The document discusses mitral stenosis, including its pathophysiology, causes, and implications for treatment and anesthesia in various surgical contexts. It covers the examination findings, diagnostic criteria, grading, clinical management strategies, and surgical options available for patients with this condition. Key emphases include the importance of maintaining diastolic filling, rhythm control, and addressing complications such as atrial fibrillation and pulmonary hypertension.

1. Mitral Stenosis
Dr Anuradha Dayananda Kamath
Department of Anaesthesiology

2. Outline
• Mitral stenosis : Pathophysiology
• Treatment options
• Anaesthesia implications in Non- cardiac surgery
• MS in pregnancy

3. Normal mitral valve is Bicuspid, Saddle Shaped
Normal mitral valve area : 4-6 cm2

4. • Malignant carcinoid disease
• Systemic lupus erythematosus
• Rheumatoid arthritis
• Mucopolysaccharidoses of the
Hunter-Hurler phenotype
• Fabry disease
• Whipple disease
• Methysergide therapy
• Post radiation therapy
• Congenital mitral stenosis
• Rheumatic Heart Disease
Causes of Mitral Stenosis

5. Do not directly involve the MV apparatus but may limit LV inflow and
simulate the clinical findings of MS
• Mitral annular calcification
• infective endocarditis with large vegetation
• Left atrial myxoma,
• Ball valve thrombus
• Cor triatriatum.
• Large LA masses
• Pulmonary vein obstruction
Causes of Mitral Stenosis

9. RV dysfunction
RV Failure
LV Function is normal
Fixed Cardiac Output
state

10. Ventricular dysfunction – LV uncommon, RV common
• Left ventricle generally normal
Causes of LV dysfunction:
• Rheumatic myocarditis
• Subvalvar apparatus
• Abnormal left –right interaction due to RV
dysfunction…PHT
• Chronic atrial fibrillation causing LV
dysfunction
• Post MVR, LV preload increases
suddenly
• V rare : Dilated Pulmonary Artery (PA)
compressing the circumflex artery
• Low-flow , low-gradient MS has
been described.
• Similar to low-gradient AS, low-flow, low-
gradient MS describes a situation in
which MVA is < 1.5 cm2 together with a
MV mean diastolic gradient < 10 mm
Hg and transmitral flow < 35
mL/m2.
• Patients with low-flow, low-gradient MS
are typically older, have more comorbidities,
and have worse outcome following valve
intervention

12. Stages of Progression : ACC/AHA Grading of Valvular heart disease

13. MS : General examination
• Generally thin built, edema if RV failure
• “Mitral facies” : pinkish-purple patches on the cheeks: indicate
chronic severe mitral stenosis leading to reduced cardiac output and
vasoconstriction
• Sinus : low volume pulse
• Atrial fibrillation : irregularly irregular
• Jugular vein distension: JVP Raised
• Prominent a wave : Increased RAP : Pulmonary HT, RV Failure
• Prominent v wave : Tricuspid regurgitation.
• Rhythm is important : SR v/s AF: Latter no “a” wave in JVP!!

14. Palpatory findings in MS – “Look for” PAH
• Apical impulse : Tapping : laterally displaced or not palpable :
severe MS : explained by decreased LV filling
( hypofilling LV )
• Diastolic thrill : at the apex with the patient in the left
lateral recumbent position
• Patient with pulmonary HT : prominent precordial pulsations
 Look for pedal edema, Hepatic systolic pulsation,
enlargement
 RV lift is palpable : The “parasternal heave ” of PAH
 Palpable P2 : 2nd left intercostal space

15. Auscultatory Findings • Loud S1
• Split S2, Prominent P2 due to
PHT
• Opening Snap
• Diastolic Rumble
Pansystolic murmur of TR and an
RVS3 originating from the RV may be
audible in the 4th left intercostal
space in the patient with right ventricular
dilatation ( DO NOT MISTAKE FOR MR)
• Others: ( rare)
• High-pitched decrescendo diastolic murmur
secondary to PR (Graham Steell murmur)
may be audible at the upper sternal border.

16. • Due to widely spaced Mitral leaflets –
supposed to float up in diastole
• As LAP already high, the leaflets are
wide open instead of semi-closed
at end diastole due to high
trans-mitral gradient
• Loudest at Apex, left lateral position
Indicates:
Valve is pliable , not thickened and calcified –
BMV may be planned
When valve is stiffer, muffled
With AFIB, Intensity may vary with louder
short cycles
May reduce with LV dysfunction
Loud S1

17. Opening Snap and Murmur
• Diagnostic of MS – A2 OS gap if possible auscultate - severity
• Heard when the movement of the mitral leaflets doming into LV suddenly stops :
sudden tensing of the valve leaflets and subvalvar apparatus after the cusps
has complete their opening in early diastole
• Crisp OS amenable to balloon valvotomy , yields good outcomes
• Corelates with better Wilkins score on ECHO
• Absent OS – Calcific MS
Mild to mod MS : Short early diastolic murmur presystolic accentuation
Longer the diastolic murmur ,more severe is the MS …Intensity is LESS
IMPORTANT

18. Investigations for Mitral stenosis
• CHEST XRAY
• ECG
• ECHO …mostly suffice for diagnosis and working plan
• CARDIAC CATH, EXERCISE ECHO -?
• For MIMICS, rarely CT may be required -??

19. CXR in Mitral stenosis
• Straightening of the left heart border:
• Obliteration of the pulmonary bay
(concavity is lost due to pulmonary HTN
• LA appendage enlarged
• RV enlargement
• Double atrial shadow :
LAE Pulm venous HTN
changes
• Backpressure changes
• Inverted Moustache
• Interstitial edema : Kerley
B lines

21. P wave changes suggest left atrial enlargement : P mitrale
Right axis deviation and right ventricular hypertrophy suggests severe pulmonary hypertension
atrial arrhythmias such as Atrial fibrillation.

