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Valvular Heart Disease & Anaesthetic Implications

Valvular heart disease, specifically mitral stenosis, places a hemodynamic burden on the heart over time. The disease results in a narrowed mitral valve opening that obstructs blood flow from the left atrium to the left ventricle. This obstruction can lead to elevated left atrial pressure and pulmonary hypertension. Symptoms include breathlessness and fatigue. Echocardiography is used to evaluate the severity based on mitral valve area and pressure gradients. Treatment involves managing symptoms medically or surgically replacing/repairing the valve. Anesthetic management focuses on maintaining preload, controlling heart rate, and avoiding pulmonary vasoconstriction.

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VALVULAR HEART DISEASE CHAIRPERSON: Dr.S.B.Gangadhar MODERATOR : Dr. Abhishek. M.S. PRESENTER : Dr. Daber Pareed VALVULAR HEART DISEASE
VALVULAR HEART DISEASE DEFINITION • An acquired or congenital disorder of a cardiac valve characterized by stenosis (obstruction) or regurgitation (backward flow) of blood
VALVULAR HEART DISEASE  All VHD are characterized by abnormalities of ventricular loading.  The status of the ventricle changes over time as ventricular function and the valvular defect are influenced by the progression of volume or pressure overload.  Valvular heart disease places a haemodynamic burden on the left ventricle and/or right ventricle  Initially tolerated, as CVS compensates for overload.  Haemodynamic overload1)Cardiac muscle dysfunction 2)CHF 3)Sudden death
VALVULAR HEART DISEASE  The most frequently encountered cardiac valve lesions produce PRESSURE OVERLOAD or VOLUME OVERLOAD on the LA/LV  Perioperative management requires understanding of haemodynamic alterations that accompany valvular dysfunction.
VALVULAR HEART DISEASE • Anaesthetic mgt during periop period is based on likely effects of drug induced changes in cardiac rhythm, heart rate, preload, afterload, myocardial contractility, systemic blood pressure, systemic vascular resistance & pulmonary vascular resistance related to pathophysiology of heart disease.
VALVULAR HEART DISEASE CARDIOLOGY-BASIC TERMS Systolic function – contract and eject blood Contractility – intrinsic ability of myocardium to contract and generate force Preload – load placed on myocardium before contraction – diastolic volume and filling pressure After load – load placed on myocardium during contraction – systolic volume and generated pressure
VALVULAR HEART DISEASE VALVULAR HEART DISEASE
VALVULAR HEART DISEASE EVALUATION OF PATIENT Preoperative evaluation of patients with valvular heart disease includes assessment of (1) the severity of the cardiac disease, (2) the degree of impaired myocardial contractility, (3) the presence of associated major organ system disease
VALVULAR HEART DISEASE • Current drug therapy • Presence of secondary effects on pulmonary, renal, and hepatic function. • The presence of concomitant coronary artery disease & other major organ system diseases
VALVULAR HEART DISEASE NEWYORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION • Class I - No limitation of physical activity. Ordinary physical activity causes no undue fatigue, palpitations, dyspnea. • Class II - Slight limitation of physical activity. Comfortable at rest, ordinary physical activity results in fatigue palpitations, or dyspnea. • Class III -Marked limitation of physical activity. Comfortable at rest, less than ordinary activity causes fatigue, palpitations dyspnea. • Class IV -Unable to carry out any physical activity without discomfort. Symptoms at rest.
VALVULAR HEART DISEASE PHYSICAL FINDINGS Signs of congestive heart Failure(CHF) • S3 gallop • Pulmonary rales • Elevated JVP • Hepatojugular reflux • Hepatosplenomegaly • Pedal edema Findings specific to individual valvular lesions (Murmur-character, systolic/diastolic , location ,intensity,grade,radiation) Neurologic deficits secondary to embolic phenomena
VALVULAR HEART DISEASE INVESTIGATIONS • Tailored to the patient and the procedure: • ECG - LVH,RVH,arrythmias, ischaemia • Chest X-ray- assess cardiac size and the presence of pulmonary vascular congestion. • Echocardiography • Cardiac catheterization to identify a)Coexisting CAD b)Severity of stenosis/regurgitation (transvalvular pressure gradients) c)Intracardiac shunts d)Clinical & Echo discrepancies
VALVULAR HEART DISEASE • Serum electrolytes • Renal function tests • Coagulation profile • ABG- significant pulmonary symptoms
VALVULAR HEART DISEASE DOPPLER ECHO IN VHD-PURPOSE • Determine significance of cardiac murmurs • Determine transvalvular pressure gradient • Determine valve area,cavity dimensions • Determine ventricular ejection fraction • Diagnose valvular regurgitation • Evaluate prosthetic valve function
VALVULAR HEART DISEASE ENDOCARDITIS PROPHYLAXIS- AHA GUIDELINES
VALVULAR HEART DISEASE HIGH- AND MODERATE-RISK PATIENTS - PROPHYLAXIS RECOMMENDED(CLASS 1) • Prosthetic valves / history of infective endocarditis • Complex cyanotic congenital heart disease • Surgically constructed systemic-pulmonary shunts or conduits • Congenital cardiac valve malformations -bicuspid aortic valves • A history of surgical valve repair • Hypertrophic cardiomyopathy with resting/latent obstruction • MVP with auscultatory evidence of valvular regurgitation and/or thickened leaflets on echocardiography
VALVULAR HEART DISEASE • Isolated secundum ASD • >6 months after successful surgical or percutaneous repair of ASD, VSD, PDA • MVP without MR or thickened leaflets on echocardiography • Physiologic heart murmurs • Echo e/o physiologic MR with absence of murmur with structurally normal valves • Echo e/o physiologic TR and or PR with absence of a murmur and with structurally normal valves LOW-RISK PATIENTS - PROPHYLAXIS NOT RECOMMENDED(CLASS 111)
VALVULAR HEART DISEASE ANTIBIOTIC REGIMENS
VALVULAR HEART DISEASE PROSTHETIC VALVES Bioprosthetic Mechanical Bioprosthetic valves • Heterogeneous grafts made from animal tissue • Low thrombogenic potential • Do not need systemic anticoagulation • Aspirin is recommended
VALVULAR HEART DISEASE Mechanical valves • Longer lasting • Need lifelong anticoagulation - Warfarin therapy. • Aspirin is usually combined with warfarin in mechanical heart valves. • Aspirin allergy – clopidogrel
VALVULAR HEART DISEASE PATIENTS WITH PROSTHETIC VALVES UNDERGOING SURGICAL PROCEDURES • Complete history and physical examination. • Type of valve inserted. • Auscultation - high-pitched, crisp opening and closing sounds • Bioprosthetic valves do not have special auscultatory characteristics. • Onset of new murmurs / change in quality of murmurs - problem with the valve /endocarditis
VALVULAR HEART DISEASE AHA BRIDGING RECOMMENDATIONS FOR INTERRUPTION OF WARFARIN THERAPY FOR NON- CARDIAC SURGERY AND INVASIVE PROCEDURES (i)Low risk of thrombosis- Eg:- Bileaflet mechanical aortic valve without risk factors o Warfarin stopped 48 to 72 hour before surgery o INR to fall to 1.5 o Warfarin restarted within 24 hours after the procedure
VALVULAR HEART DISEASE (ii)High risk for thrombosis – Eg:-Mechanical mitral valve or a mechanical aortic valve with any risk factor • Warfarin stopped 48 to 72 hrs • Unfractionated heparin(UFH) - INR falls < 2.0 , stopped 4 to 6 hours before. • Warfarin restarted soon after • Heparin continued until INR returns to therapeutic range with warfarin
VALVULAR HEART DISEASE MAJOR VALVULAR LESIONS • LT SIDED • RT SIDED
VALVULAR HEART DISEASE MITRAL VALVE DISEASE
VALVULAR HEART DISEASE Mitral stenosis ETIOLOGY Almost always rheumatic in origin Elderly - heavy calcification Rarely - • Congenital mitral stenosis • Rheumatoid arthritis
VALVULAR HEART DISEASE • Mitral stenosis primarily affects females. • Diffuse thickening of the mitral leaflets and subvalvular apparatus,commissural fusion, and calcification of the annulus and leaflets are typically present. • This process occurs slowly,and many patients do not become symptomatic for 20 to 30 years after the initial episode of rheumatic fever. • Over time, the mitral valve becomes stenotic, and CHF, pulmonary hypertension, and right ventricular failure may develop
VALVULAR HEART DISEASE CLINICAL FEATURES OF MITRAL STENOSIS Symptoms • Breathlessness - pulmonary congestion • Fatigue - low cardiac output • Oedema, ascites - right heart failure • Palpitation- atrial fibrillation • Haemoptysis - pulmonary congestion, pulmonary embolism • Cough - pulmonary congestion • Chest pain - pulmonary hypertension • Thromboembolic complication - stroke, ischaemic limb
VALVULAR HEART DISEASE Pathophysiology • The normal mitral valve orifice area is 4 to 6 cm2. • Mitral stenosis is characterized by mechanical obstruction to left ventricular diastolic filling secondary to a progressive decrease in the size of the mitral valve orifice. • This valvular obstruction produces an increase in left atrial volume and pressure. • With mild mitral stenosis, left ventricular filling and stroke volume are maintained at rest by an increase in left atrial pressure.
