This document discusses the anaesthetic management of closed mitral valvotomy. It begins with the anatomy and pathophysiology of mitral stenosis. It then discusses the indications for closed mitral valvotomy and the pre-anaesthetic assessment. The key aspects of anaesthetic management are maintaining haemodynamic stability, avoiding tachycardia and hypotension, and careful fluid management. Etomidate is recommended for induction due to hemodynamic stability. Post-operatively, risks of pulmonary edema and right heart failure must be assessed and managed.

1. DR ZIKRULLAH
ANAESTHESIA FOR CLOSED
MITRAL VALVOTOMY

2. HEADINGS
 Anatomy of Mitral valve
 Pathophysiology of Mitral
Stenosis.
 Indications for Closed
Mitral Valvotomy
 Preanaesthetic assessment
 Anaesthetic management

3. ANATOMY
 Two leaflets – Anterior
and Posterior.
 Surrounded by Mitral
valve annulus.
 Anterior cusp takes up
larger part of the ring but
Posterior leaflet has
larger surface area.
 Normal Orifice = 4-6
cm2.

4.  Normal Orifice = 4-6 cm2.
 Mild MS = >1.5 cm2
 Moderate MS = 1-1.5 cm2
 Severe MS = <1.5 cm2

5.  Mitral Valve area is calculated using Gorlin’s Equation:
Area = Cardiac Output/ (DFP or SEP) (HR)
44.3 C √ΔP
DFP = Diastolic Filling Pressure
C = Empirical Constant
SEP = Systolic Ejection Period
ΔP = Pressure Gradient
HR = Heart Rate

6. PATHOPHYSIOLOGY

8.  Decreased filling ultimately manifests as :
1. Muscle atrophy
2. Inflammatory myocardial fibrosis
3. Scarring of sub valvular apparatus
4. Abnormal pattern of left ventricle contraction
5. Decreased left ventricular compliance with diastolic
dysfunction
6. Right to left shift due to pulmonary hypertension

9. USUAL SURGERIES
 Closed mitral valvotomy
 Mitral commissurotomy
 Percutaneous balloon dilatation
 Mitral valve replacement
 Non cardiac surgery – most common LSCS

10. INDICATIONS
 Indications for Closed Mitral Valvotomy –
 1) Single valve lesion.
 2) Sinus Rhythm
 3) No Calcification.

11.  Performed through an incision in the left atrial
appendage using a purse string technique to prevent
blood loss or air embolism.
 Tubbs dilator is passed into the left ventricle via the
apex and then opened within the orifice of the valve.

12. Preanaesthetic assessment
 Assessment of
1. Severity of cardiac disease
2. Degree of impaired myocardial contractility
3. Presence of associated major organ disease (hepatic, renal
& pulmonary)
4. Compensatory mechanisms for maintaining cardiac output
(↑sympathetic activity, cardiac hypertrophy)
5. Prosthetic heart valves
6. Drug therapy

13. History
 Cough & dyspnoea: precipitating factors; exertion,
excitement, fever, severe anaemia, pregnancy,
thyrotoxicosis.
 Orthopnoea & Paroxysmal Nocturnal Dyspnea
 Exercise tolerance
 Pedal edema

14.  Heamoptysis
 Features of emboli: e.g. pulm infections, neurological
symptoms.
 Chest pain:10% patients have anginal type chest pain
not attributable to CAD.
 History suggestive of RVF
 Raised JVP
 Hepatic congestion
 Edema

15.  Drug history:
Digoxin, Diuretics, Calcium blockers,
anti coagulants, β-blockers
 Hoarseness of voice – Enlarged left atrium,
tracheobronchial enlarged lymph nodes, dilated
pulmonary artery may all compress Recurrent
Laryngeal Nerve.
 Dysphagia

16.  Grading as per NYHA classification of functional
disability:
 Class I: No symptoms
 Class II: Symptoms with ordinary activity
 Class III: Symptoms with less than ordinary activity
 Class IV: Symptoms at rest.

17. PHYSICAL EXAMINATION
• Low volume pulse
• Sign & Symptoms of right sided heart
failure - engorged neck veins, enlarged
tender liver, pedal edema
• Atrial fibrillation: irregular pulse and loss
of 'a' wave in jugular venous pressure

18. • Left parasternal heave:
Presence of right ventricular hypertrophy
due to pulmonary hypertension
• Tapping apex beat which is not displaced

19. Mitral Facies
 Pink purple patches
on the cheeks.
 cyanotic skin
changes from low
cardiac output.
 Usually seen in
severe MS.