22. ECHO in Mitral Stenosis
• Etiology
• Morphology,
• Severity
• Complications
• Associated other valve lesions
• Treatment intervention

23. • Main diagnostic feature in the parasternal long axis
view the anterior mitral leaflet (AMVL) shows diastolic
doming or hockey-stick shape: reduced mobility of the
valve tips compared to the base of the leaflets
• Posterior mitral leaflet (PMVL) has restricted motion
or is totally immobile
• Hallmark of MS is commissural fusion, LAA
enlargement
ECHO : Transthoracic TTE : Diagnosis of
MS

24. MV Area:
1. Planimetry
2. Pressure half time
3. MVA continuity
equation

25. MS severity :
1. Transvalvular pressure gradient
2. PHT Pressure half time : time required
for LA and LV pressure to equalise,
more severe MS : Longer PHT
3. Pulm HT Grading: TR JET : RVSP : RT
ventricular systolic pressure + CVP

26. Lt Atrial enlargement:
1. Thrombus
2. LA size and volume
3. spontaneous echo contrast : swirling of blood
Other valve involvement
Effusions

27. Mild Moderate Severe
MVA cm2 1.5-2 1-1.5 <1
PA systolic pressure
mm Hg
<30 30-50 >50
Mean valve gradient
mm Hg
<5 5-10 >10
Mild Moderate severe
Pressure Half time
msec
<150 150-220 >220
LA size mm <45 45-60 >60
Deceleration Time
msec
<517 517-759 >759
Spontaneous Echo
contrast
absent Usually
present
Always
present
Mitral stenosis grading : ECHO Criteria

28. Cardiac Catheterisation, Exercise TMT, ECHO
• Not routinely done in MS (Class I, LOE C)
Indications :
• Discrepancy between non invasive tests
and clinical features
• Non invasive tests are inconclusive
• Calculation of MVA using Gorlin’s
Equation
Exercise testing : test mean gradient
across Mitral valve post exertion
• Discrepancy between non invasive tests
and clinical features
• Non invasive tests are inconclusive

29. Basics of Treating MS

30. Medical management
• Improving symptoms : Reduce congestion: Diuretics Frusemide,
Spironolactone……………monitor K levels
• Infective endocarditis prophylaxis
• Decrease thromboembolism
• Decreasing recurrence of rheumatic fever : prophylaxis
Decreasing Acute Rheumtic Fever in community in a Larger
goal Treatment of GAS ( Gr A Streptococci ) associated sore
throat

31. Rheumatic Fever Prophylaxis

32. All doses shown below are administered once as a
single dose 30-60 min before the procedure:
• Standard general prophylaxis: Amoxicillin 2 g PO
• Unable to take oral medication: Ampicillin 2 g IV/IM
or cefazolin/ceftriaxone 1 g IM or IV
• Allergic to penicillin: Cephalexin 2 g PO or other
first- or second-generation oral cephalosporin in
equivalent dose (do not use cephalosporins in
patients with a history of immediate-type
hypersensitivity penicillin allergy, such as urticaria,
angioedema, anaphylaxis)
• Allergic to penicillin: Azithromycin or
clarithromycin: 500 mg PO
• Allergic to penicillin: Doxycycline 100
mg
• Allergic to penicillin and unable to take oral
medication: Cefazolin or ceftriaxone (do not use
cephalosporins in patients with a history of
immediate-type hypersensitivity penicillin allergy,
such as urticaria, angioedema, anaphylaxis): 1 g
IV/IM
INFECTIVE ENDOCARDITIS PROPHYLAXIS

33. • MS is a FIXED CARDIAC OP state
• LV filling is limited
• Heart Rate : Target…….?
• Is Tachycardia better ?.....NO !! Diastolic filling time less…COP
falls
WHY RATE CONTROL IS
ESSENTIAL ?

34. Phases of Diastole
• Isovolumic relaxation
• Rapid filling 60 -70%
filling
• Diastasis
• Atrial kick 20 – 30%
filling
• During tachycardia :
compromises duration of
Diastasis and rapid filling
phases
• In MS : Further increase in
LA Volume and Pressure
during tachycardia……
Pulmonary edema

35. Heart Rate : AVOID TACHYCARDIA
Target rate : 60 – 80/min
Maintain sinus rhythm :
MS : Atrial kick  LV filling since passive LV filling reduced by stenotic valve
Maintain Atrial contribution to LV filling – RHYTHM strategy
Atrial Fibrillation: Control ventricular rate : 60 – 80/min at rest – RATE strategy
(moderate exercise : 90-110/min)
MITRAL STENOSIS IS A FIXED CARDIAC OUTPUT
STATE

36. Atrial Fibrillation :
• Aim : to revert to sinus rhythm allowing LA contraction contribute LV filling
• r/o LA clot prior : TEE
• Hemodynamic unstable/New onset (24 hrs) : Cardioversion
• Elective : If stable
Techniques:
• Chemical cardioversion: I.V Ibutilide, Amiodarone
• Electrical Cardioversion

37. Cardioversion
Start with Lower energy : 50J
escalate..100…150..200…360

38. • Difficult to achieve rhythm control in patients with rheumatic MS
because the rheumatic process itself may lead to progressive fibrosis
and enlargement of the atria, fibrosis of the internodal and interatrial
tracts, and damage to the sinoatrial node
Cardioversion fails to revert NSR: Ventricular rate control
• ß blockers : Metoprolol, Atenolol
• Calcium Channel blockers: Diltiazem, Verapamil
• Digoxin : Na K ATPase inhibitor: increases intracellular Ca : increase
vagal tone

40. Anticoagulation
Mitral stenosis Class I indication:
• Persistent or paroxysmal Atrial fibrillation
• Presence of left atrial thrombus
• Previous embolic event
Antiplatelets not approved/ adequate
Only Vit K antagonist recommended :
Warfarin
MOA: Vit k epoxide reductase inhibitor
Vit k dependent factors : II,VII,IX,X
Protein C and S
Target INR : 2-3
DOACs only for aortic valve affliction,
not MS