VALVULAR HEART DISEASE • Symptoms usually develop when mitral valve area is less than 1.5 cm2 Symptoms usually develop when mitral valve area is less than 1.5 cm2. • As the disease progresses the pulmonary venous pressure is increased in association with the increase in left atrial pressure. • The result is transudation of fluid into the pulmonary interstitial space, decreased pulmonary compliance, and increased work of breathing, which leads to progressive dyspnea on exertion.
VALVULAR HEART DISEASE SIGNS • Mitral facies • Atrial fibrillation - irregularly irregular pulse, pulse deficit • Signs of pulmonary hypertension • Auscultation – Loud first heart sound, opening snap – Loud P2- pulmonary htn – Low-pitched rough rumbling mid-diastolic murmur with presystolic accentuation best heard at the apex with bell of steth in left lateral decubitus position,breath held in expiration • Signs of raised pulmonary capillary pressure – Crepitations, pulmonary oedema, effusions
VALVULAR HEART DISEASE • ECG-Tall peaked P wave in lead 2,upright in V1 RAD,RVH-Severe PAH • CXR- 1. Straightening of upper left cardiac border 2. Prominence of main pulmonary arteries 3. Dilatation of upper lobe pulmonary veins 4. Postr displacement of esophagus by enlarged LA 5. Kerley-B lines-Fine, dense, opaque, horizontal lines most prominent in lower&mid zones
VALVULAR HEART DISEASE
VALVULAR HEART DISEASE ECHO • Echocardiography is used to assess the anatomy of the mitral valve, including the degree of leaflet thickening, calcification, changes in mobility, and extent of involvement of the subvalvular apparatus. • The severity of mitral stenosis is assessed by calculation of mitral valve area and measurement of the transvalvular pressure gradient. • Echocardiography also allows evaluation of cardiac chamber dimensions, pulmonary hypertension, left and right ventricular function, and other valvular disease, and examination of the left atrial appendage for the presence or absence of thrombus
VALVULAR HEART DISEASE MITRAL STENOSIS SEVERITY • Mild Moderate Severe Pulmonary artery systolic pressure (mm Hg) Normal – 18-25mmHg Less than 30 30–50 Greater than 50 Valve area (cm2) Greater than 1.5 1.0–1.5 Less than 1.0
VALVULAR HEART DISEASE MANAGEMENT Minor symptoms – medical treatment • Diuretics - ↓pulmonary congestion • Digoxin, β-blockers , CCB - control ventricular rate in AF • Anticoagulants - ↓risk of embolism • Antibiotic prophylaxis - infective endocarditis Definitive treatment – Surgical Severe symptoms(NYHA III/IV) Symptomatic despite medical treatment Pulmonary hypertension)(PA systolic pressure>50mm of Hg) balloon valvuloplasty, mitral valvotomy , mitral valve replacement
VALVULAR HEART DISEASE ANAESTHETIC GOALS • Maintenance of adequate diastolic filling time(prevent tachycardia & treat promptly in periop period) • Preservation of adequate preload with out overload/pulm vascular congestion. • Avoid hypovolemia • Avoidance of factors that precipitate pulmonary vasoconstriction & impair RV function • Maintenance of the contractile state and systemic and coronary artery perfusion pressure. • Maintain sinus rhythm • Maintain afterload
VALVULAR HEART DISEASE ANAESTHETIC GRID IN MS LV PRELOAD HR RHYTHM CONTRACTILITY SVR PVR MS ↑ ↓ Controlled ventricula r response Maintain constant Maintain ↓
VALVULAR HEART DISEASE PREOPERATIVE MEDICATION • Decrease anxiety and associated tachycardia- low dose Opioids and benzodiazepines (Avoid oversedation!!!....sensitive to small doses of narcotics& hypnotics) • Drugs for HR control- continued till time of surgery • Diuretic-induced hypokalemia detected and treated preoperatively • Continue anticoagulant therapy for minor surgery • Major surgery with significant blood loss – regional techniques - discontinue anticoagulants
VALVULAR HEART DISEASE INDUCTION OF ANESTHESIA • Avoid ketamine - increase the heart rate • Intubation & muscle relaxation by cardiostable muscle relaxant - VECURONIUM • Avoid relaxants with histamine release. • Short acting β blocker for rate control(Esmolol)
VALVULAR HEART DISEASE MAINTENANCE OF ANESTHESIA • Nitrous oxide/ low conc volatile anesthetic/Opioid • Nitrous oxide - pulmonary vasoconstriction = no clinical significance unless pul HTN present. • Cardiostable muscle relaxants • Reversal - slowly to prevent drug-induced tachycardia caused by anticholinergic drug • Intraoperative fluids – careful titration – avoid fluid overload
VALVULAR HEART DISEASE MONITORING Monitoring asymptomatic patients without evidence of pulmonary congestion - routine monitors Symptomatic mitral stenosis undergoing major surgery * Central venous pressure(CVP) *Transesophageal echocardiography (TEE) *Intra-arterial pressure(IBP) *Pulmonary artery pressure(Caution in pulm htn….PA rupture from wedging catheter) *Left atrial pressure *ABG-adjust ventilatory parameters
VALVULAR HEART DISEASE POSTOPERATIVE MANAGEMENT • Risk of pulmonary edema and RV failure continues into postop period • Cardiovascular monitoring continued • Relief of postoperative pain (painhypoventilnresp acidosis & hypoxemiaincr in HR & PVR) Opioids I/V or NEURAXIAL • Decreased pulmonary compliance and increased work of breathing - mechanical ventilation maybe required
VALVULAR HEART DISEASE INTERACTION WITH PREGNANCY • Expanded blood volume of pregnancy increases the risk of pulmonary congestion and edema • Physiologic tachycardia of pregnancy ↓ left ventricular filling time ↑ left atrial and pulmonary arterial pressures.
VALVULAR HEART DISEASE • Vaginal delivery: Early admission/invasive blood pressure monitoring/ Small top-ups for epidural/avoid fluid overload .  Caesarean delivery - Spinal anaesthesia avoided.  Careful epidural anaesthesia in NYHA class 1 and 2 patients  General anaesthesia NYHA class 3 and 4 patients  Bolus oxytocin contraindicated - risk of systemic hypotension and pulmonary hypertension.  Brief period of postoperative ventilation may be required in some cases.
VALVULAR HEART DISEASE MITRAL REGURGITATION Acute • Endocarditis • Papillary muscle rupture (post-MI) • Trauma Chordal rupture • leaflet flail (MVP) Chronic • Myxomatous (MVP) • Rheumatic fever • Endocarditis (healed) • Mitral annular calcification • Congenital (cleft, AV canal) • Ischemic (LV remodeling) • Dilated cardiomyopathy
VALVULAR HEART DISEASE MR-PATHOPHYSIOLOGY • The basic hemodynamic derangement in mitral regurgitation is a decrease in forward left ventricular stroke volume and cardiac output. • A portion of every stroke volume is regurgitated through the incompetent mitral valve back into the left atrium, which results in left atrial volume overload and pulmonary congestion. • Patients with a regurgitant fraction of more than 0.6 are considered to have severe mitral regurgitation.
VALVULAR HEART DISEASE The fraction of left ventricular stroke volume that regurgitates into the left atrium depends on (1) the size of the mitral valve orifice (2) heart rate, which determines the duration of ventricular ejection (3) pressure gradients across the mitral valve. • Such gradients are related to left ventricle compliance and impedance to left ventricular ejection into the aorta. • Pharmacologic interventions that increase or decrease systemic vascular resistance have a major impact on the regurgitant fraction in patients with mitral regurgitation.
