anestesia

1. Regional Anesthesia For Valvular
Heart Disease In Noncardiac Surgery
I Ketut Wibawa Nada

2. Introduction
Despite impressive advances in anesthesia and surgical
techniques, the morbidity and mortality of patient with
severe valvular heart disease remains high
An estimate of the prevalence of moderate to severe
Valvular heart disease in patients > 75 years old is 13.3%
( Nkomo et al, 2006).
Maintenance of hemodynamic stability in these patients
can be quite challenging and The choice of anesthesia
technique is still controversy, especially for stenotic
lession

3. Regional Anesthesia
Central neuraxial block ( T5-L1)
Blocking the Inervation of arterial and venous smooth muscle
Venous : Venous pooling decrease of venous return
Arterial : Decreased of SVR
❑ High sympathetic block can also block the cardiac accelerator fiber
( arise at T1-T4)
Clinical Anesthesiology ed 5th, Morgan and mikhail’s

6. AORTIC STENOSIS

7. AORTIC STENOSIS
Core Topics in Cardiac Anesthesia, 2nd editon

8. AORTIC REGURGITATION

9. AORTIC REGURGITATION
Core Topics in Cardiac Anesthesia, 2nd editon

10. MITRAL
STENOSIS

11. MITRAL STENOSIS
Core Topics in Cardiac Anesthesia, 2nd editon

12. MITRAL
REGURGITATION

13. MITRAL REGURGITATION
Core Topics in Cardiac Anesthesia, 2nd editon

14. ► Case 1 : at L3/4 catheter
inserted, 2 mg bupivacaine
0,5% (T10) after 5 mnt add
2 mg bupivacaine 0,5%
(T8)
► Case 1 : at L3/4 catheter
inserted, 2 mg bupivacaine
0,5% (L1) , adding three
more dose 2 mg every 5
mnt (T8)

15. Both cases used
combined spinal epidural
and continuous spinal
anesthesia.
Vital signs remained stable
in both cases.
Continue spinal : at L3/4 catheter inserted, 3 mg
levobupivacaine 0,5% (0,6ml) (T12) + 0,5 mg
levobupivacaine 0,5% (0,1 ml)
CSE : Spinal at L3/4 , injected intrathecally 0,5%
hyperbaric bupivacaine 3,5 mg ( 0,7ml), then inserted
the epidural catheter

16. preferred to continue spinal
anaesthesia :
• gradually local
anaesthetic dose during
procedure
• minimise undesirable
haemodynamic changes,
such as hypotension and
tachycardia
•Decreased discharge time
Spinal catheter inserted
at level L4/5 1 ml of
0,5% plain bupivacaine
(T10) 0,5 ml 0,5% plain
bupivacaine (T6)

17. single-shot spinal
anesthesia (9 mg of 0.5 %
hyperbaric bupivacaine
plus fentanyl12.5 mcg at
L3/4 level)
started infusion of
norepinephrine (50
ng/kg/min)

18. Conclusion
The point of our interest to maintain the hemodynamic stability in
patient with VHD with regional anesthesia is how to control the SVR
and heart rate
There are no anesthesia technique is more superior than other, the
important is how we can handling our technique.
Regional anethesia become the choice of technique in Severe VHD
patient that has lower morbidity and mortality rate.

19. MATUR SUKSMA
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