ANAESTHESIA IN PATIENTS WITH MITRAL STENOSIS

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ANAESTHESIA IN PATIENTS WITH MITRAL STENOSIS: 

ANAESTHESIA IN PATIENTS WITH MITRAL STENOSIS CO-ORDINATOR – DR. SANJAY AGARWAL PRESENTER – DR. AKANKSHA

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Chambers of the heart; valves

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LATE DIASTOLE ATRIAL SYSTOLE ISOMETRIC VENTRICULAR CONTRACTION VENTRICULAR EJECTION ISOMETRIC VENTRICULAR RELAXATION THE CARDIAC CYCLE DIASTOLE

Mitral Stenosis: 

Mitral Stenosis Etiology Natural history Symptoms Physical Exam Severity Timing of Surgery

Mitral Stenosis: Etiology: 

Mitral Stenosis : Etiology Primarily a result of rheumatic fever Other causes are- Carcinoid syndrome, Left atrial myxoma , Severe mitral annular calcification, Thrombus formation, Rhuematoid arthritis, SLE Rarely congenital Pure or predominant MS occurs in approximately 40% of all patients with rheumatic heart disease Two-thirds of all patients with MS are female.

Mitral Stenosis: Natural History: 

Mitral Stenosis : Natural History Progressive, lifelong disease, Usually slow & stable in the early years. Progressive acceleration in the later years 20-40 year latency from rheumatic fever to symptom onset. Additional 10 years before disabling symptoms

Mitral Stenosis: Pathophysiology: 

Mitral Stenosis : Pathophysiology Normal valve area: 4-6 cm 2 Mild mitral stenosis: MVA 1.5-2.5 cm 2 Minimal symptoms Mod mitral stenosis MVA 1.0-1.5 cm 2 usually does not produce symptoms at rest Severe mitral stenosis MVA < 1.0 cm2

Mitral Stenosis: Pathophysiology: 

Mitral Stenosis: Pathophysiology Right Heart Failure: Hepatic Congestion JVD Tricuspid Regurgitation RA Enlargement  Pulmonary HTN Pulmonary Congestion Atrial Fib LA Thrombi LA Enlargement  LA Pressure RV Pressure Overload RVH RV Failure LV Filling

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Obstruction to LA emptying Difficulty in LV filling LA pressure Change in LA function

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Obstruction to LA emptying Difficulty in LV filling LA pressure Change in LA function Pulmonary venous pressure Pulmonary artery pressure Perivascular edema Luminal narrowing

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Obstruction to LA emptying Difficulty in LV filling LA pressure Change in LA function Pulmonary venous pressure Pulmonary artery pressure Perivascular edema Luminal narrowing Reversal of pulmonary blood flow Pulmonary compliance Work of breathing

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Obstruction to LA emptying Difficulty in LV filling LA pressure Change in LA function Pulmonary venous pressure Pulmonary artery pressure Cardiac output Stable with mild symptoms Severe pulmonary Htn Perivascular edema Luminal narrowing Reversal of pulmonary blood flow Pulmonary compliance Work of breathing

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Obstruction to LA emptying Difficulty in LV filling LA pressure Change in LA function Pulmonary venous pressure Pulmonary artery pressure Cardiac output Stable with mild symptoms Severe pulmonary Htn Pulmonary vascular resistance Perivascular edema Luminal narrowing Reversal of pulmonary blood flow Pulmonary compliance Work of breathing

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Obstruction to LA emptying Difficulty in LV filling LA pressure Change in LA function Pulmonary venous pressure Pulmonary artery pressure Cardiac output Stable with mild symptoms Severe pulmonary Htn Pulmonary vascular resistance RV overload Tricuspid regurgitation Perivascular edema Luminal narrowing Reversal of pulmonary blood flow Pulmonary compliance Work of breathing

Mitral Stenosis: Symptoms: 

Mitral Stenosis : Symptoms Breathlessness Fatigue Oedema , ascites Palpitation Haemoptysis Cough Chest pain Hoarseness of voice mitral facies or malar flush Symptoms of thromboembolic complications (e.g. stroke, ischaemic limb) Worsened by conditions that  cardiac output. Exertion,fever , anemia, tachycardia ,, pregnancy, thyrotoxicosis

Signs of Mitral Stenosis: 

Signs of Mitral Stenosis Palpation: Small volume pulse Tapping apex-palpable S1 Palpable S2 Atrial fibrillation Signs of raised pulmonary capillary pressure Crepitations , pulmonary oedema , effusions Signs of pulmonary hypertension RV heave, loud P 2 Auscultation: Loud S1 S2 to OS interval inversely proportional to severity Diastolic rumble: length proportional to severity In severe MS with low flow- S1, OS & rumble may be inaudible

Auscultation- Timing of A2 to OS Interval : 

© Continuing Medical Implementation ….. .bridging the care gap Auscultation- Timing of A2 to OS Interval Width of A2-OS inversely correlates with severity The more severe the MS the higher the LAP the earlirthe LV pressure falls below LAP and the MV opens

Mitral Stenosis: Investigations : 

Mitral Stenosis : Investigations CXR

Mitral Stenosis: Role of Echocardiography: 

© Continuing Medical Implementation ….. .bridging the care gap Mitral Stenosis: Role of Echocardiography Diagnosis of Mitral Stenosis Assessment of hemodynamic severity mean gradient, mitral valve area, pulmonary artery pressure Assessment of right ventricular size and function. Assessment of valve morphology to determine suitability for percutaneous mitral balloon valvuloplasty Diagnosis and assessment of concomitant valvular lesions Reevaluation of patients with known MS with changing symptoms or signs. F/U of asymptomatic patients with mod-severe MS

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Cardiac catheterization Valve area, ventricular function, CAD Gradient across aortic valve 50 torr or more indicates severe AS Resolves discrepencies b/w clinical and echocardiographic findings. Transvalvular pressure gradient >10mmhg- severe MS. Increased pumonary artery pressure shows pulmonary hypertension.

