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Valvular heart disease and anaesthesia


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Valvular heart disease and anaesthesia

  1. 1. Valvular Heart Disease and Anesthesia Wahid Altaf
  2. 2. Definition : <ul><li>An acquired or congenital disorder of a cardiac valve characterized by stenosis (obstruction) or regurgitation (backward flow) of blood </li></ul>
  3. 5. Incidence <ul><li>Valvular heart disease is found in 4% of patients over the age of 65 in the developed world. </li></ul>
  4. 6. Valvular Heart Disease <ul><ul><li>Mitral stenosis </li></ul></ul><ul><ul><li>Mitral insufficiency </li></ul></ul><ul><ul><li>Mitral valve prolapse </li></ul></ul><ul><ul><li>Aortic insufficiency </li></ul></ul><ul><ul><li>Aortic stenosis </li></ul></ul><ul><ul><li>Pulmonary stenosis </li></ul></ul><ul><ul><li>Pulmonary insufficency. </li></ul></ul><ul><ul><li>Tricuspid Stenosis. </li></ul></ul><ul><ul><li>Tricuspid insufficency. </li></ul></ul>
  5. 7. What Information is Required? <ul><li>Clinical history </li></ul><ul><li>Physical exam </li></ul><ul><li>Investigations </li></ul>
  6. 8. Common findings of the history and physical exam in patients with valvular disease: <ul><ul><li>A history of rheumatic fever, IV drug abuse, or heart murmur </li></ul></ul><ul><ul><li>Decreased exercise tolerance </li></ul></ul><ul><ul><li>May exhibit S/S of CHF (dyspnea, orthopnea, fatigue, pulmonary rales, JVD, hepatic congestion, and dependent edema) </li></ul></ul><ul><ul><li>Compensatory increases in SNS tone manifest as resting tachycardia, anxiety, and diaphoresis </li></ul></ul>
  7. 9. Mitral Stenosis <ul><ul><li>Normal: 4 - 6 cm 2 </li></ul></ul><ul><ul><li>Mildly stenotic: 1.5 - 2.5 cm 2 </li></ul></ul><ul><ul><li>Moderately stenotic: 1.1 - 1.5 cm 2 </li></ul></ul><ul><ul><li>Severely stenotic: < 1 cm 2 </li></ul></ul><ul><ul><li>Usually have symptoms when area is decreased by 50% </li></ul></ul>
  8. 11. Etiology <ul><ul><li>Delayed complication of rheumatic fever </li></ul></ul><ul><ul><li>66% of patients are female </li></ul></ul>
  9. 12. Pathophysiology <ul><ul><li>Valve leaflets thicken, calcify and become funnel-shaped </li></ul></ul><ul><ul><li>Left atrium dilates (pressure) </li></ul></ul>
  10. 13. <ul><li>Signs and symptoms: </li></ul><ul><ul><li>90% of patients present with CHF and Atrial fibrillation </li></ul></ul><ul><ul><li>10-15% develop chest pain </li></ul></ul><ul><ul><li>Hoarseness caused by enlarged left atrium putting pressure on left recurrent laryngeal nerve </li></ul></ul><ul><ul><li>Pulmonary hypertension from chronic increased pulmonary vascular resistance </li></ul></ul><ul><ul><ul><li>Hemoptysis often occurs </li></ul></ul></ul>
  11. 14. <ul><li>Treatment: </li></ul><ul><ul><li>Anticoagulation </li></ul></ul><ul><ul><li>Sodium restriction </li></ul></ul><ul><ul><li>Diuretics </li></ul></ul><ul><ul><li>Valve replacement </li></ul></ul><ul><ul><ul><li>Onset to incapacitation averages 5-10 years and most patients die within 2-5 years of onset </li></ul></ul></ul>
  12. 15. Anesthesia concerns <ul><ul><li>Maintain sinus rhythm </li></ul></ul><ul><ul><li>Avoid tachycardia, large increases in CO </li></ul></ul><ul><ul><li>Avoid both hypovolemia and fluid overload </li></ul></ul><ul><ul><li>Avoid increases in pulmonary vascular resistance </li></ul></ul><ul><ul><li>Phenylephrine is preferred over ephedrine </li></ul></ul><ul><ul><li>Epidural is preferred over spinal due to gradual onset of sympathetic block with epidural </li></ul></ul>