VALVULAR HEART DISEASE CLINICAL FEATURES OF MITRAL REGURGITATION Symptoms • Dyspnoea- pulmonary venous congestion • Fatigue - low cardiac output • Palpitation • Oedema, ascites - right heart failure Signs • Atrial fibrillation/flutter • Cardiomegaly • Apical pansystolic murmur ± thrill • Soft S1, apical S3 • Signs of pulmonary venous congestion- Crepitations, pulmonary oedema, effusions • Signs of pulmonary hypertension and right heart failure
VALVULAR HEART DISEASE SEVERITY OF MR Method MILD Moderate Severe Regurgitant volume 30-40 mL 40-60 mL >60 mL Regurgitant fraction 10%-30% 30%-50% >55% Regurgitant orifice area <0.2 cm2 0.3-0.4 cm2 >0.4 cm2
VALVULAR HEART DISEASE MANAGEMENT • Diuretics • Vasodilators . ACE inhibitors • Digoxin - AF • Anticoagulants – AF • Antibiotic prophylaxis - IE Surgical valvuloplasty • with moderate to severe symptoms • regurgitant volume 30-60%
VALVULAR HEART DISEASE ANAESTHETIC MANAGEMENT Primary goal - maintaining forward systemic flow & reduction regurgitant fraction HR- high-normal range -80 to 100 beats/min Avoid bradycardia -↑ duration of systole prolongs regurgitation Rhythm- maintain sinus rhythm Preload- Maintain or slightly increase- elevated preload cause an ↑regurgitant flow- low preload inadequate cardiac output Afterload- Decrease to improve forward cardiac output-avoid sudden increases in SVR Contractility- Maintain or increase to decrease left ventricular volume
VALVULAR HEART DISEASE ANAESTHETIC GRID IN MR LV PRELOAD HR RHYTHM CONTRACTILITY SVR PVR Maintai n higher rate Maintain sinus rhythm Maintain ↓ ↓
VALVULAR HEART DISEASE INDUCTION OF ANESTHESIA • With an intravenous induction drug. • Dosing adjusted to prevent ↑SVR & ↓HR • muscle relaxant - Pancuronium modest ↑in heart rate
VALVULAR HEART DISEASE MAINTENANCE OF ANESTHESIA • Volatile anesthetics- isoflurane, desflurane & sevoflurane - choices for maintenance of anesthesia. • Severely compromised myocardium - opioid-based anesthetic is preferred - minimal myocardial depression. • Mechanical ventilation - adjusted to maintain near-normal acid-base and respiratory parameters. • The pattern of ventilation - provide sufficient time between breaths for venous return. .
VALVULAR HEART DISEASE PREGNANCY CONSIDERATIONS • No specific recommendations for management of MR during labour and delivery. • Prior to labour- symptoms - managed with diuretics & vasodilators. • Labour & CS - regional anaesthesia well tolerated. • NYHA class 3-4- GA may be required.
VALVULAR HEART DISEASE MITRAL VALVE PROLAPSE • Prolapse of one or both mitral leaflets into left atrium during systole with or without mitral regurgitation • Most common form of valvular heart disease • Common in young women Associated with • Marfan syndrome • Rheumatic carditis • Myocarditis • Thyrotoxicosis • Systemic lupus erythematosus
VALVULAR HEART DISEASE • Maybe anatomical or functional • Anatomical -Redundant & thickened leaflets - Connective tissue diseases , elderly men • Functional - Normal appearing leaflets/mild bowing only
VALVULAR HEART DISEASE CLINICAL FEATURES • Anxiety • orthostatic symptoms • Palpitations • Dyspnea • Fatigue • atypical chest pain • Cardiac dysrhythmias Older men with anatomical MVP can p/w mild to moderate CHF(exercise intolerance, DOE, orthopnoea)
VALVULAR HEART DISEASE • Midsystolic click+/- systolic murmur(in absence of symptoms doesn’t warrant a cardio consultation) • S3 gallop,Midsystolic/holosystolic murmur,basal creps -CHF
VALVULAR HEART DISEASE complications • cerebral embolic events • infective endocarditis • severe mitral regurgitation requiring surgery • Dysrhythmias • sudden death
VALVULAR HEART DISEASE PREOPERATIVE EVALUATION • Functional disease from those with significant mitral regurgitation • β-blockers to control dysrhythmias continued throughout the periop period • Anticoagulants
VALVULAR HEART DISEASE Management of anaesthesia-principles Periop factors which ↑ LV emptying& ↓ filling avoided: 1)↑ sympathetic activity 2) ↓ SVR 3)Upright posture 4)Hypovolemia (↓ LV filling)
VALVULAR HEART DISEASE SELECTION OF ANESTHETIC TECHNIQUE • Most MVP have normal left ventricular function • Tolerate all forms of general and regional anesthesia. • General-volatile anaesthetic induced myocardial depression beneficial • Regional- maintain adequate intravascular volume to prevent fall in SVR
VALVULAR HEART DISEASE INDUCTION OF ANESTHESIA • Intravenous induction drug- avoid significant & prolonged ↓ SVR • Etomidate - choice for induction in hemodynamically significant MVP • Ketamine avoided - ↑ sympathetic NS activity- ↑ MVP and MR
VALVULAR HEART DISEASE MAINTENANCE OF ANESTHESIA • Volatile anesthetics /nitrous oxide / opioids-titrate doses to maintain SVR • 0.5 MAC of isoflurane, desflurane, and sevoflurane can decrease the regurgitant fraction • Muscle relaxants- Vecuronim/Pancuronium • Proper fluid balance • Vasopressors - α-agonist - phenylephrine acceptable.
VALVULAR HEART DISEASE • Invasive monitoring –in haemodynamically significant MVP only (MR/LV dysfunction) COMPLICATIONS Ventricular dysrhythmias- cause of death in young adults with undiagnosed MVP- Rx -beta blockers , Lidocaine
VALVULAR HEART DISEASE Aortic Stenosis • Two factors are associated with development of aortic stenosis. 1. Degeneration and calcification of the aortic leaflets and subsequent stenosis. This is a process of aging. 2. Presence of a bicuspid rather that a tricuspid aortic valve.
VALVULAR HEART DISEASE CAUSES OF AORTIC STENOSIS Infants, children, adolescents • Congenital aortic stenosis • Congenital subvalvular aortic stenosis • Congenital supravalvular aortic stenosis Young adults to middle-aged • Calcification and fibrosis of congenitally bicuspid aortic valve • Rheumatic aortic stenosis Elderly • Degeneration & calcification with ageing
VALVULAR HEART DISEASE AS-PATHOPHYSIOLOGY • Obstruction to ejection of blood into the aorta caused by a decrease in the aortic valve area necessitates an increase in left ventricular pressure to maintain stroke volume. • The normal aortic valve area is 2.5 to 3.5 cm2. • Transvalvular pressure gradients higher than 50 mm Hg and an aortic valve area of less than 0.8 cm2 are characteristic of severe aortic stenosis. • Aortic stenosis is almost always associated with some degree of aortic regurgitation
VALVULAR HEART DISEASE • Angina pectoris may occur in patients with aortic stenosis despite the absence of coronary disease. • Goldman and colleagues in 1977 showing that patients with aortic stenosis had an increased risk of perioperative cardiac complications, many studies have demonstrated that patients with aortic stenosis have an increased risk of perioperative mortality and of nonfatal myocardial infarction regardless of the presence or absence of risk factors for coronary artery disease
VALVULAR HEART DISEASE CLINICAL FEATURES OF AORTIC STENOSIS Symptoms(develop when preload reserve exhausted) • Angina • Exertional syncope • Exertional dyspnoea • Sudden death • Episodes of acute pulmonary oedema Signs • Slow-rising carotid pulse • Narrow pulse pressure • Heaving apex beat (LV pressure overload) • Ejection systolic murmur aortic area • Signs of pulmonary venous congestion (crepitations)
VALVULAR HEART DISEASE DIAGNOSIS • ECG:LVH • CXR-Ascending aorta dilatation(post-stenotic) • Echo+Doppler-Assess severity of AS: a) Aortic valve area b) Transvalvular pressure gradient c) LVH Other points noted in Echo- Valve thickening/calcification Mobility of leaflets Bicuspid valve Systolic/diastolic dysfunction
VALVULAR HEART DISEASE C-Xray – Ascending aorta dilation
VALVULAR HEART DISEASE SEVERITY OF AS Grade Mean Pressure Gradient (mm Hg) Valve Area (cm2) Mild <25 ≥1.5 Moderate 25-40 1.0-1.5 Severe 40-50 0.7-1.0 Critical >50 <0.7 The normal valve area is 2.5 to 3.5 cm2
VALVULAR HEART DISEASE TREATMENT • Asymptomatic - medical management • Symptomatic - Aortic valve replacement • Coronary revascularization - pts with both aortic stenosis and CAD • Percutaneous aortic balloon valvotomy - adolescents & young adults with congenital /rheumatic etiology
VALVULAR HEART DISEASE Indications for aortic valve replacement • Severe AS with any of the classic symptoms(angina/syncope/dyspnoea) • Severe AS undergoing CABG • Severe AS undergoing surgeries on aorta or other heart valves • Operative mortality is high in pts with severe LV dysfunction & low transvalvular pressure gradient but improves fnctionl status.