41. Surgical options vs Percutaneous
1. CMC : Closed Mitral
Commisurotomy
2. OMC : Open Mitral
Commisurotomy
• Valve repair •
Percutaneous
• Valve Replacement
1. Open cardiac surgery
Bioprosthetic
Mechanical
1. Percutaneous Balloon Mitral
Valvotomy
2. Percutaneous Mitral valve
replacement

42. Procedure :
• Transvenous approach : Femoral Vein : 7Fr sheath
• (rarely transarterial FA>>>Aorta>>LV>>MV : Avoids
ASD)
• Fluoroscopic Guidance
• Guidewire FV>>> IVC.>>RA
• Mullen’s Sheath fed over the wire RA
• Thru sheath is passed Brockenbrough needle for
transeptal puncture (creating ASD)
• LA pressure is measured
• Needle and sheath removed, wire kept in LA
• Dilatation of septum
• Inoue Balloon : nylon and rubber micromesh,
pressure extensible
• Size calculation : Vernier Calliper
• (Patient height in cms/10) + 10
• Distal portion of Balloon is pulled back to oppose
the valve
• Proximal portion then inflated to engage the valve
• Middle portion inflated : split the commissures and
open the valve

43. Percutaneous Balloon Mitral Valvotomy
Indications:
• Symptomatic Severe MS (MVA <1.5cm2)
• Asymptomatic Severe MS (MVA <1.5cm2)
PASP> 50mm Hg
New onset atrial fibrillation
High risk for surgery
• Mild/ Mod MS (MVA> 1.5cm2) but
symptomatic
PCWP >25 mm Hg
Mean Gradient across Valve>
15mm Hg
Prerequisites
Favourable Valve morphology
In the absence of LA thrombus
Mitral Regurgitation MR<2

44. S T M C
• Sub-valvar thickening
• Thickening of the leaflets
• Mobility
• Calcification
• Prior TEE : R/O LA
thrombus Score:
• < 8 : predicts Excellent long
term results
• 9 -12 : intermediate
• >12: poor results
WILKINS
SCORE

45. • Contraindications:
• Presence of LA thrombus
• Moderate to severe MR
• Other lesions requiring surgery :
CAD : CABG + VALVE can be
done
• Severe Aortic valve or Tricuspid
valve disease
• Unfavourable valve anatomy:
Wilkins’ Score
• Absence of commissural fusion
• Severe bicommisssural
calcification higher MR

46. Percutaneous Balloon Mitral Valvoplasty
• Complications :
• Acute Mitral regurgitation :
 leaflet perforation or tearing, excessive commissurotomy, sub
chordal damage
Severe : sudden increase in LA pressure  Pulm Edema Emerg
MVR 
 Blood crossmatch to be ready
• ASD creation: closes within few weeks
• Cardiac Tamponade
• TIA : Micro embolization

47. Surgical options
Valve replacement
• Mechanical : lifelong anticoagulation
• Bioprosthetic Valve :
older patients (> 65 yrs),
women planning to complete family
 avoid anticoagulation
Valve Repair
• Closed Mitral Commissurotomy : less common
• Open Mitral Commisurotomy

48. Technique 1: Finger fracture technique, with the
finger introduced via the left atrium
Technique 1 : Tubb's dilator, which is introduced via
the apex of the left ventricle and guided to the mitral
orifice via the operator's finger, which is introduced
via the left atrium
Closed Mitral Commisurotomy

49. Closed Mitral Commisurotomy
• Off –Pump : advantage
• Disadvantages:
• Relatively blind procedure
• Sub-valvar disease not corrected
• Significant MR
• General Anaesthesia

50. Open mitral commisurotomy
• Requires CPB and General
Anaesthesia
• Valve can be spared
• Avoids prosthetic valve
• Avoids risk of coagulation

51. CARDIAC OUTPUT = HR X STROKE VOLUME
PRELOAD
STROKE VOLUME
MYOCARDIAL
CONTRACTILTY AFTERLOAD
Mitral Stenosis: Hemodynamic Goals

52. Heart Rate : AVOID TACHYCARDIA
Target rate : 60 – 80/min
Maintain sinus rhythm :
MS : atrial kick contributes more to LV filling since passive lv filling reduced
by stenotic valve
Maintain Atrial contribution to LV filling
Atrial Fibrillation: Control ventricular rate : 60 – 80/min at rest
(moderate exercise : 90-110/min)
MITRAL STENOSIS IS A FIXED CARDIAC OUTPUT
STATE

53. Maintain Preload Don’t Overload
MITRAL STENOSIS : Hemodynamic Goals : Preload
Increased LA pressure to
overcome the stenotic
MV and fill the LV
Sudden increase in
central blood volume :
PULMONARY EDEMA
• Trendelenburg position
• Rapid fluid boluses
• Straining during Labour

54. • LV : Generally Normal
• RV Dysfunction is the problem
• Afterload to RV : PVR (Pulmonary Vascular Resistance)
• Avoid increase in PVR :
1. Hypoxia
2. Hypercarbia
3. Acidosis,
4. Light plane of anaesthesia
5. Pain
6. Maintain lung volume at FRC : Avoid atelectasis and hyperinflation
MITRAL STENOSIS : Hemodynamic Goals : Myocardium

55. • RV inodilators : (iv) : increase contractility and reduce afterload
• Dobutamine( 5mcg/kg/min)
• Milrinone(0.375 - 0.75 mcg/kg/min)
• Levosimendan (0.1 – 0.2 mcg/kg/min)
• Combined with Vasopressors : Maintain SVR : Coronary Perfusion
Pressure
• Noradrenaline : 0.05 mcg/kg/min
• Vasopressin : 0.0003 to 0.003U/kg/min
MITRAL STENOSIS : Hemodynamic Goals : Myocardium

56. MITRAL STENOSIS : Hemodynamic Goals : Myocardium
Pulmonary Vasodilators :
• Inhaled : NO(Nitric Oxide 20 to 40
ppm)
• Inhaled Iloprost : Prostacyclin
• Inhaled Milrinone
• Inhaled NTG
• Iv Sildenafil 1 – 2 mcg/kg/min
• I.V NTG
Pulmonary
Vasodilators caution
in Pulmonary Venous
Hypertension

