VALVULAR HEART DISEASE

Manfred c Mtandi
Levocatus Exavery

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 PART 2

 Principles of anaesthesia care and

management of patient with valvular heart
diseases requiring non cardiac surgical
interventions.

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 Contents

 Introduction
 Preoperative assessment
 Preoperative investigation
 Intraoperative anaesthesia management
 Postoperative care of patients with valvular
heart disease

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 Valvular Heart Disease

 An acquired or congenital disorder of a

cardiac valve characterized by stenosis
[obstruction] or regurgitation [backward flow]
of blood.
 Valvular heart disease can be;
 Mitral stenosis
 Mitral regurgitation
 Mitral prolapse
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 Valvular Heart………

 Aortic regurgitation
 Aortic stenosis
 Pulmonary regurgitation
 Pulmonary stenosis
 Tricuspid regurgitation
 Tricuspid stenosis

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 Risk of provide anesthesia to a
patients with valvular heart
disease.

 A patient with a diseased heart valve can

have associated heart failure or cardiac
dysrhythmias such as atrial fibrillation which
increase the risk of perioperative adverse
events.

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 Common findings of the history
and physical exam in patients with
valvular heart disease

 A history of rheumatic fever , IV drug abuse

or heart murmur.
 Decrease exercise tolerance ; May exhibit
S/S of CHF[dyspnea,
orthopnea ,fatigue ,pulmonary rales ,JVD ,
hepatic congestion, and dependent edema]
 Compensatory increases in SNS tone
manifest as resting tachycardia, anxiety and
diaphoresis
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 Mitral Stenosis

 History
• Dyspnoea, haemoptysis, recurrent bronchitis.
• Fatigue.
• Palpitations.

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 Examination

• Mitral facies—malar flush on cheeks.

• Peripheral cyanosis.
• Signs of right heart failure (elevated jugular
venous pressure ( JVP),hepatomegaly,
peripheral oedema, ascites).
Tapping apex beat. Loud 1st heart sound,
opening snap (if in sinus rhythm), and low-
pitched diastolic murmur heard best at the apex
(with the bell of the stethoscope).
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 Investigations

• E CG: P mitrale (left atrial enlargement) if

sinus rhythm. AF usual.
• CXR: valve calcification. Large left atrium
(lateral film). Double shadow behind the heart
on PA film. Splaying of the carina. Kerley B
lines indicating pulmonary congestion.
• Echocardiography: measures the gradient
and valve area.
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 Optimization

 Anticoagulation
 Sodium restriction
 Diuretics
 Patients with poor functional capacity need to
be considered for mitral valve replacement.

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 Anesthesia concerns

 Epidural is preferred over spinal anesthesia

due to gradual onset of sympathetic block
with epidural.
General Anesthesia
 Induction: Etomidate being the most cardiac
stable is the agent of choice.
 Relaxant : As vecuronium is the most
cardiac stable, it is the muscle relaxant of
choice.
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 Anaesthesia concer…….

 Maintenance: Isoflurane being most cardiac

stable is most preferred however sevoflurane
and desfiurane in lower concentrations can be
safely used. Nitrous oxide can cause mild
pulmonary vasoconstriction therefore should
be avoided.
 Reversal: As tachycardia is not acceptable
atropine should not be used with neostigmine.

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 Intraoperative

•HR- keep slow to allow for diastolic filling.[ Low

normal HR 50–70bpm].
•Treat tachycardia aggressively with β-blockers.

• Maintain sinus rhythm, if possible. Immediate

cardioversion if AF occurs perioperatively.
• Preload- maintain or slightly increase to help
with left ventricular filling ; excess preload may
cause pulmonary edema.
14 • Avoid hypercapnia, acidosis, and hypoxia,
 Intraoperative…..

 Afterload- SVR should be maintained; avoid

decrease in SVR ; avoid increase in PVR.
 Maintain an adequate afterload; slow the HR,
and avoid hypovolaemia.
 Contractility- Maintain to provide adequate
cardiac output.
 Measure CVP/pulmonary artery occlusion
pressure (PAOP), and maintain an adequate
preload.
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 Postoperative

 Pain management- to reduce stress, adverse

hypercoagulable states.
 Prevention of hypotension, hypovolemia,
hypoxemia.

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 Mitral Regurgitation

 Mitra! regurgitation (MR) is said to be severe

if regurgicant fraction is> 0.6.
History
 Fatigue, weakness.
 Dyspnoea.

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 Examination

 Displaced and forceful apex (the more

severe the regurgitation, the larger the
ventricle).
 Soft S1, apical pansystolic murmur radiating
to the axilla, loud S3.
 • AF.

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 Investigations

 ECG: left atrial enlargement. AF.

 CXR: left atrial and LV enlargement. Mitral
annular calcification.
 Echocardiography assesses the degree of
regurgitation (TOE particularly useful as
mitral valve close to the oesophagus

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 Optimization

 Medical treatment; Digoxine, diuretics and

vasodilators
 Preload reduction with vasodilators and
diuretics
 Minimize drug-induced myocardial
depression.