VALVULAR HEART DISEASE MANAGEMENT OF ANESTHESIA  Principle: AS is a fixed cardiac output state & hypertrophied LV is sensitive to ischemia  Prevention of hypotension & hemodynamic changes that ↓cardiac output Anesthetic Considerations • Maintain normal sinus rhythm /Avoid bradycardia or tachycardia • Avoid hypotension • Optimize intravascular fluid volume to maintain venous return and left ventricular filling
VALVULAR HEART DISEASE ANAESTHETIC GRID IN AS LV PRELOAD HR RHYTHM CONTRACTILITY SVR PVR ↑ Avoid ↓ or↑ Maintain sinus rhythm Maintain constant ↑ Maintain constant
VALVULAR HEART DISEASE Key pts in intraop BP management • Rx intraop hypotension with directly acting alpha agonists(phenylephrine)…. • Rapid transfusion to correct hypovolemia /cardioversion shouldn’t delay administration of direct acting vasopressors • Inotropes-if signs of myo ischemia persist despite above Rx • Avoid vasodilators to Rx intraop HTN
VALVULAR HEART DISEASE INDUCTION OF ANESTHESIA • General anesthesia selected in preference to neuraxial block – HYPOTENSION Induction of anesthesia Etomidate, opioids, midazolam Ketamine - avoid Thiopentone - decreases preload Propofol – hypotension
VALVULAR HEART DISEASE MAINTENANCE OF ANESTHESIA • Nitrous oxide / volatile anesthetic and opioids or by opioids alone. • Marked LV dysfunction - nitrous oxide + opioids or high dose opioids alone - recommended • Fentanyl (10–25μg/kg) OR Sufentanil (2–5μg/kg) primary anesthetic for maintenance
VALVULAR HEART DISEASE MAINTENANCE • Neuromuscular blocking drugs with minimal hemodynamic effects
VALVULAR HEART DISEASE PREGNANCY CONSIDERATIONS CS • GA with invasive haemodynamic monitoring • Spinal anaesthesia contraindicated VAGINAL DELIVERY • careful epidural analgesia • maintenance of BP with vasopressors – phenylephrine
VALVULAR HEART DISEASE AORTIC REGURGITATION ETIOLOGY Congenital • Bicuspid valve or disproportionate cusps Acquired • Rheumatic disease • Infective endocarditis • Trauma • Aortic dilatation - Marfan's syndrome, aneurysm, dissection, syphilis, ankylosing spondylitis
VALVULAR HEART DISEASE PATHOPHYSIOLOGY • The basic hemodynamic derangement in aortic regurgitation is a decrease in cardiac output because of regurgitation of a part of the ejected stroke volume from the aorta back into the left ventricle during diastole. Combined pressure and volume overload on the left ventricle
VALVULAR HEART DISEASE The magnitude of the regurgitant volume depends on (1) the time available for the regurgitant flow to occur, which is determined by the heart rate (2) the pressure gradient across the aortic valve, which is dependent on the systemic vascular resistance. • The magnitude of aortic regurgitation is decreased by tachycardia and peripheral vasodilation. • With aortic regurgitation, the entire stroke volume is ejected into the aorta. Because the pulse pressure is proportional to the stroke volume and aortic elastance, the increased stroke volume increases systolic pressure, and systolic hypertension increases afterload.
VALVULAR HEART DISEASE • The left ventricle compensates by developing hypertrophy and enlarging to accommodate the volume overload. • Because of the increased oxygen requirements necessitated by left ventricular hypertrophy and the decrease in aortic diastolic pressure, which reduces coronary blood flow, angina pectoris may occur in the absence of coronary artery disease.
VALVULAR HEART DISEASE CLINICAL FEATURES Symptoms Mild to moderate AR • Often asymptomatic • palpitations Severe AR • Breathlessness • Angina
VALVULAR HEART DISEASE CLINICAL FEATURES Signs • Pulse - collapsing' pulse • increased pulse pressure • Bounding peripheral pulse • Capillary pulsation in nail beds • Femoral bruit Murmurs • Early diastolic murmur • Systolic murmur (increased stroke volume) • Austin Flint murmur (soft mid- diastolic) Other signs • Displaced, heaving apex beat (volume overload) • Fourth heart sound • Pulmonary venous congestion (crepitations)
VALVULAR HEART DISEASE SEVERITY OF AORTIC REGURGITATION by Echocardiography • Mild Moderate Severe Regurgitant jet width as percentage of LVOT width 25–46 47–64 >65 Regurgitant jet area as percentage of LVOT area 4–24 25–59 >60
VALVULAR HEART DISEASE TREATMENT Medical Therapy Asymptomatic Patients with Normal Left Ventricular Function  Afterload reduction Vasodilators Nifedipine ACE inhibitors Hydralazine Surgical Therapy Acute Aortic Regurgitation 1) Vasodilators – Nitroprusside 2)course of antibiotics 3) Valve replacement /repair Chronic Aortic Regurgitation Aortic valve repair Aortic valve prosthesis
VALVULAR HEART DISEASE ANAESTHETIC GOALS • Normal heart rate - Avoid bradycardia • Maintain sinus rhythm • Adequate volume loading • High normal systemic vascular resistance • Minimize myocardial depression
VALVULAR HEART DISEASE ANAESTHETIC GRID IN AR LV PRELOAD HR RHYTHM CONTRACTILITY SVR PVR ↑ ↑ Maintain sinus rhythm Maintain ↓ Maintain constant
VALVULAR HEART DISEASE INDUCTION OF ANESTHESIA • In stable patients - sodium thiopental / Etomidate • Alternatively - high dose narcotic and benzodiazepine induction • critically ill with acute AR - require inotropic and vasodilatory support prior to induction of anesthesia.
VALVULAR HEART DISEASE MAINTENANCE OF ANESTHESIA • Severe LV dysfunction- nitrous oxide plus a volatile anesthetic and/or opioid. • Isoflurane, desflurane & sevoflurane • Severe LV dysfunction - high dose opioid • Bradycardia and myocardial depression – N2O / BZD high-dose narcotic
VALVULAR HEART DISEASE  Increase in heart rate associated with PANCURONIUM administration could be helpful.  Bradycardia with hemodynamic compromise treated promptly.  Atropine 0.4–0.8mg  Ephedrine - poor choice because ↑in afterload Hypotension not treated routinely with vasopressors Spinal/Epidural well tolerated.
VALVULAR HEART DISEASE PREGNANCY CONSIDERATIONS • Avoidance of aortocaval compression • Epidural analgesia and anesthesia ↓ afterload and is preferred for vaginal / cesarean delivery • During labor early administration of epidural analgesia prevents the pain-associated ↑ SVR –prevent acute LV volume overload • Bradycardia not tolerated - treated promptly.
VALVULAR HEART DISEASE Right-sided valvular lesions TRICUSPID STENOSIS • Rare & usually coexists with MS • Back pressure into the right atrium • Upper-extremity venous congestion, hepatic enlargement, and ascites • Medical:Salt restriction, digitalization, diuretics • Surgical therapy- valvuloplasty/ valve replacement • Anaesthetic goal: Maintain preload & control HR
VALVULAR HEART DISEASE TRICUSPID REGURGITATION • It is usually functional • Caused by tricuspid annular dilation secondary to RV enlargement or pulmonary hypertension OTHER CAUSES OF TR • infective endocarditis, • rheumatic fever • chest trauma • Ebstein’s anomaly
VALVULAR HEART DISEASE • TR is well tolerated by most patients in the absence of pulmonary hypertension. • In moderate to severe TR, tricuspid annuloplasty may be considered  N2O can increase TR  Inotropes like dobutamine, isoproterenol dilate pulmonary vasculature
VALVULAR HEART DISEASE THE PULMONIC VALVE • Isolated from the other three heart valves by the infundibulum. • Pulmonary valvular disease is usually congenital • Stenosis > regurgitation • Congenital pulmonary stenosis is usually treated with balloon valvuloplasty.
VALVULAR HEART DISEASE • Mild pulmonary regurgitation occurs in cardiac surgical patients with a PAC • Significant PR rare & well tolerated • RV dysfunction secondary to pulmonary regurgitation should be surgically corrected.
VALVULAR HEART DISEASE REFERENCES • Stoelting’s Textbook of Coexisting diseases • Miller’s Textbook of Anaesthesia • Kaplan’s Textbook of Cardiac anaesthesia • Practical Approach to Cardiac Anaesthesia(Henseley & Martin) • Harrison’s Textbook of Internal Medicine • Davidson’s Textbook Of Medicine
VALVULAR HEART DISEASE THANK YOU

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Valvular Heart Disease & Anaesthetic Implications

  • 1.
    VALVULAR HEART DISEASE CHAIRPERSON: Dr.S.B.Gangadhar MODERATOR: Dr. Abhishek. M.S. PRESENTER : Dr. Daber Pareed VALVULAR HEART DISEASE
  • 2.