57. • Afterload to LV : Systemic Vascular Resistance : SVR
• MS : Fixed output from LV :
SVR…..?
MITRAL STENOSIS : Hemodynamic Goals : Afterload

58. Maintain SVR
• If SVR drops : tachycardia: further decrease LV filling
• Rationale : limited tap volume : stiff pipes : maintains distal
perfusion
MITRAL STENOSIS : Hemodynamic Goals : Afterload

59. Case
Scenarios:
25 yr old Female patient with Mitral Stenosis coming for :
• Lap Cholecystectomy
• Lap Appendicectomy
• Lap Ovarian Cystectomy
• Intracranial Bleed: SDH evacuation
• Ruptured Ectopic Pregnancy
• Normal Pregnancy

61. • Suprainguinal Vascular
• Thoracic
• Transplant
• neurosurgery
High risk
• General
• otolaryngology,
• genitourinary,
• orthopedic surgery
Intermedi
ate Risk
• endocrine
• breast
• gynecology
• obstetrics
Low risk
• Patient comorbidities : The
risk associated with anesthesia
in patients with comorbid
disease may not be completely
captured when solely
considering surgery type.
• Changes in surgical approach
can reduce the risk of MACE in
some surgeries.
• The timing of surgery
emergency surgeries : higher
risk
NCS can be classified by the risk of major adverse cardiac and cerebral event
(MACCE)

62. ACC/AHA 2024 Surgery classified based on Timing and Risk Category

64. • Patients with moderate to severe MS are at increased risk of
perioperative adverse cardiovascular events.
• There is a paucity of data guiding the management of patients
with MS undergoing NCS, and much has been extrapolated from
pregnancy literature
• Patients with MS who meet criteria for MV intervention should
receive treatment before elective NCS
• Criteria for MV intervention include patients
• severe symptomatic rheumatic MS who are (NYHA class ≥II)
• asymptomatic with PA systolic pressure >50 mm Hg

65. • In cases where MV intervention cannot be performed before surgery
(emergency or urgent surgery) perioperative goals include :
• maintaining a low-normal heart rate
• high-normal systemic vascular resistance
• ensuring adequate preload
• rhythm control strategy to maintain sinus rhythm
• Longer durations of observation in the postanesthesia/recovery care unit
may allow for earlier detection and intervention of complications

66. • MS with PH : adverse perioperative events and changes in pulmonary
hemodynamics may increase cardiovascular risk
• Patients with MS are at higher risk of pulmonary edema, hypotension, and
arrhythmia
• NCS with significant intravascular fluid shifts :
• earlier detection and treatment of clinically significant hemodynamic
changes essential
• Invasive hemodynamic monitoring beneficial
1. Swan-Ganz catheters,
2. arterial lines
3. TEE
• The intensity and level of monitoring should be commensurate to the risk
of surgery and anesthesia technique

67. Choice of anaesthesia technique and challenges
• Local
• Regional
• Central neuraxial block
• General Anaesthesia

68. Spinal anaesthesia
• Using local anaesthetic drugs: cautious : profound sympathetic block
• MS maintain hemodynamic targets:
• Avoid drop in SVR
• Avoid tachycardia
• Avoid hypotension
• Maintainance of preload : avoid overload : Co-loading vs Preloading

69. Epidural Anaesthesia
• Gradual onset of sympathetectomy
• Graded epidural
• Fluid boluses can be avoided
• Adrenaline in test dose avoided
• Hypotension in central neuraxial blockade treatment :
• i.v Phenylephrine : pure α1 agonist : boluses 50 -100 mcg (stimulation of
α1 receptors on peripheral blood vessels: SVR increase)
• Avoid ephedrine/Mephenteramine : both α and ß receptor stimulation :
tachycardia

70. ASRA Guidelines on time
intervals before and after
neuraxial blocks for anticoagulant
agents (2021)
• Unfractionated heparin (UFH)
binds to antithrombin, thereby
potentiating inactivation of
thrombin (factor IIa), factor Xa
and factor IXa.
• i.v. acts immediately
• 5,000 I.U. subcutaneously : 1
h
• Guidelines dependent on
the route of administration
• s.c. UFH on the dose.
• patients receiving UFH >4
days should have a platelet
count before CNB or catheter
removal to exclude heparin-
induced thrombocytopenia

71. • LMWHs inhibit factor Xa
• Guidelines by ASRA recommend
against routine testing of anti-factor Xa
levels since there is no known safe
level for performing CNBs.
• A 12 h time interval should be
considered after neuraxial puncture
until the first prophylactic dose
• 24 h time interval for therapeutic
LMWH.
• Maintain catheters if the patient
receives a prophylactic dose daily.
• The catheter should be removed
12 h
after the last daily prophylactic
dose.

72. ASRA’s guidelines recommend
normal INR (i.e. 1.1) : Prior insertion
• Administration of the drug with a neuraxial
catheter in place is acceptable with caution
(e.g. neurological observations of sensory
and motor function), where the INR is 1.5-
3.0.
• Removal of catheters is recommended
with an INR below 1.5 and with continuance
of neurological observations for 24 h
• Warfarin can be reversed in the absence of
major bleeding :
• Vitamin K (i.v. infusion acts in 6-8 h)
• Prothrombin complex concentrates :
significant quantities of clotting factors,
including factor VII
• Fresh frozen plasma is not
recommended

73. Heparin – warfarin bridging therapy
American Society of Regional Anesthesia (ASRA) 2018 guidelines / American
College of Surgeons 2018 guidelines.
During the preoperative period:
• Discontinue warfarin 5 days before surgery.
• Three days before surgery, start subcutaneous LMWH or unfractionated heparin
(UFH) at therapeutic doses, depending on the patient's renal function.
• Two days before surgery assess INR, if greater than 1.5 vitamin K can be
administered at a dose of 1 to 2 mg.
• Discontinue s.c LMWH 24 hours before surgery or
• Discontinue UFH 4 to 6 hours before surgery.

