Valvular heart disease

www.anaesthesia.co.in

anaesthesia.co.in@gmail.com
CAD Vs VHD
 Unlike CAD the symptoms are not related
to poor myocardial performance in VHD
 The ventricular function may be normal or
even supranormal in VHD
 Symptoms are related to the alterations in
the loading conditions in VHD:
 Volume overload
 Pressure overload
Anaesthetic management
 Patient is asleep
 Maintain haemodynamics

 Pathophysiology
 Haemodynamic effects of

anaesthetic agents
Normal
Everything goes in the right direction
without impediment

RA 7 12 LA

RV 25 / 7 120 / 12 LV

25 / 12 120 / 80
PA Ao
Your Basic Loop

D
ESV C
SV
EDV
A B
 Mitral Stenosis
Fixed, chronic obstruction to LV filling LA,
RV 

10 19 LV 

45 / 10 100 / 10

45 / 19 100 / 65
Mitral Stenosis
PRESSURE

VOLUME
Left atrial pressure overload
 Diastolic inflow to LV: maintained by
development of elevated pressure
gradient across mitral valve
 Dilatation of LA Pressure
 Increase in PVR: pulmonary hypertension
 RV dilatation TR
 Biventricular failure with pulmonary
congestion, peripheral edema and ascites
Changes in left ventricle
 Restriction of diastolic inflow: preload
reserve is limited
 Intrinsic myocardial depression: rheumatic
etiology
 Excess afterload: inadequate wall
thickness, accounts for higher afterload at
relatively normal end-systolic pressure
Assessment of severity
 Symptoms and Clinical examination
 X-ray chest
 Echo:
 Valve area:
 Normal: 4.5 cm2
 Mild: 1.5 to 2.5 cm2
 Moderate: 1 to 1.5 cm2
 Severe: < 1 cm2
 RVSP
Anaesthetic goals
 Mild disease: not to worry?
 Control the heart rate
 Restore and preserve sinus rhythm if
possible
 Avoid hypovolemia
 Avoid systemic vasodilators
 Maintain normocarbia
 Nitroglycerin/nitroprusside
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
Tempe DK, et al: J Cardiothorac Vasc Anesth 1995;9:552-557
 Mitral Regurgitation
Chronic LV & LA volume overload  orifice LA, LV 
size, time, pressure gradient

19
7

25 / 7 130/19

25 / 19
130/55
Mitral regurgitation

PRESSURE

VOLUME
Pulmonary hypertension in
mitral regurgitation
 Passive congestion of the pulmonary
circulation
 Reactive pulmonary vasoconstriction
 Intrinsic LV dysfunction
 Combination of above
MR: assessment of the severity
 Symptoms and clinical examination
 X-ray chest
 Echo:
 Jet area
 RVSP
 LV dimensions: end-systolic > 4.5 cm
 LV ejection fraction
Anaesthetic goals
In general, patients suffering from
MR (except those with severe MR
and severe PAH) tolerate anaesthesia
well

Faster, fuller, vasodilated

 Aortic Insufficiency
Chronic LV volume overload  orifice size, LV 
time, pressure gradient

7 15

25 / 7 150 / 17

25 / 15 150 / 55
 Aortic Insufficiency

CHRONIC
PRESSURE

ACUTE

VOLUME
AR: assessment of severity
 History and clinical examination
 X-ray chest

 Echo:

 Mild, moderate, severe

 LV dimensions: End-systolic >5.5

cm
AR: anaesthetic goals
 In general, patients tolerate surgery
and anaesthesia well, unless CHF or
LV dysfunction is present
 Aim: to decrease the regurgitant
fraction
 Faster, fuller and vasodilated
 Monitor MAP
 Aortic Stenosis
Fixed , chronic obstruction to LV ejection at LV 
the level of the aortic valve

7 17

25 / 7 190 / 22

30 / 15 110 / 65
Aortic Stenosis
PRESSURE

VOLUME
Low Compliance Ventricle
Pressure

Volume
Aortic stenosis: pathophysiology
 Normal aortic valve area: 2.5 to 3.5
cm2
 Haemodynamically significant
obstruction occurs at valve area of <
1 cm2
 Pressure overload causes concentric
hypertrophy of LV
 Thickened LV wall

compliance of LV

 Ventricular filling depends upon adequate

intravascular volume and atrial contraction
 NSR is very important: atrial contraction
can contribute up to 40% of LV filling
 Decreased compliance