Mitral Stenosis: Complications: 

Mitral Stenosis : Complications Atrial dysrrhythmias Systemic embolization (10-25%) Risk of embolization is related to, age, presence of atrial fibrillation, previous embolic events Congestive heart failure Pulmonary infarcts (result of severe CHF) Hemoptysis Massive: 2 0 to ruptured bronchial veins (pulmonary HTN) Streaking/pink froth: pulmonary edema, or infection Endocarditis Pulmonary infections

Mitral Stenosis:Therapy: 

© Continuing Medical Implementation ….. .bridging the care gap Mitral Stenosis:Therapy Medical Diuretics for LHF/RHF Digitalis/Beta blockers/CCB: Rate control in A Fib Anticoagulation: In A Fib Endocarditis prophylaxis Balloon valvuloplasty Effective long term improvement

Mitral Stenosis:Therapy: 

© Continuing Medical Implementation ….. .bridging the care gap Mitral Stenosis:Therapy Surgical Mitral commissurotomy Mitral Valve Replacement Mechanical Bioprosthetic

PREMEDICATION IN PATIENTS WITH MS: 

PREMEDICATION IN PATIENTS WITH MS Morphine (0.1-0.2 mg/kg) Promethzine (12.5-25mg) given to be intramuscularly 1-2 hours before surgery. Anticholinergics are usually avoided as they increase the heart rate.

Anesthetic Goals: 

Anesthetic Goals 1 Maintain a slow heart rate. 2. Maintain a sinus rhythm, if present. Aggressively treat acute atrial fibrillation. 3. Avoid aortocaval compression. Maintain venous return and PCWP to maximize LVEDV without causing pulmonary edema . 4. Maintain adequate SVR. 5. Prevent pain, hypoxemia, hypercarbia , and acidosis, which may increase pulmonary vascular resistance

ANAESTHETIC CONSIDERATION PRE-OPERATIVE EVALUATION: 

ANAESTHETIC CONSIDERATION PRE-OPERATIVE EVALUATION It includes assessment of- 1-) Severity of cardiac disease. 2-) Degree of impaired myocardial contractility. 3-) Presence of associated major organ system disease. 4-) presence of prosthetic heart valves.

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History and physical examination- Questions designed to define exercise tolerance to evaluate cardiac reserve.

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Types of murmur- to assess severity. Cardiac dysrrhythmias - eg . AF Angina pectoris Drug therapy- ß blockers, Calcium channel blockers, digitalis, ace inhibitors, vasodialators , diuretics, ionotropes , antidysrrhythmic drugs.

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Presence of prosthetic valves- 2 types- Mechanical Bioprosthetic Complications with prosthetic valves- valve thrombosis systemic embolisation strutural failure subclinical intravascular hemolysis paravalvular leak endocarditis

MANAGEMENT OF ANTICOAGULATION IN PATIENTS WITH PROSTHETIC HEART VALVES: 

MANAGEMENT OF ANTICOAGULATION IN PATIENTS WITH PROSTHETIC HEART VALVES Patients on anticoagulation are usually because of mechanical heart valves or atrial fibrillation. Risk of thrombo -embolism- 5-8% For minor surgeries where blood loss are minimal- anticoagulation can be continued. For major surgeries- warfarin is discontinued 3-5 days pre-operatively. i /v unfractionated heparin or subcutaneous LMW heparin is administered and continued till the day of surgery.

INDUCTION: 

INDUCTION Any agent can be used except Ketamine b/o its propensity to increase HR..

MAINTENANCE: 

MAINTENANCE Muscle relaxant should be used that do not induce cardiovascular changes- tachycardia and hypotension from histamine release. Vecuronium + narcotics can lead to dangerous bradycardia , so better avoided. Rocuronium has vagolytic action, so it can cause slight increase in HR and decrease in PA press. Benzodiazepines ( midazolam and diazepam) should be used cautiously as they can lead to profound vasodialation .

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For patients undergoing open heart procedures, high dose narcotic technique with pancuronium / vecuronium should be preffered . Intraoperative use of vasodialator therapy (NTG/ Nitrprusside 0.5-1.0 µg/kg/min) is desirable in patients having severe PAH. Intraoperative monitoring should include :- ECG Direct atrial pressure CVP Pulmonary artery catheterisation PCWP along with CO- offers a v.good estimate of overall ventricular function.

POST-OPERATIVE MANAGEMENT: 

POST-OPERATIVE MANAGEMENT Risk of pulmonary oedema and RHF continues in post-op period, so cardiovascular monitoring should be continued as well. Mild hypercarbia ( upto 48 mmhg ) should be avoided. As it can cause significant increase in PVR and RVEDP, which lead to RV stress. Decreased pulmonary compliance and increased work of breathing may necessiate a period of mechanical ventillation . Relief of post op pain with neuraxial opioids can be very useful.

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Ionotropic support and the vasodialator therapy should be continued for a prolonged period (24-48 hours) in patients having severe PAH. Avoidance of tachycardia and hypovolumia are to be of main concern post-operatively also.