74. During the postoperative period:
• If the patient is tolerating oral intake, and there are no unexpected surgical issues
that would increase bleeding risk, restart warfarin 12 to 24 hours after surgery.
• If the patient received preoperative bridging therapy (high thromboembolic risk)
 Underwent a minor surgical procedure : resume LMWH or UFH 24 hours
after surgery
 Underwent a major surgical procedure: resume LMWH or UFH 48 to 72
hours after surgery.
• Always assess the bleeding risk and adequacy of homeostasis before the
resumption of LMWH or UFH

75. Warfarin : Emergency surgery
• Reversal of warfarin anticoagulation
• Prothrombin complex concentrate (PCC)
• Fixed dose:
Non-intracranial hemorrhage: 1000 units
Intracranial hemorrhage: 1500–2000 units
• INR and weight dose driven :
INR 2-4: PCC 25 IU/kg IV
INR ≥4-6: PCC 35 IU/kg IV
INR >6: PCC 50 IU/kg IV
• Vitamin K: 10 mg IV administered slowly
• FFP: 10 to 20 ml/kg
• Trauma patients: 1 gm of tranexamic acid can be used at arrival, and a repeat dose of 1 gm in 8
hours

76. Heparin reversal : Protamine
• For UFH reversal:
1 mg for every 100 units when used within 2–4 h from the last
UFH exposure
• For LMWH reversal:
1 mg for each 1 mg administered within the prior eight
hours…….??

77. ASRA 2021 : Guidelines for peripheral nerve
blocks
• Anticoagulated patients receiving perineuraxial, deep plexus, or
deep peripheral nerve blocks should be managed as if they are
undergoing neuraxial anesthesia.
• Clinical discretion should be used for decision-making regarding the safety
of other regional anesthesia techniques, such as superficial plexus blocks
and nerve blocks.
• Vascularity and compressibility of the anatomical site where the blocks
are being performed and the potential consequences of bleeding at those
sites should be kept in mind.
• The risks of discontinuing anticoagulation therapy in these patients
should be weighed versus the benefits of neuraxial and nerve block
anesthesia and analgesia

78. Anaesthetic
drugs
SVR PVR HR RV Contractility
Thiopentone ↓ ↑ ↓
Propofol ↓↓ ↓↓ ↓ ↓↓
Ketamine ↑ ↑ ↑ ↓
Etomidate - -
Opioids ↓ ↓/ ↓
Inhalational
agents
SVR PVR HR RV
Contractility
isoflurane ↓ ↑ ↑ ↓↓
sevoflurane ↓ ↓/ ↓↓
Desflurane
↓
↑ ↑ ↓↓
Nitrous
oxide
↑↑ ↑↑ ↓
Anaesthetic drugs and hemodynamic interactions

79. Choice of Muscle relaxants
• Rocuronium and Vecuronium are preferred : Cardiostable
• Pancuronium avoided: Tachycardia
• Atracurium and Mivacurium : Histamine release : PVR↑
• Scoline
• Cisatracurium

80. • Avoid prolonged fasting
• Premedication : glycopyrrolate avoided tachycardia
• Benzodiazepine : low doses : SVR effect
• Continue rate control medications
• Follow guidelines anticoagulants
• Electrolytes : K : Diuretics, Digoxin

81. Monitoring
• Multilead ECG,
• SpO2
• Urine output
• NIBP,
• Temperature
• EtCO2, AGM
• Depth of anaesthesia
• NM monitoring
Invasive monitoring :
• Arterial line : beat-beat ABP,
sampling
• CVP: Volume, inotropes, right
sided pressures
• PA catheter : Caution : PA
rupture if tense
• TEE/TTE

82. • PCWP = LAP = LVEDP
if MV normal
• Assuming the lungs and the
vasculature are normal
PA catheter as a
Monitoring tool

83. Limitation of PA catheter in MS : Rt sided pressures primarily

84. Mitral stenosis patient for Laparoscopy
Advantages of Laparoscopy
• minimally invasive
• Less pain
• Earlier mobilisation
• Less thromboembolism

85. intervention effect management
Hemodynamic
fluctuations
Tachycardia, Atrial
tachycardia : CO2
• Gradual positioning
• Slow abdominal insufflation to
buildup attenuate abdominal stretch
Changes in SVR,PVR
response
• Maintain intraabdominal pressure
Positioning :
Tredelenberg :
below 10 mm of Hg
• Tachycardia: esmolol
• PVR ↓ : Higher Fio2 0.6, washout
appendicectomy ; pulm
edema
CO2, Avoid Nitrous oxide
• Maintain depth of anaesthesia
• Adequate analgesia :
• TAP, QLIP Block
• Port site infiltration
Laparoscopy and Mitral Stenosis

86. intervention effect management
CO2 insufflation ↑PaCO2, increased
difference in ETCO2 and
PACO2
Increased PVR and PHT
Ventilation strategy:
• Paralysed, controlled
positive pressure
ventilation
• maintain
minute
ventilation
• ↑RR : EtCO2 :
30-35
Pneumoperitoneum Diaphragm pushed up,
decrease lung capacity,
atelactasis, Decrease
FRC>>↑PVR
• Keep lower peak
inspiratory pressures
• Prefer : PRVC/PCV-VG
mode
• Keep PEEP
• Adjust I: E Ratio
Laparoscopy and Mitral Stenosis

87. Mitral Stenosis
Mild
Moderate
Severe
Surgery
• Lap Cholecystectomy
• Lap Appendicectomy
• Lap Ovarian Cystectomy
• Intracranial Bleed: SDH
evacuation
• Ruptured Ectopic Pregnancy

