical stimulation

acute )ecompensation of LV

• Ira)*car)ia # ↑ time for retro+ra)e bloo) flow

• Dru+ in)uce) m*ocar)ial )epression


54/66


55/66

Anest!etic


56/66

>ec!ni?ue of anest!esia =n M

Regional v" General Ane"t+e"ia in MR

' Peripheral nerve bloc9s

• Safe

• Avoi) intravascular )ru+ inQections ultrasoun)2nerve stimulator +ui)e)

bloc9s!

%' -entral neura,ial bloc9s

• Preloa): ? /.: T2


57/66

Monitoring

Asymptomatic

9 Standard non"

invasive

) E2>E>EE%

9 2ardiac cat!eteri6ation

M t f


58/66

Management of


59/66

Non*oioid induction agent"

T+ioentone !roofol Etomidate 7etamine Mida0olam

MAP ↓ ↓ T ↑ ↓

/. ↑ ↓ T ↑ ↓

-B ↓ ↓ T ↑ ↓

SV. ↓ ↓ T2? ↑ ↓

PV. T T2? ? < T

contr ? T2 ? T T2< T


60/66

Muscle .ela,ants

!an Vec Roc Atra Miv Sc+

MAP ↑ # ↑ ↓ ↓ ↓

/. ↑ # ↑ ↔ ↔ ↓

-B ↑ # ↑ ↑ ↑ #

SV. # # # ↓ ↓ #

/istamine # # #


61/66


62/66

Maintenance

Volatile agents$=sosevodes%

53, 8 SV,minimalnegativeinotropic effects

/D; can evo#ePV constriction

eversal Slow/M@anest!esiareversal

=V 4luid L/Scolloidsblood products 2VP guided E1cessive: PE

Post"operative monitoring and care


63/66


64/66

Summary

• Valvular heart )isease poses challen+e )urin+ anesthesia

• @e shoul) 9now pathoph*siolo+* of each valvular heart )iseases

• Most of the time; valvular heart )iseases occur in combination

•Bur aim is to maintain normal car)iac output & tissue perfusion b*re+ulatin+ heart rate2rh*thm; preloa); afterloa); m*ocar)ial

contractilit*'

• Xse of re+ional anesthesia is not contrain)icate) in theses patients;

but proper patients selection & precaution are must'


65/66

.eferences

• KaplanHs -ar)iac Anesthesia8 (th e)ition

• MillerHs Anesthesia8 th e)ition

• -linical Anesthesia8 Iarash; -ullen; Stoeltin+; (th e)ition

• Stoeltin+Hs Anesthesia & -o#e,istin+ Disease8 (th e)ition

• /arrisonHs 1nternal Me)icine8 th e)ition

• @*lie & -hurchill# Davi)sonHs A Practice of Anesthesia8 th

e)ition• -linical Anesthesia8 Mor+an "th e)ition


66/66

Thank you

mitral stenosis mitral regurgitation

Documents