Increased LVEDP

Pulmonary congestion CPP

CHF Ischaemia
Myocardial contractility is
usually well preserved with
normal ejection fraction until
very late in the course of the
disease
Aortic stenosis: anaesthetic
goals
 Mild disease: not to worry
 Sinus rhythm is important
 Bradycardia is dangerous
 Maintain adequate preload
 Avoid ischaemia
(Hypertension/Hypotension)
 PA catheter?
OPEN HEART SURGERY
Open heart surgery
 Induction of anaesthesia
 Monitoring
 Heparinisation
 Establishing the bypass
 Termination of bypass
 Protamine administration
 Transfer to ICU
 Postoperative management
 Ventilation
 Management of pain and sedation
 Anaesthetic management
 Opioids should form a “base”
 Hypnotics and / or

benzodiazepines in small doses

used as supplemental agents
during induction of anaesthesia
Muscle relaxants
 Succinylcholine : 1 to 1.5 mg/ Kg
 Pancuronium : 0.08 to 0.15 mg/Kg
 Vecuronium : 0.08 to 0.2 mg/Kg
 Atracurium : 0.5 to 1 mg/Kg
 rocuronium : 0.6 mg/Kg
 Pt arrives in the OT

venous access

additional morphine/midazolam if premed. inadequate

arterial cannulation (lt radial)

good LV: induction bad LV: PAC, CVC and wide

bore venous access
Induction
 Morphine : 0.5 to 0.75 mg/Kg
OR
 Fentanyl : 5 to 10 µg/Kg
 Hypnosis with: diazepam or midazolam
(2-5 mg)
:thiopental (50-100 mg)
Maintenance of anaesthesia
 Opioid
 Nitrous oxide
 Volatile agents
 Halothane
 Isoflurane

 Isoflurane: The clinical evidence suggests that

isoflurane is safe in patients with CAD and if
hypotention is avoided, it is safe even in patients
with steal prone anatomy
Maintenance of anaesthesia (contd.)
On bypass
 Opioid + relaxant + benzodiazepine in the
prime
 Repeat half dose every hour
 Propofol
 Inhalational agent
Haemodynamic monitoring
 ECG
 Arterial pressure

 CVP

 PA catheter

 LA pressure

 Trans-oesophageal echo (TOE)

Mehta N, Lochab S,
Tempe DK, Cath
Cardiovasc Diag
1998;43:87
Heparinisation
 3-4 mg/Kg of heparin is administered
3-5 min before aortic cannulation
 ACT monitoring
 >300 sec is safe as no clot formation
has been reported below this limit
 Generally acceptable figure is >400 sec

 Dose response curve

Cardiopulmonary bypass
 Partial bypass
 Total bypass
 Aortic cross clamping
 Infusion of cardioplegia
 Into the root of aorta
 Directly in to the coronaries
 Retrograde: coronary sinus
 Release the aortic clamp
 Come off CPB
Cardiovascular support

Inotropes
 Epinephrine Milrinone
 Dobutamine Amrinone
 Dopamine Enoximone

 Dopexamine

 Norepinephrine

 Isoprenaline

Dilators
 NTG

 SNP

Ca blockers, Beta blockers

Changing trends in anaesthetic
management
Based on the objective of facilitating
early extubation
 General anaesthesia
 Lower or no doses of opioids

 Propofol

 Isoflurane, sevoflurane

 vecuronium
Problems of such anaesthetic
technique
 Awareness
 Postoperative pain relief

 Haemodynamic instability?
 Patients can be reversed with
neostigmine at the end of the
surgery
 Extubation can be managed in

the ICU
Postoperative pain relief
 Thoracic epidural (bupivacaine 0.5%,
0.05-0.1 mL/Kg) with general
anaesthesia
 Intrathecal morphine (5-10 µg/Kg) by
lumbar approach with general
anaesthesia
 Intrapleural analgesia
 Intercostal block
Conclusions
 Opioids in variable doses still form the
basis of cardiac anaesthesia
 With the availability of newer anaesthetic
agents, the safety has improved
 Early extubation in valvular heart surgery
is being practiced at few centres, but care
should be exercised in sicker patients.
www.anaesthesia.co.in
anaesthesia.co.in@gmail.com