  13. 16. Management <ul><ul><li>HR - keep slow to allow for diastolic filling; avoid sinus tachycardia </li></ul></ul><ul><ul><li>Rhythm - sinus rhythm; if A-fib, control rate </li></ul></ul><ul><ul><li>Preload - Maintain or slightly increase to help with left ventricular filling; excess preload may cause pulmonary edema </li></ul></ul><ul><ul><li>Afterload - SVR should be maintained; avoid decreases in SVR; avoid increases in PVR </li></ul></ul><ul><ul><li>Contractility - Maintain to provide adequate cardiac output </li></ul></ul><ul><ul><li>** epidural preferred over spinal </li></ul></ul>
  14. 17. Pregnancy Considerations <ul><li>Vaginal delivery: Early admission/invasive blood pressure monitoring/ Small top-ups for epidural/avoid iv fluids. </li></ul><ul><li>Caesarean delivery : </li></ul><ul><li>Spinal anaesthesia is best avoided. </li></ul><ul><li>Careful epidural anaesthesia in class 1 and 2 patients </li></ul><ul><li>General anaesthesia NYHA class 3 and 4 patients . Specific pharmacotherapy to obtund the intubation response. </li></ul><ul><li>Bolus oxytocin is contraindicated in view of the risk of precipitous systemic hypotension and pulmonary hypertension. </li></ul><ul><li>A brief period of postoperative ventilation may be required in some cases. </li></ul>
  15. 18. Mitral Regurgitation <ul><li>A portion of the LV volume is ejected back into LA during systole because of an incompetent valve. This leads to: </li></ul><ul><ul><li>Increased left atrial pressure, **but the atrium usually does not enlarge </li></ul></ul><ul><ul><li>Increased pulmonary artery pressure </li></ul></ul><ul><ul><li>Pulmonary edema/HTN </li></ul></ul><ul><ul><li>Left ventricular hypertrophy occurs due to the increased workload required to maintain volume output </li></ul></ul>
  16. 20. Etiology <ul><ul><li>ACUTE </li></ul></ul><ul><ul><li>Myocardial ischemia or infarctions </li></ul></ul><ul><ul><li>Infective endocarditis </li></ul></ul><ul><ul><li>Chest trauma </li></ul></ul><ul><li>CHRONIC </li></ul><ul><ul><li>Rheumatic fever </li></ul></ul><ul><ul><li>Incompetent valve </li></ul></ul><ul><ul><li>Destruction of mitral valve annulus </li></ul></ul>
  17. 21. Pathophysiology <ul><ul><li>Reduction in forward SV due to backward flow of blood into left atrium during systole (can be as much as 50% of SV) </li></ul></ul><ul><ul><li>Left ventricle compensates by dilating and increasing end-diastolic volume </li></ul></ul><ul><ul><li>Regurgitation reduces left ventricular afterload, but may enhance contractility </li></ul></ul><ul><ul><li>End-systolic volume remains normal, but eventually increases as disease progresses </li></ul></ul>
  18. 23. Signs and symptoms <ul><ul><li>Degree of atrial compliance will determine the clinical manifestations </li></ul></ul><ul><ul><ul><li>Normal or reduced atrial compliance (acute MR) will result in pulmonary vascular congestion and edema </li></ul></ul></ul><ul><ul><ul><li>Increased atrial compliance (chronic MR) will demonstrate signs of decreased cardiac output </li></ul></ul></ul><ul><ul><li>Chronic weakness and fatigue </li></ul></ul><ul><ul><li>“ Blowing pansystolic murmur” best heard at the cardiac apex and often radiating to left axilla </li></ul></ul>
