Intra operative

considerations in
mitral stenosis patient

Salil Maheshwari
ANATOMY
Normal Orifice: 4 – 6 Cm2

Symptoms start < 2.5 Cm2

Mild MS – 1.5 – 2.5 Cm2 (Dyspnea on severe exertion)

Moderate MS – 1.0 – 1.5 Cm2 (PND ± pulmonary oedema)

Severe/ Critical - < 1.0 Cm2 (Orthopnea – Class IV)

Mitral Valve area is calculated using Gorlin’s Equation:

Area = Cardiac Output/ (DFP or SEP) (HR)

44.3 C √ΔP

DFP = Diastolic Filling Pressure

C = Empirical Constant(0.85 for

mitral valve)

SEP = Systolic Ejection Period

ΔP = Pressure Gradient
 MITRAL STENOSIS

• Narrowing of the mitral valve orifice causing obstruction to blood

flow from left atrium to the left ventricle.
Etiology
• Most common cause - Rheumatic heart disease.
• Much less common causes include :
carcinoid syndrome
left atrial myxoma
severe mitral annular calcification
thrombus formation
rheumatoid arthritis
systemic lupus erythematosus, and
congenital mitral stenosis.
Pathophysiology
Decreased LV filling
Palpitations

Increased left atrial

Adaptation Atrial Kick
pressure and volume

Pulmonary vein pressure Adaptation

Transudation of fluid into thickening of basement membrane

pulmonary interstitial space of pulmonary viens

Pulmonary compliance
Pulmonary hypertension

Work of breathing
Breathlessness Haemoptysis
Progressive Dyspnea
COMPLICATIONS
Atrial dysrhythmias (AF,AFL)
Systemic embolisation (10-25%)
Hemoptysis due to
Rupture of bronchial/pulmonary veins
Chronic bronchitis
Acute pulmonary edema- pink, frothy sputum
Pulmonary infarction, anticoagulation, hemosiderosis
-
Congestive heart failue

Recurrent broncho pulmonary infections

Pulmonary hypertension

Infective Endocarditis
• TREATMENT

• Grade 1 ( Mild MS by echo + dyspnea < Grade III)

Diuretics for congestive symptoms

Prophylaxis against Rheumatic fever & Infective
endocarditis
IN presence of AF- anticoagulation, digoxin & other drugs for
rate control.
• Grade II ( Tight MS + lung congestive symptoms- dyspnea < Grade III)
First line treatment as above
Severe symptoms not responding to medicines-

• surgery with commissurotomy, MVR, or balloon valvuloplasty

• Grade III ( Tight MS + pulmonary hypertension )
Surgical repair

• Grade IV ( Tight MS + pulmonary hypertension + RHF)

Surgery + Treatment of RHF
• CHF- restriction of physical activity, salt restricted diet,
diuretics and digoxin

• Atrial fibrillation-Digoxin, β-blockers, calcium channel

blockers, or a combination of these medications. Control of
the heart rate is critical .
Cardioversion for new onset AF.
• Anticoagulation – in atrial fibrillation because of the risk of
embolic stroke in such patients is about 7% to 15% per year.
Warfarin is administered to a target (INR) of 2.5 to 3.0.

• Prophylaxis against recurrence of acute rheumatic fever

• Percutaneous balloon valvotomy-indicated in
-Progressive deterioration despite medical treatment

-MS with complications

- Asymptomatic patients with a single attack of thromboembolism
-Mitral valve orifice < 1 cm2
• Surgical correction – indicated in
MS with MI Active rheumatic carditis
MS with left atrial thrombus Extremely tight stenosis
Heavy valvular calcification Restenosis

• Surgical options are -Surgical commissurotomy, valve

reconstruction, or valve replacement.
• Anaesthetic management
INVESTIGATIONS
• Complete Haemogram
• Blood sugar
• Serum Electrolytes
• Liver function tests
• Renal Function tests
• Chest X- Ray
• ECG
• Echocardiography
Goals-

• Preload should be maintained.

• Heart Rate -Tachycardia must be avoided.
• Contractility should be maintained.
• SVR to be maintained.
• PVR - Pulmonary vasoconstriction to be avoided.
• Maintenance of Sinus rhythm.
 MONITORING

• Noninvasive monitoring like HR, BP , ECG, RR,

SpO2.

• Invasing monitoring

-Invasive arterial pressure

-CVP measurement

-Pulmonary artery catheter

Premedication
• Anticholinergics to be avoided .

• Opioids like fentanyl are used to give analgesia.

• Generous amounts of opioids to abolish hemodynamic response to

intubation. It will also decrease the requirement of induction agents.

• Adequate preoxygenation to avoid any degree of hypoxia.

Induction

• No single correct agent.

• Induction agents should be double diluted and given slowly in titrated

doses.

• Etomidate is the best agent for hemodynamic stability, but thiopentone

can be used instead.

• Propofol should be avoided as it can lead to precipitous hypotension.

Muscle relaxant

• For muscle relaxation agents that do not release histamine are preferred
as histamine causes tachycardia and hypotension.

• Steroidal group of muscle relaxants does not cause histamine release.

Example are- VECURONIUM, ROCURONIUM except
PANCURONIUM.

• Benzylisoquinolinium group causes histamine release. Example are –

ATRACURIUM, CISATRACURIUM, MIVACURIUM
Maintenance

•  Oxygen + Air + High dose narcotic or volatile anaesthetics such as

isoflurane, desflurane or sevoflurane at low vol %

• Nitrous oxide is best avoided due to its effect on pulmonary

resistance.

• Deep plane of anaesthesia should be maintained.

• Ensure appropriate ventilation and proper fluid therapy

Reversal & post operative management

• Slowly with neostigmine and glycopyrrolate to reduce drug induced tachycardia

caused by glycopyrrolate.

• Post operative management proper pain management to avoid tachycardia.

• Risk of pulmonary edema and right heart failure continue so cardiovascular

monitoring should be continued.

• Oxygen supplementation until adequate oxygenation is established.

• Management of post op hypothermia and shivering.

Thank you