20. ON AUSCULTATION
 Opening snap
 Rumbling diastolic murmur best heard at apex radiating
to the axilla
 Loud P2 component of S2: pulmonary hypertension
 Severity: distance between OS & aortic component of S2
 Closer OS to S2 more severe the stenosis
 Calcification of valve: OS disappears

21. LABORATORY INVESTIGATIONS
 Routine investigations like Hb, TLC, DLC, RFT etc.
 L.F.T. for assessing hepatic dysfunction d/t RVF
 A.B.G.-- severe pulmonary symptoms
 Serum Electrolytes
 Coagulation profile
 Chest X-ray- straightening of left heart border,
cardiomegaly, double shadow
 ECG- P mitrale (LAH),Right axis deviation, RVH, AF
 Echocardiography (TEE)

22.  An enlarged left atrium
(white arrow) which is
also seen to be elevating
the left main bronchus
(blue arrow). The blood
vessels at the apex are at
least as large as those at
the base in this upright
chest indicating
cephalization and
elevated pulmonary
venous pressure(white
circle)

24. Echocardiography
 In most cases, the diagnosis of mitral stenosis is
most easily made by echocardiography, which shows
decreased opening of the mitral valve leaflets, and
blunted flow of blood in early diastole.
 The trans-mitral gradient as measured by doppler
echocardiography is the gold standard in the
evaluation of the severity of mitral stenosis.

25. Severity of mitral stenosis (Echo)

26. Anaesthetic Management
 Avoid Tachycardia :
 Prevent decrease in
cardiac output, as
hypotension because of
this causes reflex
tachycardia, which in turn
reduces ventricular filling
further compromising
cardiac output.

27.  Avoid Hypotension.
 Avoid factors precipitating CHF.
 Avoid precipitation of Right Ventricular Failure
Hypercarbia
Hypoxemia
Lung Hyperinflation
Increase in lung water

28. PRE MEDICATION
 Narcotics, benzodiazepine -- To decrease anxiety & any
associated likelihood of adverse circulatory responses
produced by tachycardia
 Anticholinergics- avoided as they increase heart rate
 Diuretics- Evaluate fluid status ,
Check electrolytes on day of surgery ,
Withhold on night before surgery if massive fluid shifts
expected in surgery.

29.  Drugs to control AF ( Digoxin, beta blockers, CCB) –
Continue in perioperative period
 Watch serum potassium- in patients receiving digoxin
and diuretics
 Current ACC/AHA guidelines do not recommend
endocarditis antibiotic prophylaxis for patients with
isolated mitral stenosis undergoing surgical procedures.

30. ANTICOAGULANT THERAPY
 Management of Patients on warfarin
 Emergency surgery
Discontinue warfarin
Give vitamin K 0.5 – 2.0 mg IV
FFP 15 ml/kg repeat if necessary
Accept for surgery if INR <1.5
 Elective surgery
Stop 3 days preoperatively
monitor INR daily
Give heparin when INR <1.5

31. Stop heparin 6 hours prior to surgery
Check INR
Accept for surgery if INR <1.5
Restart heparin post-operatively as soon as
possible

32. Management of Patients on Heparin
 Emergency surgery
 Consider reversal with IV protamine 1 mg
for every 100 IU of heparin
 Elective Surgery
 Stop heparin 6 hours prior to surgery
 Check INR, accept for surgery if INR <1.5
 Restart heparin in post-op as soon as
possible
If patient is on LMWH, we rarely need to stop
it.

33. Induction of Anaesthesia
 No ideal general anesthetic
 An opioid is a better choice than a volatile agent for
induction. Because volatile agent can produce
undesirable vasodilatation, or precipitate
junctional rhythm with loss of effective atrial kick.
 Etomidate best for hemodynamic stabilty

34. 1. Avoid Ketamine – Increases heart rate, blood
pressure
2. Avoid Atracurium – Increased histamine release
causes hypotension which manifests as
tachycardia.

35.  Maintenance of Anaesthesia
1. Drugs should have minimal effects on hemodynamic pattern
2. Balanced anaesthesia with N2O/ Narcotic/ Volatile anaesthetic
3. N2O causes insignificant pulmonary vasoconstriction. It is
significant only if pulmonary hypertension exists. So, one needs
to treat pulmonary hypertension preoperatively.
4. Cardiac stable muscle relaxants are to be used. (preferably
avoid Pancuronium)
5. Avoid lighter planes of anaesthesia (To avoid tachycardia)

36.  Fluid Management:
1) Avoid Hypervolemia --> Worsens pulmonary edema.
2) Avoid Hypovolemia --> Sacrifices already
decreased left ventricular filling, which further
decreases Cardiac output. Hypovolemia secondary to
blood loss and vasodilatory effects of anaesthesia
ought to be avoided.

37.  Monitoring
1. Transesophageal Echocardiography
2. Intra-arterial pressure
3. Pulmonary artery pressure to be monitored
4. Left atrial pressure
 A word of caution regarding Pulmonary artery pressure
monitoring: -
When measured too frequently, the risk of pulmonary
artery rupture is far too high.

38.  Post Operative
1. Assess postoperative risk of pulmonary oedema and right
heart failure and manage accordingly.
2. Avoid pain as pain begets hypoventilation which leads to
respiratory acidosis, hypoxemia which manifests as raised
heart rate and pulmonary vascular resistance.

39. CONCLUSION
 Etomidate best for haemodynamic stability.
 Avoid ketamine and Atracurium.
 Avoid Tachycardia.
 Avoid hyper/hypovolemia
 Take good care of post op pain.

40.  THANK YOU