  19. 24. Treatment <ul><ul><li>Medical Tx: digoxin, diuretics and vasodilators </li></ul></ul><ul><ul><li>Surgical valvuloplasty </li></ul></ul><ul><ul><ul><li>Usually reserved for those with moderate to severe symptoms (regurgitant volume 30-60% or >60%, respectively, of SV) </li></ul></ul></ul>
  20. 25. Management <ul><ul><li>HR - maintain or increase; avoid bradycardia which worsens regurgitant flow </li></ul></ul><ul><ul><li>Rhythm - sinus rhythm </li></ul></ul><ul><ul><li>Preload - Maintain or slightly increase ; an elevated preload will cause an increase in regurgitant flow, and low preload causes inadequate cardiac output </li></ul></ul><ul><ul><li>Afterload - Decrease to improve forward cardiac output; avoid sudden increases in SVR </li></ul></ul><ul><ul><li>Contractility - Maintain or increase to decrease left ventricular volume </li></ul></ul><ul><ul><li>**spinal & epidurals well tolerated, but bradycardia must be avoided** </li></ul></ul>
  21. 26. Anesthesia concerns <ul><ul><li>Avoid slow heart rate (ideally 80-100 bpm) </li></ul></ul><ul><ul><li>Avoid increase in afterload </li></ul></ul><ul><ul><li>WATCH IV FLUIDS </li></ul></ul><ul><ul><ul><li>excess fluids will dilate the LV and worsen regurgitation </li></ul></ul></ul><ul><ul><ul><li>Need adequate volume to maintain forward SV </li></ul></ul></ul><ul><ul><li>Preload reduction with vasodilators and diuretics </li></ul></ul><ul><ul><li>Minimize drug-induced myocardial depression </li></ul></ul><ul><ul><li>Spinal and epidural are well tolerated (avoid bradycardia) </li></ul></ul><ul><ul><li>Give prophylactic antibiotics </li></ul></ul>
  22. 27. Anesthetic Considerations <ul><li>Prevent peripheral vasoconstriction </li></ul><ul><li>Avoid myocardial depressants </li></ul><ul><li>Treat acute atrial fibrillation immediately </li></ul><ul><li>Maintain a normal or slightly elevated heart rate </li></ul><ul><li>Monitor PCW pressure or intensity of murmur </li></ul>
  23. 28. Pregnancy Considerations <ul><li>No specific recommendations for the management of mitral regurgitation during labour and delivery. </li></ul><ul><li>Prior to labour symptoms may be managed with diuretics and vasodilators. </li></ul><ul><li>During labour, regional anaesthesia is usually well tolerated. However, in complicated NYHA class 3-4 cases, general anaesthesia may be required. </li></ul>
  24. 29. Mitral Valve Prolapse Anesthetic Considerations <ul><li>Avoid decreases in preload </li></ul><ul><li>Continue antiarrhythmic therapy </li></ul><ul><li>With MVP and moderate to severe mitral insufficiency the same considerations as listed for mitral insufficiency alone apply </li></ul>
  25. 30. Aortic Stenosis <ul><li>Aortic Valve Area </li></ul><ul><li>Normal 2.6 - 3.5 cm2 </li></ul><ul><li>Mild 1.2 – 1.8 cm2 </li></ul><ul><li>Moderate 0.8 – 1.2 cm2 </li></ul><ul><li>Significant 0.6 .0.8 cm2 </li></ul><ul><li>Critical < 0.6 cm2 </li></ul><ul><li>LV-Aortic Gradient </li></ul><ul><li>Mild 12 – 25 mmHg </li></ul><ul><li>Moderate 25 – 40 mmHg </li></ul><ul><li>Significant 40-50 mmHg </li></ul><ul><li>Critical > 50 mmHg </li></ul>
  26. 31. Etiology <ul><li>congenital bicuspid aortic valve (2%). </li></ul><ul><li>Rheumatic heart disease. </li></ul><ul><li>Valve Calcification. </li></ul>
