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ANAESTHESIA
MITRAL STENOSIS
MITRAL REGURGITATION
MITRAL VALVE
PROLAPSE
Cardiac Output
+ +
- + + +
Increase Increase Increase
Parasympathetic Sympathetic End-diastolic
Activity Activity Volume
(and epi)
+
+ Increase
Venous
Return
Another way to look at cardiac function:
Pressure - Volume Loops
130 Ejection
RAPID
120 C A = Mitral Valve
C EJECTION
110
Closure
100
B B = Aortic Valve Opens
LV Pressure 90 B
(mm Hg) 80 C = Aortic Valve
70 Isovolumic Closure
60 Relaxation
ISOVOLUMETRIC SV Isovolumic
ISOVOLUMETRI
Contraction D = Mitral Valve Opens
50 RELAXATION C
40 CONTRACTION
30
20
D A
10
A
10 20
D
30 40 50 60 70 80
CO = SV x HR
ESV EDV LV Volume (ml)
EF = SV / EDV
Diastolic Filling
The effects of increased HR on diastolic filling:
Mitral Stenosis: Etiology
Primarily a result of rheumatic fever
(~ 99% of MV’s @ surgery show rheumatic
damage )
Scarring & fusion of valve apparatus
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
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 Valve
Area
Normal 4 to 6 cm2
Mild stenosis 1.6 to 2.0
cm2
Moderate 1.1 to 1.5 cm2
Severe ≤ 1.0 cm2
Recognizing Mitral
Stenosis
Palpation:
Small volume pulse Auscultation:
Tapping apex-palpable Loud S1- as loud as S2 in
S1 aortic area
+/- palpable opening A2 to OS interval
snap (OS) inversely proportional
RV lift to severity
Palpable S2
Diastolic rumble:
length proportional to
ECG: severity
LAE, AFIB, RVH, RAD In severe MS with low
flow- S1, OS & rumble
may be inaudible
Mitral Stenosis: Physical
Exam
S1 S2 OS S1
S2-OS interval
Avoid hypercarbia---premed ??
Antibiotic prophylaxis ??
EDV
MR Stages
LV size and function defined by echo
Stage 1-compensated:
End-diastolic dimension less 63mm, ESD less
42mm
EF more than 60
Stage 2-transitional
EDD 65-68mm, ESD 44-45mm, EF 53-57
Stage 3-decompensated
EDD more than 70mm, ESD more than 45mm,
EF less than 50
Anaesthetic Goals
Decrease regurgitant fraction
Facilitate forward output
FASTER FULLER
VASODIALATED
80-90 Adequate Minimally
beats/min preload vasodilated
MONITORING
Routine
TEE
Will depend on the type of
PA catheter surgery and severity of
MR
Regional techniques beneficial…..
avoid drastic falls in blood pressure,
adequately preload
Avoid suxamethonium related
bradycardia
Prompt replacement of blood loss
Vasodilators most beneficial in
patients with ventricular dilation and
associated systolic dysfunction
MITRAL VALVE
PROLAPSE PARASTERNAL
VIEW
An inherited connective tissue
disorder
Thickening and redundancy of mitral
valve
Affects 5 – 10% of population, young
women more affected.
Associations: Marfan’s Syndrome,
Rheumatic
endocarditis,Thyrotoxicosis,SLE
Majority patients are asymptomatic
Mostly non specific symptoms of
fatiguability, palpitations, etc.
Rule out Coronary disease if chest
pain….since the chest pain is atypical
for angina
Late systolic click and
CLICK
or late systolic
murmur
S S
1 2
Murmur
M-MODE
M-MODE ECHO
ECHO
M
V
P
N
O
R
M
A
NORMAL MITRAL L
VALVE
Anaesthetic Implications
Goal of preop assessment is to
distinguish patients with a purely
functional disease from those with
symptomatic MR.
Goals of management same as with
MR.
Patients may be on beta blockers for
control of palpitations which should
be continued
Antibiotic prophylaxis not needed if