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 Anesthesia concerns

 As decrease in afterload decreases the

regurgitation Central neuraxial blocks
appears to be a good selection however
excessive hypotension should be avoided.
General Anesthesia
 Induction: Etomidate
 Maintenance: lsoflurane
 Muscle relaxant: Vecuronium
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 Intraoperative

 HR- maintain or increase ; avoid bradycardia which

worsens regurgitant flow
 Rhythm- sinus rhythm
 Preload- Maintain or slight increase ; an elevated
preload will cause an increase in regurgitant flow and
low preload cause inadequate cardiac output.
 Afterload- decrease to improve forward cardiac output;
avoid sudden increases in SVR
 Contractility- maintain or increase to decrease left
ventricular volume.
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 Intraoperative

 Avoid bradycardia: Bradycardia by increasing

the diastole will increase the regurgitation.
 Avoid hypertension: Hypertension by
increasing the afterload increases the
regurgitation

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 Aortic stenosis

History
Angina, breathlessness, syncope. The
majority of patients with symptomatic AS will be
dead within 3yr, if not treated.
Symptoms do not correlate well with the
severity of stenosis; some patients with small
valve areas can be asymptomatic.

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 Examination

 Slow rising pulse with narrow pulse pressure.

 Ejection systolic murmur, maximal at the 2nd
intercostal space, right sternal edge,
radiating to the neck.

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 Investigations

 ECG: LV hypertrophy and strain (with 2° ST–T wave

abnormalities).
 CXR: normal until the LV begins to fail, post-stenotic
dilatation of the aorta, calcified aortic annulus.
 Echocardiogram: enables calculation of the valve
gradient (Table 3.3)and assessment of LV
performance.
 Cardiac catheterization is also used to estimate the
gradient across the valve and to quantify any
concurrent CAD.
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 Optimization

 Symptomatic patients for elective non-cardiac

surgery should have aortic valve replacement first
as they are at risk of sudden death perioperatively.
 ACE inhibitors, which can open blood vessels
more fully.
 Beta-blockers, which slow your heart rate.
 Diuretics (“water pills”), which lessen the amount of
fluid in your body and ease stress on your heart.

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 Choice of Anesthesia

 As central neuraxial blocks can cause hypotension

therefore anesthetic technique of choice is GA.
General Anesthesia
 Induction: Etomidate.
 Maintenance: 0 2 + N20 and isotlurane if LV
function is not significantly compromised however if
LV fun ction is compromised then opioids are
selected over inhaJational agent.
 Muscle relaxant: Vecuronium.
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 Intraoperative

 Maintain normal sinus rhythm; neither bradycardia

nor tachycardia is acceptable.
 Bradycardia can cause over distension of already
hypertrophied left ventricle while tachycardia by
decreasing the ventricular filling can further
decrease the cardiac output.
 Maintain normal blood pressure. Hypertension by
increasing the afterload can further deteriorate left
ventricular function.
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 Intraoperative……

 Hypotension is not acceptable at any cost; severe

hypotension by reducing the coronary blood flow
can p recipitate myocardial ischemia or even
cardiac arrest. Unfortunately patients with severe
AS may not be able to generate adequate stroke
making CPR to be ineffective. Therefore
hypotension should be managed very aggressively.
As phenylephrine does not causes tachycardia it is
the vasopressor of choice for patients with AS.

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 Post-operative management

 Have a low threshold for admission to

ICU/HDU.
 Meticulous attention must be paid to fluid and
pain management.
 Infusions of vasoconstrictors may be
required.

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 Aortic regurgitation

History
Dyspnoea, 2° to pulmonary congestion.
Palpitations.

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 Examination

 Widened pulse pressure.

 Collapsing (‘waterhammer’) pulse; Corrigan’s
sign—visible neck pulsation; de Musset’s
sign—head nodding; Quincke’s sign—visible
capillary pulsations in the nail beds.
 Diastolic murmur—2nd intercostal space,
right sternal edge.

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 Investigations

 CXR: cardiomegaly, boot-shaped heart.

 ECG: non-specific LV hypertrophy.
 Echocardiography gives qualitative analysis
of the degree of regurgitation.

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 Haemodynamic goals

 High normal HR—around 90bpm.

 Adequate volume loading.
 Low SVR.
 Maintain contractility.

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 Choice of Anesthesia

 General Anesthesia
 Induction: Etomidate
 Maintenance: 0 2 + N20 and isoflurane if LV
function is normal otherwise opioids.
 Muscle relaxant: Vecuronium

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 Intraoperative

 The selected anaesthetic should maintain

afterload in the low normal range to maintain
diastolic pressure.
 Avoid bradycardia and hypertension.
Bradycardia by increasing diastole and
hypertension by increasing the afterload can
increase the regurgitant fraction.

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 Intraoperative..

 As decrease in afterload decreases the

regurgitation central neuraxial blocks appears
to be a good selection however excessive
hypotension should be avoided.
 Treat perioperative supraventricular
tachycardia (SVT)/AF promptly with
synchronized direct current (DC) cardioversion,
particularly if associated with hypotension.

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 Intraoperative..

 Persistent bradycardia may need to be

treated with β-agonist or anticholinergic
agents.
 Intra-arterial pressure monitoring is useful for
major surgery

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 Post-operative management of
valvular heart disease

 Smooth extubation of these patients with a

pain-free post-operative period, judicious
volume titration and cardiac support will go a
long way for better clinical outcomes and
uneventful recovery.
 Decrease pulmonary compliance and
increased work of breathing- mechanical
ventilator maybe required.

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 References

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