88. Pregnancy in Mitral Stenosis

89. Miller’s Anaesthesia.10th edition
Physiological Changes in Pregnancy

90. Relevant Changes in pregnancy
Compared to
prepregnancy
levels
CARDIAC OUTPUT
1st Trim
2nd Trim
3rd Trim
30-40%
40-50%
Stable till labour
Compared to
Prelabour
values
10-25%
40%
80-100%
Labour
1st stage
2nd stage
Post
delivery
This abrupt increase in CO post delivery :
• secondary to the autotransfusion of
uteroplacental blood as the evacuated
uterus contracts
• reduced maternal vascular
capacitance from loss of the intervillous
space
• diminished lower extremity venous
pressure from release of the aortocaval
compression

91. • Cardiac output returns toward
• Prelabor values : within 24 hours postpartum depending on
the mode of delivery and degree of blood loss
• Toward prepregnant values : 2 weeks postpartum
• Complete return to nonpregnant levels : between 12 and 24
weeks after delivery

92. How does pregnancy influence pt with MS ?
• Increased transmitral gradient across MV
• Progression of symptoms during pregnancy to higher NYHA
functional class
• Maternal morbidity increases with higher NYHA
• Asymptomatic MS may tolerate MS

93. How does pregnancy influence pt with MS ?
• Bearing down : Valsalva maneuver ,Pain, tachycardia, anaemia, ↑PVR,
Autotransfusion with every uterine contraction
• Limited ability to handle autotransfusion : Pulm Edema and Heart
failure : peripartum more common
• Rapid RV decompensation
• Increased incidence of arrhythmia : atrial tachycardia, atrial fibrillation:
second trimester
• Increased incidence CV thromboembolic events, death
• Peripartum period : max morbidity and mortality : Day 2 to 9

94. Risk factors of MS to fetus
• Utero-placental insufficiency
• Growth retardation/IUGR
• Preterm Labour
• Respiratory distress
• Fetal/Neonatal death
• Warfarin is the most effective
anticoagulant at
preventing thrombotic
complications
• Warfarin crosses the placenta can
cause miscarriage, spontaneous
abortion
• Fetal embryopathy (Conradi
Syndrome), Fetal
intracranial
haemorrhage
• Warfarin dose < 5mg/day
less
complications

95. MS: maternal complications increase with severity of MS

96. Risk stratification tools during Pregnancy include:
• Cardiac Disease in Pregnancy (CARPEG) I & II
• Zwangerschap bij Aangeboren Hartafwijking (ZAHARA)
• World Health Organization (WHO) risk stratification
• CARPREG I & II and ZAHARA determine the likelihood of a significant
cardiac event based on individual maternal risk factors
• WHO risk stratification system divides individuals into 4 risk
categories

98. CARPREG II Score
The predicted risks for primary
cardiac events stratified according
to point score 0 to 1points :(5%)
2 points : (10%)
3 points : (15%)
4 points : (22%)
>4points : (41%)
MVA< 2cm2
AV < 1.5cm2
AV Gradient >
30 mmHg

100. “ Normal ”heart sounds in pregnancy
• Accentuated (S1) can be heard
• Split S1 : dissociated closure of the tricuspid and mitral valves
• Third heart sound (S3) : final trimester
• S3 may not have clinical significance.
• Benign grade 2/6 systolic ejection murmur is typically heard over the
left sternal border and is secondary to mild regurgitation at the
tricuspid valve from the annular dilation associated with the
increased cardiac volume

101. What is not normal in Pregnancy
• Chest pain…think of SCAD of coronaries
• Syncope
• High-grade flow murmurs, esp with known history of syncope /TIA
• Arrhythmias
• Heart failure symptoms such as hypoxia, clinically significant
shortness of breath

102. What is not normal in Pregnancy

103. Medical management
• Bed rest, propped up, Left Uterine Displacement (LUD)
• Diuretics : K monitor, risk of IUGR
• Tachycardia : Rate control : ß blockers, CCB
• ß blockers :
• ß1 selective preferred to maintain uterine relaxation of ß2 receptor stimulation
• Metoprolol : drug of choice ( Atenolol found to cause IUGR)
• Atrial Fibrillation : Cardioversion : hemodynamic unstable or less than 48hrs
onset
• Rate control : Digoxin, Metoprolol…(Amiodarone avoided)
• Rheumatic fever prophylaxis
• Anticoagulation

104. ANTI COAGULATION IN PREGNANCY- ACC, ESC

106. Prophylactic PBMV? ….or Valve sugery
• Severe rheumatic MS  significant risk of maternal adverse outcome during
pregnancy.
• In asymptomatic women with severe rheumatic MS (mitral valve area ≤1.5 cm2,
Stage C) and favorable valve morphology who are considering pregnancy,
PBMV results in an increase in mitral valve area and reduction in transmitral
gradient, which makes the patient more resilient to the hemodynamic
load of pregnancy

107. Goals of Management

108. During Labour………
• Avoid Trendelenberg
position: prefer modified
Fowler’s Position
• O2 supplementation
• Maintain LUD:
Aortocaval compression
• Fetal Heart Rate
monitoring
• Multilead ECG,
• SpO2
• Urine output
• NIBP,
• Temperature
Invasive monitoring :
• Arterial line : beat-beat
ABP, sampling, insert
before neuraxial block
• CVP: Volume, inotropes,
right sided pressures
• PA catheter : Caution :
PA rupture if tense
• TEE/TTE

109. 1st stage labour
• Segmental lumbar epidural anaesthesia preferred
• Target block : T10 – L1
• Eliminates pain, tachycardia, Prevents fatigue, issues of Valsalva
maneuver
• Avoid preloading
• Hypotension :
• i.v Phenylephrine 1-2 mcg/kg
• i.v Noradrenaline (0.025-0.05mcg/kg/min)
• Avoid adrenaline in test dose

110. 1st stage labour
Combined Spinal – Epidural
• Intrathecal fentanyl 10–25 mcg profound analgesia : 90–120 minutes
………..CAUTION
• Epidural infusion bupivacaine 0.0625% with/out opioid
• Started within 10 minutes of spinal injection
• Epidural component may be activated when necessary
• Dural Puncture Epidural : cautious