  27. 33. Pathophysiology <ul><li>Obstruction of left ventricular ejection. </li></ul><ul><li>Concentric hypertrophy of left ventricular muscle. </li></ul><ul><li>Decreased compliance of left ventricle making it difficult to fill. </li></ul>
  28. 34. Anesthesia concerns: <ul><ul><li>Maintain normal sinus rhythm, heart rate and intravascular volume </li></ul></ul><ul><ul><ul><li>Optimal heart rate 70-80 bpm </li></ul></ul></ul><ul><ul><li>WATCH OUT FOR VASODILATION </li></ul></ul><ul><ul><li>Treat hypotension with phenylephrine </li></ul></ul><ul><ul><li>Mild to moderate AS may tolerate spinal or epidural (epidural preferred) </li></ul></ul><ul><ul><li>Spinal and epidural contraindicated in severe AS </li></ul></ul><ul><ul><li>High risk of myocardial ischaemia </li></ul></ul>
  29. 35. Peri-operative Care. <ul><li>Symptomatic patients for elective non-cardiac surgery should have aortic valve replacement first as they are at great risk of sudden death perioperatively (untreated severe symptomatic stenosis has a 50% one year survival). </li></ul><ul><li>Asymptomatic patients for major elective surgery associated with marked fluid shifts (thoracic, abdominal, major orthopaedic) with gradients across the valve > 50 mmHg should have valve replacement considered prior to surgery. </li></ul><ul><li>Asymptomatic patients for intermediate or minor surgery generally do well if managed carefully. </li></ul>
  30. 36. Haemodynamic goals <ul><li>(Low) normal heart rate </li></ul><ul><li>Maintain sinus rhythm </li></ul><ul><li>Adequate volume loading </li></ul><ul><li>High normal systemic vascular resistance </li></ul><ul><li>(Phenylepherine / Metarminol) </li></ul><ul><li>Effective analgesia. </li></ul>
  31. 37. Postoperative Management <ul><li>Have a low threshold for admission to ICU / HDU </li></ul><ul><li>Meticulous attention must be paid to fluid balance and post operative pain management </li></ul><ul><li>Infusions of vasoconstrictors may be required to maintain haemodynamic stability </li></ul>
  32. 38. Pregnancy considerations <ul><ul><li>Caesarean section: </li></ul></ul><ul><ul><li>General anaesthesia with the aid of invasive haemodynamic monitoring. Aggressive maintenance of systemic blood pressure with vasopressors (e.g. phenylephrine). </li></ul></ul><ul><li>Spinal anaesthesia is generally contraindicated. </li></ul><ul><li>There are reports of the successful management of </li></ul><ul><li>vaginal delivery under carefully introduced and limited </li></ul><ul><li>epidural analgesia, but this should be restricted to very </li></ul><ul><li>experienced hands. </li></ul>
  33. 39. Aortic regurgitation <ul><li>Etiology: </li></ul><ul><li>Rheumatic heart disease. </li></ul><ul><li>Endocarditis. </li></ul><ul><li>Aortic dissection </li></ul><ul><li>Connective tissue disorders </li></ul>
  34. 40. Management <ul><li>HR - Avoid sudden decreases; an increase (10-15 beats) causes shortening of diastolic phase which decreases the regurgitant fraction and increases cardiac output </li></ul><ul><ul><li>Rhythm - sinus rhythm preferred </li></ul></ul><ul><ul><li>Preload - increase to maximize forward cardiac output and maintain blood pressure </li></ul></ul><ul><ul><li>Afterload - decrease afterload to favor forward cardiac output (keep moving forward); avoid sudden increase in afterload </li></ul></ul><ul><ul><li>Contractility - maintain </li></ul></ul><ul><ul><li>** most patients tolerate spinal or epidural provided intravascular volume is maintained </li></ul></ul>