    VALVULAR HEART DISEASE DEFINITION • Anacquired or congenital disorder of a cardiac valve characterized by stenosis (obstruction) or regurgitation (backward flow) of blood
  • 3.
    VALVULAR HEART DISEASE  AllVHD are characterized by abnormalities of ventricular loading.  The status of the ventricle changes over time as ventricular function and the valvular defect are influenced by the progression of volume or pressure overload.  Valvular heart disease places a haemodynamic burden on the left ventricle and/or right ventricle  Initially tolerated, as CVS compensates for overload.  Haemodynamic overload1)Cardiac muscle dysfunction 2)CHF 3)Sudden death
  • 4.
    VALVULAR HEART DISEASE  Themost frequently encountered cardiac valve lesions produce PRESSURE OVERLOAD or VOLUME OVERLOAD on the LA/LV  Perioperative management requires understanding of haemodynamic alterations that accompany valvular dysfunction.
  • 5.
    VALVULAR HEART DISEASE • Anaestheticmgt during periop period is based on likely effects of drug induced changes in cardiac rhythm, heart rate, preload, afterload, myocardial contractility, systemic blood pressure, systemic vascular resistance & pulmonary vascular resistance related to pathophysiology of heart disease.
  • 6.
    VALVULAR HEART DISEASE CARDIOLOGY-BASIC TERMS Systolicfunction – contract and eject blood Contractility – intrinsic ability of myocardium to contract and generate force Preload – load placed on myocardium before contraction – diastolic volume and filling pressure After load – load placed on myocardium during contraction – systolic volume and generated pressure
  • 7.
  • 8.
    VALVULAR HEART DISEASE EVALUATION OFPATIENT Preoperative evaluation of patients with valvular heart disease includes assessment of (1) the severity of the cardiac disease, (2) the degree of impaired myocardial contractility, (3) the presence of associated major organ system disease
  • 9.
    VALVULAR HEART DISEASE • Currentdrug therapy • Presence of secondary effects on pulmonary, renal, and hepatic function. • The presence of concomitant coronary artery disease & other major organ system diseases
  • 10.
    VALVULAR HEART DISEASE NEWYORK HEARTASSOCIATION FUNCTIONAL CLASSIFICATION • Class I - No limitation of physical activity. Ordinary physical activity causes no undue fatigue, palpitations, dyspnea. • Class II - Slight limitation of physical activity. Comfortable at rest, ordinary physical activity results in fatigue palpitations, or dyspnea. • Class III -Marked limitation of physical activity. Comfortable at rest, less than ordinary activity causes fatigue, palpitations dyspnea. • Class IV -Unable to carry out any physical activity without discomfort. Symptoms at rest.
  • 11.
    VALVULAR HEART DISEASE PHYSICAL FINDINGS Signsof congestive heart Failure(CHF) • S3 gallop • Pulmonary rales • Elevated JVP • Hepatojugular reflux • Hepatosplenomegaly • Pedal edema Findings specific to individual valvular lesions (Murmur-character, systolic/diastolic , location ,intensity,grade,radiation) Neurologic deficits secondary to embolic phenomena
  • 12.
    VALVULAR HEART DISEASE INVESTIGATIONS • Tailoredto the patient and the procedure: • ECG - LVH,RVH,arrythmias, ischaemia • Chest X-ray- assess cardiac size and the presence of pulmonary vascular congestion. • Echocardiography • Cardiac catheterization to identify a)Coexisting CAD b)Severity of stenosis/regurgitation (transvalvular pressure gradients) c)Intracardiac shunts d)Clinical & Echo discrepancies
  • 13.
    VALVULAR HEART DISEASE • Serumelectrolytes • Renal function tests • Coagulation profile • ABG- significant pulmonary symptoms
  • 14.
    VALVULAR HEART DISEASE DOPPLER ECHOIN VHD-PURPOSE • Determine significance of cardiac murmurs • Determine transvalvular pressure gradient • Determine valve area,cavity dimensions • Determine ventricular ejection fraction • Diagnose valvular regurgitation • Evaluate prosthetic valve function
  • 15.
  • 16.
    VALVULAR HEART DISEASE HIGH- ANDMODERATE-RISK PATIENTS - PROPHYLAXIS RECOMMENDED(CLASS 1) • Prosthetic valves / history of infective endocarditis • Complex cyanotic congenital heart disease • Surgically constructed systemic-pulmonary shunts or conduits • Congenital cardiac valve malformations -bicuspid aortic valves • A history of surgical valve repair • Hypertrophic cardiomyopathy with resting/latent obstruction • MVP with auscultatory evidence of valvular regurgitation and/or thickened leaflets on echocardiography
  • 17.
    VALVULAR HEART DISEASE • Isolatedsecundum ASD • >6 months after successful surgical or percutaneous repair of ASD, VSD, PDA • MVP without MR or thickened leaflets on echocardiography • Physiologic heart murmurs • Echo e/o physiologic MR with absence of murmur with structurally normal valves • Echo e/o physiologic TR and or PR with absence of a murmur and with structurally normal valves LOW-RISK PATIENTS - PROPHYLAXIS NOT RECOMMENDED(CLASS 111)
  • 18.
  • 19.
    VALVULAR HEART DISEASE PROSTHETIC VALVES Bioprosthetic Mechanical Bioprostheticvalves • Heterogeneous grafts made from animal tissue • Low thrombogenic potential • Do not need systemic anticoagulation • Aspirin is recommended
  • 20.
    VALVULAR HEART DISEASE Mechanical valves •Longer lasting • Need lifelong anticoagulation - Warfarin therapy. • Aspirin is usually combined with warfarin in mechanical heart valves. • Aspirin allergy – clopidogrel
  • 21.
    VALVULAR HEART DISEASE PATIENTS WITHPROSTHETIC VALVES UNDERGOING SURGICAL PROCEDURES • Complete history and physical examination. • Type of valve inserted. • Auscultation - high-pitched, crisp opening and closing sounds • Bioprosthetic valves do not have special auscultatory characteristics. • Onset of new murmurs / change in quality of murmurs - problem with the valve /endocarditis
  • 22.
    VALVULAR HEART DISEASE AHA BRIDGINGRECOMMENDATIONS FOR INTERRUPTION OF WARFARIN THERAPY FOR NON- CARDIAC SURGERY AND INVASIVE PROCEDURES (i)Low risk of thrombosis- Eg:- Bileaflet mechanical aortic valve without risk factors o Warfarin stopped 48 to 72 hour before surgery o INR to fall to 1.5 o Warfarin restarted within 24 hours after the procedure
  • 23.
    VALVULAR HEART DISEASE (ii)High riskfor thrombosis – Eg:-Mechanical mitral valve or a mechanical aortic valve with any risk factor • Warfarin stopped 48 to 72 hrs • Unfractionated heparin(UFH) - INR falls < 2.0 , stopped 4 to 6 hours before. • Warfarin restarted soon after • Heparin continued until INR returns to therapeutic range with warfarin
  • 24.
    VALVULAR HEART DISEASE MAJOR VALVULARLESIONS • LT SIDED • RT SIDED
  • 25.
  • 26.
    VALVULAR HEART DISEASE Mitral stenosis ETIOLOGY Almostalways rheumatic in origin Elderly - heavy calcification Rarely - • Congenital mitral stenosis • Rheumatoid arthritis
  • 27.
    VALVULAR HEART DISEASE • Mitralstenosis primarily affects females. • Diffuse thickening of the mitral leaflets and subvalvular apparatus,commissural fusion, and calcification of the annulus and leaflets are typically present. • This process occurs slowly,and many patients do not become symptomatic for 20 to 30 years after the initial episode of rheumatic fever. • Over time, the mitral valve becomes stenotic, and CHF, pulmonary hypertension, and right ventricular failure may develop
  • 28.
    VALVULAR HEART DISEASE CLINICAL FEATURESOF MITRAL STENOSIS Symptoms • Breathlessness - pulmonary congestion • Fatigue - low cardiac output • Oedema, ascites - right heart failure • Palpitation- atrial fibrillation • Haemoptysis - pulmonary congestion, pulmonary embolism • Cough - pulmonary congestion • Chest pain - pulmonary hypertension • Thromboembolic complication - stroke, ischaemic limb
  • 29.
    VALVULAR HEART DISEASE Pathophysiology • Thenormal mitral valve orifice area is 4 to 6 cm2. • Mitral stenosis is characterized by mechanical obstruction to left ventricular diastolic filling secondary to a progressive decrease in the size of the mitral valve orifice. • This valvular obstruction produces an increase in left atrial volume and pressure. • With mild mitral stenosis, left ventricular filling and stroke volume are maintained at rest by an increase in left atrial pressure.
  • 30.