111. • Initial dose:
• 5– 8 mL of 0.0625% bupivacaine/levobupivacaine or 0.2% Ropivacaine with
fentanyl
• Maintenance :
1. Continuous infusion
• (0.1 ml/kg/h) of 0.0625% bupivacaine or levobupivacaine, or 0.1%
ropivacaine.
• Fentanyl 1–2 mcg/mL may be added
2. Bolus doses:
• Doses should be administered before the nerve block regresses to the point
the patient experiences pain,commonly referred to as “time to two-segment
regression.”
• This is defined as the time it takes for the sensory nerve block to regress by
two dermatome levels
• When two-segment regression has occurred, one-third to one-half of the
initial loading dose can safely be administered to maintain the nerve block
• About 2hrs for 0.1% bupivacaine and Ropivacaine

112. 3. PCEA : Patient Control Epidural Analgesia
• maintenance infusion ( 3-5mL/h)………-
• local anesthetic (bupivacaine, levobupivacaine, ropivacaine
0.0625%–0.125%) with or without an opioid (fentanyl 1–2 mcg/mL).
• epidural demand bolus of 3 - 5 mL with a lockout period of 10
minutes between doses

113. Systemic Opioids
I.V PCA :
• Fentanyl patient-controlled analgesia bolus 25mcg, lockout time : 10 to
15 minutes, max 100 mcg /hour
• Remifentanil :
1. short half-life
2. plasma-esterase metabolism,
3. very low risk of significant transfer across the placenta.
4. maternal sedation and risk of respiratory depression are higher
for patients receiving remifentanil versus fentanyl alone for patient-
controlled analgesia
5. side effect of pruritis

114. Second stage of labour
• Only uterine contractile force
• Avoid maternal bearing down
• Assisted Vaginal Delivery : Forceps>> Vacuum Delivery
• Continue epidural with S2-S4 level Desired level
• Additional bolus drug may be required if infusion not on
• Supplemental pudendal nerve block…?

115. • After baby delivery, Oxytocin : low dose infusion 10U slowly or Bolus 3U
followed by incremental doses 3U max 10U
• Rapid infusion : drop in SVR, increase in PVR
• Misoprostol : relatively safe
• Avoid Methylergometrine, Carboprost : both increase PVR, tachycardia
• i.v Frusemide : prevent Pulmonary edema of autotransfusion
• Intermittent BIPAP, Even intubation : Flash pulm edema
• Postop monitoring in intensive care upto 48 – 72 hrs
• Neonatologist available

116. Planning an elective Caeserian section
1. Obstetric indications…………………….Graded Epidural with monitoring
2. If a woman goes into labor while on warfarin: Because warfarin
results in an anticoagulated fetus, there is a high risk of fetal
intracranial hemorrhage if vaginal delivery is attempted.
Appropriate reversal of anticoagulation followed by cesarean
section …………….General Anaesthesia
3. Maternal indication: Severe Symptomatic MS, PASP> 50 mm Hg, in
pulm edema/ Heart failure NYHA III/IV……………General Anaesthesia

117. Choice of Anaesthesia : Elective LSCS
• Single shot Spinal Anaesthesia with LA: contraindicated : profound
drop in SVR
• Graded Epidural, with invasive monitoring : preferred for Elective CS
when obstretic indication
• Slow doses, less hypotension : allows maternal CVS to adjust to
sympathetectomy
• Lesser motor blockade, maintains “Pump” action of lower limb,
less thromboembolism

118. Choice of Anaesthesia
• Urgent/emergency CS: General Anaesthesia
• Modified Rapid Sequence Intubation
• Preoxygenation : 5 vital capacity breaths
• i.v Etomidate : 0.3mg/kg
• i.v Rocuronium 1.2mg/kg
• i.v opioid fentanyl :inform neonatologist
• Blunt intubation: i.v Esmolol 1mg/kg : inform neonatologist
• Maintenance with AIR: O2: Sevoflurane 0.6 MAC
• Phenylephrine boluses(1-2 mcg/kg) or low dose Noradrenaline to maintain
MAP

119. • After baby delivery, Oxytocin : low dose infusion 10U slowly or Bolus
3U followed by incremental doses 3U max 10U
• Rapid infusion : drop in SVR, increase in PVR
• Avoid Methylergometrine, Carboprost : both increase PVR, tachycardia
• i.v Frusemide : prevent Pulmonary edema of autotransfusion
• Reversal : Suggamadex?? Avoids glycopyrrolate
• Avoid extubation response
• Postop monitoring in intensive care upto 48 – 72 hrs
• Neonatologist available

120. Valve intervention during Pregnancy
• PBMV
• CMV (Closed Mitral Valvotomy)
Maternal outcomes for CMC and PBMV are similar
Slightly higher fetal loss in CMV than PMBV
• OMV (Open Mitral Commissurotomy)
• Mitral Valve Replacement
Bioprosthetic : Less risk of warfarin anticoagulation
Mechanical valve

121. Valve intervention during Pregnancy
• Patients with severe rheumatic MS may develop progressive HF or sudden
hemodynamic deterioration during the hemodynamic stress of pregnancy.
• Percutaneous balloon dilation of the mitral valve is a high-risk procedure
during pregnancy for both the mother and the fetus
• Ideally performed after 20 weeks
 should be performed only if there is hemodynamic deterioration
 if there are severe NYHA class III or IV HF symptoms.
 acceptable valve morphology, less than grade 2 MR
No LA thrombus
• Should always be performed in a center with a multidisciplinary group
of cardiologists, interventionalists, cardiac anesthesiologists, and
obstetricians specializing in high-risk obstetrics

122. Valve intervention during Pregnancy
• Valve surgery during pregnancy is high risk, with a 30% to 40% fetal mortality rate
and up to 9% maternal mortality rate reported.
• Reserved only for patients with severe, intractable symptoms unresponsive to
bed rest and maximally tolerated medical therapy.