  35. 41. Treatment <ul><ul><li>Once symptomatic, death can occur within 5 years unless lesion is surgically repaired </li></ul></ul><ul><ul><li>Digitalis, diuretics and afterload reduction (ACE inhibitors) for chronic (eventual surgical repair) </li></ul></ul><ul><ul><li>Inotropes (dopamine, dobutamine) and vasodilator for severe, chronic aortic regurgitation (requires surgery) </li></ul></ul>
  36. 42. Anesthetic considerations <ul><ul><li>Maintain normal heart rate </li></ul></ul><ul><ul><ul><li>Increased frequency of conduction abnormalities, consider pacing </li></ul></ul></ul><ul><ul><li>Keep SVR low </li></ul></ul><ul><ul><li>Avoid myocardial depression </li></ul></ul><ul><li>Maintain or slightly increase preload </li></ul><ul><ul><li>Give prophylactic antibiotics </li></ul></ul><ul><ul><li>Most patients will tolerate spinal or epidural, provided intravascular volume is maintained </li></ul></ul>
  37. 43. Peri-operative Care <ul><li>Asymptomatic Patients- tolerate surgery well. </li></ul><ul><li>Patients with low functional capacity- Consider valve replacement surgery first. </li></ul><ul><li>Haemodynamic goals </li></ul><ul><li>High normal heart rate – around 90 bpm </li></ul><ul><li>Adequate volume loading </li></ul><ul><li>Low systemic vascular resistance </li></ul><ul><li>Maintain contractility </li></ul><ul><li>Spinal/Epidural well tolerated. </li></ul>
  38. 44. Pregnancy considerations <ul><li>During labour, epidural analgesia improves forward flow, and is therefore the anaesthetic of choice in patient’s requiring an operative delivery. </li></ul>
  39. 45. Pulmonary Stenosis <ul><ul><li>Haemodynamic management: Maintain right ventricular preload, left ventricular afterload and right ventricular contractility. </li></ul></ul><ul><ul><li>Avoid hypothermia, hypercarbia, acidosis, </li></ul></ul><ul><ul><li>hypoxia and high ventilatory pressures. </li></ul></ul><ul><ul><li>Spinal anaesthesia may be associated with an uncontrolled reduction in right ventricular preload and should therefore be avoided in severe cases. </li></ul></ul>
  40. 46. Pregnancy Considerations <ul><li>Spinal anaesthesia may be associated with an uncontrolled reduction in right ventricular preload and should therefore be avoided in severe cases. </li></ul>
  41. 47. Endocarditis prophylaxis <ul><li>Consider prophylaxis for all patients with valvular lesions. </li></ul><ul><li>Three main questions: </li></ul><ul><li>Which patients have a high risk? </li></ul><ul><li>Which procedures cause &quot;significant&quot; </li></ul><ul><li>bacteraemia? </li></ul><ul><li>Which antibiotics are active against </li></ul><ul><li>these bacteria? </li></ul>
  42. 48. Prophylaxis for valvular heart disease. <ul><li>Prophylaxis against infective endocarditis is recommended for the following patients: </li></ul><ul><li>Patients with prosthetic heart valves and patients with a history of infective endocarditis. (Level of Evidence: C) </li></ul><ul><li>Patients with congenital cardiac valve malformations, particularly those with bicuspid aortic valves, and patients with acquired valvular dysfunction (e.g., rheumatic heart disease). (Level of Evidence: C) </li></ul><ul><li>Patients who have undergone valve repair. (Level of Evidence: C) </li></ul><ul><li>Patients who have hypertrophic cardiomyopathy when there is latent or resting obstruction. (Level of Evidence:C) </li></ul><ul><li>Patients with MV prolapse (MVP) and auscultatory evidence of valvular regurgitation and/or thickened leaflets on echocardiography.* (Level of Evidence: C) </li></ul>