    VALVULAR HEART DISEASE • Symptomsusually develop when mitral valve area is less than 1.5 cm2 Symptoms usually develop when mitral valve area is less than 1.5 cm2. • As the disease progresses the pulmonary venous pressure is increased in association with the increase in left atrial pressure. • The result is transudation of fluid into the pulmonary interstitial space, decreased pulmonary compliance, and increased work of breathing, which leads to progressive dyspnea on exertion.
  • 31.
    VALVULAR HEART DISEASE SIGNS • Mitralfacies • Atrial fibrillation - irregularly irregular pulse, pulse deficit • Signs of pulmonary hypertension • Auscultation – Loud first heart sound, opening snap – Loud P2- pulmonary htn – Low-pitched rough rumbling mid-diastolic murmur with presystolic accentuation best heard at the apex with bell of steth in left lateral decubitus position,breath held in expiration • Signs of raised pulmonary capillary pressure – Crepitations, pulmonary oedema, effusions
  • 32.
    VALVULAR HEART DISEASE • ECG-Tallpeaked P wave in lead 2,upright in V1 RAD,RVH-Severe PAH • CXR- 1. Straightening of upper left cardiac border 2. Prominence of main pulmonary arteries 3. Dilatation of upper lobe pulmonary veins 4. Postr displacement of esophagus by enlarged LA 5. Kerley-B lines-Fine, dense, opaque, horizontal lines most prominent in lower&mid zones
  • 33.
  • 34.
    VALVULAR HEART DISEASE ECHO • Echocardiographyis used to assess the anatomy of the mitral valve, including the degree of leaflet thickening, calcification, changes in mobility, and extent of involvement of the subvalvular apparatus. • The severity of mitral stenosis is assessed by calculation of mitral valve area and measurement of the transvalvular pressure gradient. • Echocardiography also allows evaluation of cardiac chamber dimensions, pulmonary hypertension, left and right ventricular function, and other valvular disease, and examination of the left atrial appendage for the presence or absence of thrombus
  • 35.
    VALVULAR HEART DISEASE MITRAL STENOSISSEVERITY • Mild Moderate Severe Pulmonary artery systolic pressure (mm Hg) Normal – 18-25mmHg Less than 30 30–50 Greater than 50 Valve area (cm2) Greater than 1.5 1.0–1.5 Less than 1.0
  • 36.
    VALVULAR HEART DISEASE MANAGEMENT Minor symptoms– medical treatment • Diuretics - ↓pulmonary congestion • Digoxin, β-blockers , CCB - control ventricular rate in AF • Anticoagulants - ↓risk of embolism • Antibiotic prophylaxis - infective endocarditis Definitive treatment – Surgical Severe symptoms(NYHA III/IV) Symptomatic despite medical treatment Pulmonary hypertension)(PA systolic pressure>50mm of Hg) balloon valvuloplasty, mitral valvotomy , mitral valve replacement
  • 37.
    VALVULAR HEART DISEASE ANAESTHETIC GOALS •Maintenance of adequate diastolic filling time(prevent tachycardia & treat promptly in periop period) • Preservation of adequate preload with out overload/pulm vascular congestion. • Avoid hypovolemia • Avoidance of factors that precipitate pulmonary vasoconstriction & impair RV function • Maintenance of the contractile state and systemic and coronary artery perfusion pressure. • Maintain sinus rhythm • Maintain afterload
  • 38.
    VALVULAR HEART DISEASE ANAESTHETIC GRIDIN MS LV PRELOAD HR RHYTHM CONTRACTILITY SVR PVR MS ↑ ↓ Controlled ventricula r response Maintain constant Maintain ↓
  • 39.
    VALVULAR HEART DISEASE PREOPERATIVE MEDICATION •Decrease anxiety and associated tachycardia- low dose Opioids and benzodiazepines (Avoid oversedation!!!....sensitive to small doses of narcotics& hypnotics) • Drugs for HR control- continued till time of surgery • Diuretic-induced hypokalemia detected and treated preoperatively • Continue anticoagulant therapy for minor surgery • Major surgery with significant blood loss – regional techniques - discontinue anticoagulants
  • 40.
    VALVULAR HEART DISEASE INDUCTION OFANESTHESIA • Avoid ketamine - increase the heart rate • Intubation & muscle relaxation by cardiostable muscle relaxant - VECURONIUM • Avoid relaxants with histamine release. • Short acting β blocker for rate control(Esmolol)
  • 41.
    VALVULAR HEART DISEASE MAINTENANCE OFANESTHESIA • Nitrous oxide/ low conc volatile anesthetic/Opioid • Nitrous oxide - pulmonary vasoconstriction = no clinical significance unless pul HTN present. • Cardiostable muscle relaxants • Reversal - slowly to prevent drug-induced tachycardia caused by anticholinergic drug • Intraoperative fluids – careful titration – avoid fluid overload
  • 42.
    VALVULAR HEART DISEASE MONITORING Monitoring asymptomaticpatients without evidence of pulmonary congestion - routine monitors Symptomatic mitral stenosis undergoing major surgery * Central venous pressure(CVP) *Transesophageal echocardiography (TEE) *Intra-arterial pressure(IBP) *Pulmonary artery pressure(Caution in pulm htn….PA rupture from wedging catheter) *Left atrial pressure *ABG-adjust ventilatory parameters
  • 43.
    VALVULAR HEART DISEASE POSTOPERATIVE MANAGEMENT •Risk of pulmonary edema and RV failure continues into postop period • Cardiovascular monitoring continued • Relief of postoperative pain (painhypoventilnresp acidosis & hypoxemiaincr in HR & PVR) Opioids I/V or NEURAXIAL • Decreased pulmonary compliance and increased work of breathing - mechanical ventilation maybe required
  • 44.
    VALVULAR HEART DISEASE INTERACTION WITHPREGNANCY • Expanded blood volume of pregnancy increases the risk of pulmonary congestion and edema • Physiologic tachycardia of pregnancy ↓ left ventricular filling time ↑ left atrial and pulmonary arterial pressures.
  • 45.
    VALVULAR HEART DISEASE • Vaginaldelivery: Early admission/invasive blood pressure monitoring/ Small top-ups for epidural/avoid fluid overload .  Caesarean delivery - Spinal anaesthesia avoided.  Careful epidural anaesthesia in NYHA class 1 and 2 patients  General anaesthesia NYHA class 3 and 4 patients  Bolus oxytocin contraindicated - risk of systemic hypotension and pulmonary hypertension.  Brief period of postoperative ventilation may be required in some cases.
  • 46.
    VALVULAR HEART DISEASE MITRAL REGURGITATION Acute •Endocarditis • Papillary muscle rupture (post-MI) • Trauma Chordal rupture • leaflet flail (MVP) Chronic • Myxomatous (MVP) • Rheumatic fever • Endocarditis (healed) • Mitral annular calcification • Congenital (cleft, AV canal) • Ischemic (LV remodeling) • Dilated cardiomyopathy
  • 47.
    VALVULAR HEART DISEASE MR-PATHOPHYSIOLOGY • Thebasic hemodynamic derangement in mitral regurgitation is a decrease in forward left ventricular stroke volume and cardiac output. • A portion of every stroke volume is regurgitated through the incompetent mitral valve back into the left atrium, which results in left atrial volume overload and pulmonary congestion. • Patients with a regurgitant fraction of more than 0.6 are considered to have severe mitral regurgitation.
  • 48.
    VALVULAR HEART DISEASE The fractionof left ventricular stroke volume that regurgitates into the left atrium depends on (1) the size of the mitral valve orifice (2) heart rate, which determines the duration of ventricular ejection (3) pressure gradients across the mitral valve. • Such gradients are related to left ventricle compliance and impedance to left ventricular ejection into the aorta. • Pharmacologic interventions that increase or decrease systemic vascular resistance have a major impact on the regurgitant fraction in patients with mitral regurgitation.
  • 49.
    VALVULAR HEART DISEASE CLINICAL FEATURESOF MITRAL REGURGITATION Symptoms • Dyspnoea- pulmonary venous congestion • Fatigue - low cardiac output • Palpitation • Oedema, ascites - right heart failure Signs • Atrial fibrillation/flutter • Cardiomegaly • Apical pansystolic murmur ± thrill • Soft S1, apical S3 • Signs of pulmonary venous congestion- Crepitations, pulmonary oedema, effusions • Signs of pulmonary hypertension and right heart failure
  • 50.
    VALVULAR HEART DISEASE SEVERITY OFMR Method MILD Moderate Severe Regurgitant volume 30-40 mL 40-60 mL >60 mL Regurgitant fraction 10%-30% 30%-50% >55% Regurgitant orifice area <0.2 cm2 0.3-0.4 cm2 >0.4 cm2
  • 51.