123. CPB risks
Review of Mayo Clinic surgical database, 35 years (1976-2009)
• premature deliveries : 52%
• fetal deaths : 14% (16-33% fetal mortality)
• intra-uterine growth retardation :5%
• respiratory distress syndrome :33%
• development delay : 14%
• Maternal mortality : older data : 15%, newer : 1.4%(same as non-
pregnant females

124. CPB during Pregnancy
• Uterine tone monitoring
• Fetal heart rate monitoring :
Cardiotachometer
• FHR : 110-160/min
 <24 weeks gestation :
intermittent
 ≥ 24 weeks gestation :
continuous
 postoperatively at least 12-24 h risk
of preterm labor in this period
Intraop Fetal ECHO
Transvaginal probes : difficult
• Wedge under RT hip : to maintain
15deg LUD
: prevent aortocaval compression
• Maternal Haematocrit:>25%
• High perfusion pressure(>70mm Hg)
• High perfusion rates (>2.5L/min/m2)
• Minimise CPB time
• Pulsatile perfusion
• Use α –stat Ph management
• Tocolytic therapy :(magnesium
sulphate,ß2 agonists
caution)
• Neonatologist and Obstretician on
standby for emergency delivery

125. Cardioplegia Basics :
• Myocardial rewarming may be avoided with the use of continuous
cold pericardial irrigation or continuous warm blood cardioplegia
• Maternal hyperkalemia causes increased potassium diffusion into the
fetal circulation through the placental chorionic villi.
• Fetal hyperkalemia leads to conduction disturbances and may
even cause fetal cardiac arrest.
• Discarding coronary sinus return during cardioplegia delivery
• Serum potassium concentration maintain it <5 mmol/L

126. Fetal Issues to be looked for :
Fetal bradycardia causes
• feto-placental dysfunction
• fetal hypoxia
• acidosis
• maternal hypothermia
• hypothermia CPB onset
• drugs that cross the
placental barrier, such as β-
adrenergic blockers
Fetal hypoxia:
• Uterine arteriovenous shunting
• obstruction of venous drainage
by inferior vena caval
cannulation
• particulate/gaseous emboli
• uterine artery spasm with
the onset of CPB

127. Fetal asphyxia during maintenance of CPB – Risk factors
Fetal asphyxia during maintenance of CPB
• reduced maternal SVR,
• low uterine blood flow,
• hemodilution,
• hypothermia,
• prolonged CPB
• maternal narcotic administration

128. Post MVR patient for Non cardiac surgery
TTE
• Valve functioning
• Gradients across the valve (< 5mm acceptable)
• Paravalular leak : nidus for infection
• Vegetation, Thrombus
• Pannus
• Tricuspid Regurgitation : RVSP, PAH
• Ventricular Function
Warfarin – Heparin Bridging therapy

129. Mitral Stenosis in Pregnancy
Mild
Moderate
Severe
Normal Labour
Labour…..> C Section
C Section

130. Thank You………

131. References
• Writing Committee Members, Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin III JP, Gentile F, Jneid H, Krieger EV,
Mack M, McLeod C. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the
American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the
American College of Cardiology. 2021 Feb 2;77(4):e25-197.
• Writing Committee Members, Thompson A, Fleischmann KE, Smilowitz NR, de Las Fuentes L, Mukherjee D, Aggarwal NR,
Ahmad FS, Allen RB, Altin SE, Auerbach A. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative
cardiovascular management for noncardiac surgery: a report of the American College of Cardiology/American Heart
Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2024 Nov
5;84(19):1869-969.
• Kaplan’s Cardiac Anaesthesia : 8th Edition
• Miller Anesthesia : 10th Edition

138. drug When neuraxial block can
be performed after drug
is stopped
Restarting with therapy
with neuraxial catheter in
situ
Restarting therapy after
neuraxial
blockade/catheter
removal
Unfractionated Heparin subcutaneous
Low dose prophylaxis: 4-6 h and after Acceptable to give whilst 1
hr 5000U bd/tds coagulation status catheter in situ
checked (Normal APTT)
Catheter removal 4-6 hr
after administration
High dose prophylaxis 12 hr and after Analyse risk/ benefit in No
guidelines 7500-10,000U BD or coagulation status that patient
< 20,000u daily dose checked (Normal APTT) Institute neurological
monitoring regimen
Therapeutic dose 24 h and after coagulation Analyse risk/ benefit in No
guidelines (>10,000U per status checked (Normal that patient
dose;>20,000U daily total APTT) Institute
neurological
monitoring regimen

139. drug When neuraxial block can
be performed after drug
is stopped
Restarting with therapy
with neuraxial catheter in
situ
Restarting therapy after
neuraxial
blockade/catheter
removal
Unfractionated Heparin i.v
i.V UFH 4-6 h and after Acceptable to give whilst
1 hr coagulation status catheter in situ
checked(Normal APTT)
Catheter removal 4-6 hr
after administration
High dose prophylaxis 12 hr and after Analyse risk/ benefit in No
guidelines 7500-10,000U BD or coagulation status that patient
< 20,000u daily dose checked (Normal APTT) Institute neurological
monitoring regimen
Therapeutic dose 24 h and after coagulation Analyse risk/ benefit in No
guidelines (>10,000U per status checked (Normal that patient
dose;>20,000U daily total APTT) Institute
neurological
monitoring regimen

140. drug When neuraxial block can be
performed after drug is
stopped
Restarting with therapy with
neuraxial catheter in situ
Restarting therapy after
neuraxial blockade/catheter
removal
LMWH s.c
prophylaxis
Therapeutic dose
12 hrs
24 hrs
• Prophylactic o.d. dose:
catheters do not represent
additional risk;
• first dose acceptable 24 h
after catheter placement
• remove catheter 12 h after
last dose
Not recommended
Prophylactic dose: 4 h
24 h after non-high-bleeding-
risk surgery/neuraxial block
placement
48–72 h after high-bleeding-
risk surgery;
catheters should be removed at
least 24 h after needle/catheter
placement
first dose should be given at
least 4 h after catheter removal