GENERAL SURGERY GROUP ASSIGNMENT

Valvular heart disease

Session outline:
 Aortic stenosis
 Aortic regurgitation
 Mitral stenosis
 Mitral regurgitation
Aortic stenosis

 Aetiology
 Rheumatic
 Degenerative calcification
 Congenital
Aortic stenosis
 Pathophysiology:
 It is a progressive disease
 The normal AVA is 2.6–3.5 cm2 in adults
 Significant haemodynamic effect as it approach 1cm2
 LVH occurs
 LV filling becomes dependent on atrial contraction
 LV O2 demand increased
AS - Assessment
 History
 Angina, breathlessness, syncope.
 Examination
 Slow rising and low volume pulse with narrow pulse pressure.
 Ejection systolic murmur maximal at the 2nd intercostal space, right sternal
edge radiating to the neck.
AS - Assessment
 Investigations:
 ECG
 LVH,
 T-wave inversion, ST-segment depression, AV block
 CXR
 Echo
AS classification
 Mild
 AVA = 1.2-1.8cm2, and mean gradient 12-25mmHg
 Moderate
 AVA = 0.8-1.2cm2, and mean gradient 25-40mmHg
 Severe
 AVA = <0.8cm2, and mean radiate >50mmHg
AS-Principles of anaesthetic management

 Preop management:
 Echo is highly desirable
 Full assessment and consultation is required
 Consider Prior valve replacement in high risk patients
 Asymptomatic patients for intermediate or minor surgery generally do
well if managed carefully
AS-Principles of anaesthetic management

 Intraoperative management:
 Careful haemodynamic monitoring is vital(A-line, CV)
 Intraoperative transoesophageal echocardiography, if available.
 (Low) normal heart rate.
 Maintain sinus rhythm.
 Adequate volume loading.
 High normal systemic vascular resistance.
AS-Principles of anaesthetic management

 Intraoperative management:
 Avoid systemic hypotension
 Vasoconistrictor at hand
 Which anaesthetic techniques?
 Plasma K+
 Potential surgical causes of haemodynamic instability should be considered
and modified wherever possible
 Antibiotic prophylaxis
AS- Principles of anaesthetic management
 Postoperative Management:
 Adequate analgesia
 Invasive monitoring if ASA<1cm2
 Maintain appropriate IV filling and BP
 Consider reginal block
 vasoconstrictor infusion
 Avoid NSAIDs
Aortic regurgitation
 Aetiology:
 Rheumatic fever
 Aortic dissection
 Endocarditis
 Connective tissue disorders
 Congenital defect
 Chest trauma, ankylosing spondylitis, syphilis
Aortic regurgitation
 In patients who have chronic aortic regurgitation:
 Afterload and HR determine the degree of regurgitation.

 Vasodilators increase forward flow

 HR>90bpm reduce diastolic ‘regurgitation’ time and degree of

regurgitation.
 Aortic diastolic pressure is dependent on the aortic valve and

decreases when the valve becomes incompetent.

Aortic regurgitation - assessment
 History
 Dyspnoea, secondary to pulmonary congestion.
 Palpitations.
 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.
Aortic regurgitation - assessment
 Investigations
 CXR: cardiomegaly, boot-shaped heart.

 ECG: non-specific LVH.

 Echocardiography gives qualitative analysis of the degree of

regurgitation.
Aortic regurgitation – perioperative care

 Asymptomatic patients usually tolerate non-cardiac surgery well.

 Patients with poor functional capacity need to be considered for valve

replacement surgery.
Aortic regurgitation – perioperative care

 Haemodynamic goals

 High normal heart rate—around 90bpm.

 Adequate volume loading.

 Low systemic vascular resistance.

 Maintain contractility.
Mitral stenosis

 Normal valve surface are >4cm2

 Symptom-free until 1.6–2.5cm2
 Moderate stenosis 1–1.5cm2
 Severe stenosis <1.0cm2
Mitral stenosis
 Aetiology/epidemiology:
 Rheumatic fever
 Degenerative calcification
 Endocarditis
 Less common causes
▪ These include infiltrating diseases, and congenital deformities, or diseases that affect multiple
systems, such as sarcoidosis
Mitral stenosis
 Signs/symptoms:
 Dyspnoea, haemoptysis, recurrent bronchitis.
 Fatigue.
 Palpitations.
 Peripheral cyanosis
 Signs of right heart failure
 AF
Mitral stenosis

 Investigations:

 ECG

 CXR

 Echo
Mitral stenosis

 Treatment:

 Medical

 Surgical
 MS - Anaesthetic management
 Preoperative assessment:
 Asymptomatic patients usually tolerate non-cardiac surgery well.

 Patients with poor functional capacity need to be considered for mitral

valve replacement.
MS - Anaesthetic management

 Preop Investigations:
 Exercise tolerance testing

 Echocardiography

 ECG
MS - Anaesthetic management
 Perioperative management
1. Rate/rhythm
2. Preload
3. Afterload
4. Contractility
5. Neuraxial anaesthesia
6. Avoid hypercarbia, acidosis, and hypoxia, which may exacerbate
pulmonary hypertension
MS - Anaesthetic management

 Postoperative management
 Careful monitoring

 HDU

 Avoid fluid bolus

 Avoid hypotension
Mitral regurgitation

 Acute or chronic
 Primary or secondary
 Left atrium dilates as blood is ejected back into it
 AF is common

 Left ventricular ejection fraction is therefore supranormal.

Mitral regurgitation

 Pulmonary vascular congestion develops, followed by pulmonary hypertension.

 The degree of regurgitation is determined by:
 Afterload,

 Size of the regurgitant orifice,

 Heart rate
Mitral regurgitation
MR- Anaesthetic management

 Preoperative assessment:
 Acute MR- can present as cardiac failure and severe pulmonary

edema
 Chronic MR- can be tolerated for many years

 History

 Examination
MR- Anaesthetic management
 Preoperative assessment(cont….)
 Investigations:
1. ECG
2. CXR
3. Echo
4. Blood test
5. Exercise testing
MR- Anaesthetic management
 Cardiopulmonary exercise testing
 Indicated if the Echo findings do not match with Hx
 May give a clearer picture of ventricular function
 Indication for medical preoperative optimization:
 LVEF<30%
 Symptomatic patients
 Cardiac surgery
MR- Anaesthetic management
 Intraoperative management:
 Haemodynamic goals can be summarized as ‘3F’
1. Rate/rhythm
 A high normal heart rate (80–100bpm) reduces filling time of
the LV
2. Preload
 Assessment of preload can be difficult in MR. Erring on the side of well
filled is preferable as it also promotes forward flow.
MR- Anaesthetic management
 Intraoperative management(cont…)
3. Afterload
 Low systemic vascular resistance

 Strict avoidance of hypoxia, hypercapnia, and acidosis and avoiding the

use of nitrous oxide

MR- Anaesthetic management

 Intraoperative management(cont…)
4. Contractility
 In acute MR, inotropes such as dobutamine

5. Neuraxial anaesthesia
 Generally well tolerated
Thanks