    VALVULAR HEART DISEASE MANAGEMENT • Diuretics •Vasodilators . ACE inhibitors • Digoxin - AF • Anticoagulants – AF • Antibiotic prophylaxis - IE Surgical valvuloplasty • with moderate to severe symptoms • regurgitant volume 30-60%
  • 52.
    VALVULAR HEART DISEASE ANAESTHETIC MANAGEMENT Primarygoal - maintaining forward systemic flow & reduction regurgitant fraction HR- high-normal range -80 to 100 beats/min Avoid bradycardia -↑ duration of systole prolongs regurgitation Rhythm- maintain sinus rhythm Preload- Maintain or slightly increase- elevated preload cause an ↑regurgitant flow- low preload inadequate cardiac output Afterload- Decrease to improve forward cardiac output-avoid sudden increases in SVR Contractility- Maintain or increase to decrease left ventricular volume
  • 53.
    VALVULAR HEART DISEASE ANAESTHETIC GRIDIN MR LV PRELOAD HR RHYTHM CONTRACTILITY SVR PVR Maintai n higher rate Maintain sinus rhythm Maintain ↓ ↓
  • 54.
    VALVULAR HEART DISEASE INDUCTION OFANESTHESIA • With an intravenous induction drug. • Dosing adjusted to prevent ↑SVR & ↓HR • muscle relaxant - Pancuronium modest ↑in heart rate
  • 55.
    VALVULAR HEART DISEASE MAINTENANCE OFANESTHESIA • Volatile anesthetics- isoflurane, desflurane & sevoflurane - choices for maintenance of anesthesia. • Severely compromised myocardium - opioid-based anesthetic is preferred - minimal myocardial depression. • Mechanical ventilation - adjusted to maintain near-normal acid-base and respiratory parameters. • The pattern of ventilation - provide sufficient time between breaths for venous return. .
  • 56.
    VALVULAR HEART DISEASE PREGNANCY CONSIDERATIONS •No specific recommendations for management of MR during labour and delivery. • Prior to labour- symptoms - managed with diuretics & vasodilators. • Labour & CS - regional anaesthesia well tolerated. • NYHA class 3-4- GA may be required.
  • 57.
    VALVULAR HEART DISEASE MITRAL VALVEPROLAPSE • Prolapse of one or both mitral leaflets into left atrium during systole with or without mitral regurgitation • Most common form of valvular heart disease • Common in young women Associated with • Marfan syndrome • Rheumatic carditis • Myocarditis • Thyrotoxicosis • Systemic lupus erythematosus
  • 58.
    VALVULAR HEART DISEASE • Maybeanatomical or functional • Anatomical -Redundant & thickened leaflets - Connective tissue diseases , elderly men • Functional - Normal appearing leaflets/mild bowing only
  • 59.
    VALVULAR HEART DISEASE CLINICAL FEATURES •Anxiety • orthostatic symptoms • Palpitations • Dyspnea • Fatigue • atypical chest pain • Cardiac dysrhythmias Older men with anatomical MVP can p/w mild to moderate CHF(exercise intolerance, DOE, orthopnoea)
  • 60.
    VALVULAR HEART DISEASE • Midsystolicclick+/- systolic murmur(in absence of symptoms doesn’t warrant a cardio consultation) • S3 gallop,Midsystolic/holosystolic murmur,basal creps -CHF
  • 61.
    VALVULAR HEART DISEASE complications • cerebralembolic events • infective endocarditis • severe mitral regurgitation requiring surgery • Dysrhythmias • sudden death
  • 62.
    VALVULAR HEART DISEASE PREOPERATIVE EVALUATION •Functional disease from those with significant mitral regurgitation • β-blockers to control dysrhythmias continued throughout the periop period • Anticoagulants
  • 63.
    VALVULAR HEART DISEASE Management ofanaesthesia-principles Periop factors which ↑ LV emptying& ↓ filling avoided: 1)↑ sympathetic activity 2) ↓ SVR 3)Upright posture 4)Hypovolemia (↓ LV filling)
  • 64.
    VALVULAR HEART DISEASE SELECTION OFANESTHETIC TECHNIQUE • Most MVP have normal left ventricular function • Tolerate all forms of general and regional anesthesia. • General-volatile anaesthetic induced myocardial depression beneficial • Regional- maintain adequate intravascular volume to prevent fall in SVR
  • 65.
    VALVULAR HEART DISEASE INDUCTION OFANESTHESIA • Intravenous induction drug- avoid significant & prolonged ↓ SVR • Etomidate - choice for induction in hemodynamically significant MVP • Ketamine avoided - ↑ sympathetic NS activity- ↑ MVP and MR
  • 66.
    VALVULAR HEART DISEASE MAINTENANCE OFANESTHESIA • Volatile anesthetics /nitrous oxide / opioids-titrate doses to maintain SVR • 0.5 MAC of isoflurane, desflurane, and sevoflurane can decrease the regurgitant fraction • Muscle relaxants- Vecuronim/Pancuronium • Proper fluid balance • Vasopressors - α-agonist - phenylephrine acceptable.
  • 67.
    VALVULAR HEART DISEASE • Invasivemonitoring –in haemodynamically significant MVP only (MR/LV dysfunction) COMPLICATIONS Ventricular dysrhythmias- cause of death in young adults with undiagnosed MVP- Rx -beta blockers , Lidocaine
  • 68.
    VALVULAR HEART DISEASE Aortic Stenosis •Two factors are associated with development of aortic stenosis. 1. Degeneration and calcification of the aortic leaflets and subsequent stenosis. This is a process of aging. 2. Presence of a bicuspid rather that a tricuspid aortic valve.
  • 69.
    VALVULAR HEART DISEASE CAUSES OFAORTIC STENOSIS Infants, children, adolescents • Congenital aortic stenosis • Congenital subvalvular aortic stenosis • Congenital supravalvular aortic stenosis Young adults to middle-aged • Calcification and fibrosis of congenitally bicuspid aortic valve • Rheumatic aortic stenosis Elderly • Degeneration & calcification with ageing
  • 70.
    VALVULAR HEART DISEASE AS-PATHOPHYSIOLOGY • Obstructionto ejection of blood into the aorta caused by a decrease in the aortic valve area necessitates an increase in left ventricular pressure to maintain stroke volume. • The normal aortic valve area is 2.5 to 3.5 cm2. • Transvalvular pressure gradients higher than 50 mm Hg and an aortic valve area of less than 0.8 cm2 are characteristic of severe aortic stenosis. • Aortic stenosis is almost always associated with some degree of aortic regurgitation
  • 71.
    VALVULAR HEART DISEASE • Anginapectoris may occur in patients with aortic stenosis despite the absence of coronary disease. • Goldman and colleagues in 1977 showing that patients with aortic stenosis had an increased risk of perioperative cardiac complications, many studies have demonstrated that patients with aortic stenosis have an increased risk of perioperative mortality and of nonfatal myocardial infarction regardless of the presence or absence of risk factors for coronary artery disease
  • 72.
    VALVULAR HEART DISEASE CLINICAL FEATURESOF AORTIC STENOSIS Symptoms(develop when preload reserve exhausted) • Angina • Exertional syncope • Exertional dyspnoea • Sudden death • Episodes of acute pulmonary oedema Signs • Slow-rising carotid pulse • Narrow pulse pressure • Heaving apex beat (LV pressure overload) • Ejection systolic murmur aortic area • Signs of pulmonary venous congestion (crepitations)
  • 73.
    VALVULAR HEART DISEASE DIAGNOSIS • ECG:LVH •CXR-Ascending aorta dilatation(post-stenotic) • Echo+Doppler-Assess severity of AS: a) Aortic valve area b) Transvalvular pressure gradient c) LVH Other points noted in Echo- Valve thickening/calcification Mobility of leaflets Bicuspid valve Systolic/diastolic dysfunction
  • 74.
    VALVULAR HEART DISEASE C-Xray –Ascending aorta dilation
  • 75.
    VALVULAR HEART DISEASE SEVERITY OFAS Grade Mean Pressure Gradient (mm Hg) Valve Area (cm2) Mild <25 ≥1.5 Moderate 25-40 1.0-1.5 Severe 40-50 0.7-1.0 Critical >50 <0.7 The normal valve area is 2.5 to 3.5 cm2
  • 76.
    VALVULAR HEART DISEASE TREATMENT • Asymptomatic- medical management • Symptomatic - Aortic valve replacement • Coronary revascularization - pts with both aortic stenosis and CAD • Percutaneous aortic balloon valvotomy - adolescents & young adults with congenital /rheumatic etiology
  • 77.
    VALVULAR HEART DISEASE Indications foraortic valve replacement • Severe AS with any of the classic symptoms(angina/syncope/dyspnoea) • Severe AS undergoing CABG • Severe AS undergoing surgeries on aorta or other heart valves • Operative mortality is high in pts with severe LV dysfunction & low transvalvular pressure gradient but improves fnctionl status.