  43. 49. No prophylaxis required <ul><li>Prophylaxis against infective endocarditis is not recommended for the following patients: </li></ul><ul><li>Patients with MVP without MR or thickened leaflets on echocardiography.* (Level of Evidence: C) </li></ul><ul><li>Patients with physiological, functional, or innocent heart murmurs, including patients with aortic valve sclerosis as defined by focal areas of increased echogenicity and thickening of the leaflets without restriction of motion and a peak velocity less than 2.0 m per second. (Level of Evidence: C) </li></ul><ul><li>Patients with echocardiographic evidence of physiologic MR in the absence of a murmur and with structurally normal valves. (Level of Evidence: C) </li></ul><ul><li>Patients with echocardiographic evidence of physiological tricuspid regurgitation (TR) and/or pulmonary regurgitation in the absence of a murmur and with structurally normal valves. (Level of Evidence: C) </li></ul>
  44. 50. <ul><li>Prophylaxis recommended Prophylaxis not recommended </li></ul><ul><li>Dental procedures </li></ul><ul><li>with mucosal bleeding without mucosal bleeding </li></ul><ul><li>Respiratory tract </li></ul><ul><li>tonsillectomy / adenoidectomy intubation of the trachea </li></ul><ul><li>flexible bronchoscopy </li></ul><ul><li>Gastrointestinal tract </li></ul><ul><li>procedures damaging the intestinal mucosa endoscopy </li></ul><ul><li>surgery or endoscopy of the biliary tract </li></ul><ul><li>sclerotherapy of oesophageal varices </li></ul><ul><li>Urogenital tract </li></ul><ul><li>surgery of the prostate hysterectomy* </li></ul><ul><li>cystoscopy vaginal delivery*, Caesarean section </li></ul><ul><li>dilatation of the urethra bladder catheterization (in the </li></ul><ul><li>absence of infection) </li></ul><ul><li>* consider prophylaxis in high risk </li></ul><ul><li>patients </li></ul>
  45. 51. Antibiotic regimens <ul><li>1. Dental, Oral, Respiratory Tract, or Oesophageal Procedure </li></ul><ul><li>Standard: Amoxicillin 2.0 g (child: 50 mg/kg) per os 1 h preoperatively </li></ul><ul><li>Ampicillin 2.0 g (child 50 mg/kg) iv 30 min preoperatively </li></ul><ul><li>* Alternative: Clindamycin 600 mg (child 20 mg/kg) per os </li></ul><ul><li>or Cefalexin per os or Cefazolin iv or Erythromycin per os </li></ul><ul><li>2. Gastrointestinal or Genitourinary Procedure </li></ul><ul><li>High-risk patient: </li></ul><ul><li>Standard: Ampicillin + Gentamicin (2.0 g + 1.5 mg/kg) iv, </li></ul><ul><li>after 6 h, Ampicillin 1.0 g iv or Amoxicillin 1.0 g per os </li></ul><ul><li>* Alternative: Vancomycin + Gentamicin (1.0 g+ 1.5 mg/kg, </li></ul><ul><li>infuse over 1-2 h directly preoperatively, child: 20 mg/kg + 1.5 mg/kg) </li></ul><ul><li>Moderate-risk patient: </li></ul><ul><li>Standard: Amoxicillin per os or Ampicillin iv </li></ul><ul><li>* Alternative: Vancomycin (1.0 g) iv infuse over 1-2 h directly preoperatively </li></ul>
  46. 52. <ul><li>Anaesthesia for a patient with valvular heart disease can be challenging. </li></ul><ul><li>The aim of anaesthesia is to keep the diseased heart within its &quot;optimal working conditions&quot; </li></ul>