  • 78.
    VALVULAR HEART DISEASE MANAGEMENT OFANESTHESIA  Principle: AS is a fixed cardiac output state & hypertrophied LV is sensitive to ischemia  Prevention of hypotension & hemodynamic changes that ↓cardiac output Anesthetic Considerations • Maintain normal sinus rhythm /Avoid bradycardia or tachycardia • Avoid hypotension • Optimize intravascular fluid volume to maintain venous return and left ventricular filling
  • 79.
    VALVULAR HEART DISEASE ANAESTHETIC GRIDIN AS LV PRELOAD HR RHYTHM CONTRACTILITY SVR PVR ↑ Avoid ↓ or↑ Maintain sinus rhythm Maintain constant ↑ Maintain constant
  • 80.
    VALVULAR HEART DISEASE Key ptsin intraop BP management • Rx intraop hypotension with directly acting alpha agonists(phenylephrine)…. • Rapid transfusion to correct hypovolemia /cardioversion shouldn’t delay administration of direct acting vasopressors • Inotropes-if signs of myo ischemia persist despite above Rx • Avoid vasodilators to Rx intraop HTN
  • 81.
    VALVULAR HEART DISEASE INDUCTION OFANESTHESIA • General anesthesia selected in preference to neuraxial block – HYPOTENSION Induction of anesthesia Etomidate, opioids, midazolam Ketamine - avoid Thiopentone - decreases preload Propofol – hypotension
  • 82.
    VALVULAR HEART DISEASE MAINTENANCE OFANESTHESIA • Nitrous oxide / volatile anesthetic and opioids or by opioids alone. • Marked LV dysfunction - nitrous oxide + opioids or high dose opioids alone - recommended • Fentanyl (10–25μg/kg) OR Sufentanil (2–5μg/kg) primary anesthetic for maintenance
  • 83.
    VALVULAR HEART DISEASE MAINTENANCE • Neuromuscularblocking drugs with minimal hemodynamic effects
  • 84.
    VALVULAR HEART DISEASE PREGNANCY CONSIDERATIONS CS •GA with invasive haemodynamic monitoring • Spinal anaesthesia contraindicated VAGINAL DELIVERY • careful epidural analgesia • maintenance of BP with vasopressors – phenylephrine
  • 85.
    VALVULAR HEART DISEASE AORTIC REGURGITATION ETIOLOGY Congenital •Bicuspid valve or disproportionate cusps Acquired • Rheumatic disease • Infective endocarditis • Trauma • Aortic dilatation - Marfan's syndrome, aneurysm, dissection, syphilis, ankylosing spondylitis
  • 86.
    VALVULAR HEART DISEASE PATHOPHYSIOLOGY • Thebasic hemodynamic derangement in aortic regurgitation is a decrease in cardiac output because of regurgitation of a part of the ejected stroke volume from the aorta back into the left ventricle during diastole. Combined pressure and volume overload on the left ventricle
  • 87.
    VALVULAR HEART DISEASE The magnitudeof the regurgitant volume depends on (1) the time available for the regurgitant flow to occur, which is determined by the heart rate (2) the pressure gradient across the aortic valve, which is dependent on the systemic vascular resistance. • The magnitude of aortic regurgitation is decreased by tachycardia and peripheral vasodilation. • With aortic regurgitation, the entire stroke volume is ejected into the aorta. Because the pulse pressure is proportional to the stroke volume and aortic elastance, the increased stroke volume increases systolic pressure, and systolic hypertension increases afterload.
  • 88.
    VALVULAR HEART DISEASE • Theleft ventricle compensates by developing hypertrophy and enlarging to accommodate the volume overload. • Because of the increased oxygen requirements necessitated by left ventricular hypertrophy and the decrease in aortic diastolic pressure, which reduces coronary blood flow, angina pectoris may occur in the absence of coronary artery disease.
  • 89.
    VALVULAR HEART DISEASE CLINICAL FEATURES SymptomsMild to moderate AR • Often asymptomatic • palpitations Severe AR • Breathlessness • Angina
  • 90.
    VALVULAR HEART DISEASE CLINICAL FEATURES Signs •Pulse - collapsing' pulse • increased pulse pressure • Bounding peripheral pulse • Capillary pulsation in nail beds • Femoral bruit Murmurs • Early diastolic murmur • Systolic murmur (increased stroke volume) • Austin Flint murmur (soft mid- diastolic) Other signs • Displaced, heaving apex beat (volume overload) • Fourth heart sound • Pulmonary venous congestion (crepitations)
  • 91.
    VALVULAR HEART DISEASE SEVERITY OFAORTIC REGURGITATION by Echocardiography • Mild Moderate Severe Regurgitant jet width as percentage of LVOT width 25–46 47–64 >65 Regurgitant jet area as percentage of LVOT area 4–24 25–59 >60
  • 92.
    VALVULAR HEART DISEASE TREATMENT Medical Therapy AsymptomaticPatients with Normal Left Ventricular Function  Afterload reduction Vasodilators Nifedipine ACE inhibitors Hydralazine Surgical Therapy Acute Aortic Regurgitation 1) Vasodilators – Nitroprusside 2)course of antibiotics 3) Valve replacement /repair Chronic Aortic Regurgitation Aortic valve repair Aortic valve prosthesis
  • 93.
    VALVULAR HEART DISEASE ANAESTHETIC GOALS •Normal heart rate - Avoid bradycardia • Maintain sinus rhythm • Adequate volume loading • High normal systemic vascular resistance • Minimize myocardial depression
  • 94.
    VALVULAR HEART DISEASE ANAESTHETIC GRIDIN AR LV PRELOAD HR RHYTHM CONTRACTILITY SVR PVR ↑ ↑ Maintain sinus rhythm Maintain ↓ Maintain constant
  • 95.
    VALVULAR HEART DISEASE INDUCTION OFANESTHESIA • In stable patients - sodium thiopental / Etomidate • Alternatively - high dose narcotic and benzodiazepine induction • critically ill with acute AR - require inotropic and vasodilatory support prior to induction of anesthesia.
  • 96.
    VALVULAR HEART DISEASE MAINTENANCE OFANESTHESIA • Severe LV dysfunction- nitrous oxide plus a volatile anesthetic and/or opioid. • Isoflurane, desflurane & sevoflurane • Severe LV dysfunction - high dose opioid • Bradycardia and myocardial depression – N2O / BZD high-dose narcotic
  • 97.
    VALVULAR HEART DISEASE  Increasein heart rate associated with PANCURONIUM administration could be helpful.  Bradycardia with hemodynamic compromise treated promptly.  Atropine 0.4–0.8mg  Ephedrine - poor choice because ↑in afterload Hypotension not treated routinely with vasopressors Spinal/Epidural well tolerated.
  • 98.
    VALVULAR HEART DISEASE PREGNANCY CONSIDERATIONS •Avoidance of aortocaval compression • Epidural analgesia and anesthesia ↓ afterload and is preferred for vaginal / cesarean delivery • During labor early administration of epidural analgesia prevents the pain-associated ↑ SVR –prevent acute LV volume overload • Bradycardia not tolerated - treated promptly.
  • 99.
    VALVULAR HEART DISEASE Right-sided valvularlesions TRICUSPID STENOSIS • Rare & usually coexists with MS • Back pressure into the right atrium • Upper-extremity venous congestion, hepatic enlargement, and ascites • Medical:Salt restriction, digitalization, diuretics • Surgical therapy- valvuloplasty/ valve replacement • Anaesthetic goal: Maintain preload & control HR
  • 100.
    VALVULAR HEART DISEASE TRICUSPID REGURGITATION •It is usually functional • Caused by tricuspid annular dilation secondary to RV enlargement or pulmonary hypertension OTHER CAUSES OF TR • infective endocarditis, • rheumatic fever • chest trauma • Ebstein’s anomaly
  • 101.
    VALVULAR HEART DISEASE • TRis well tolerated by most patients in the absence of pulmonary hypertension. • In moderate to severe TR, tricuspid annuloplasty may be considered  N2O can increase TR  Inotropes like dobutamine, isoproterenol dilate pulmonary vasculature
  • 102.
    VALVULAR HEART DISEASE THE PULMONICVALVE • Isolated from the other three heart valves by the infundibulum. • Pulmonary valvular disease is usually congenital • Stenosis > regurgitation • Congenital pulmonary stenosis is usually treated with balloon valvuloplasty.
  • 103.
    VALVULAR HEART DISEASE • Mildpulmonary regurgitation occurs in cardiac surgical patients with a PAC • Significant PR rare & well tolerated • RV dysfunction secondary to pulmonary regurgitation should be surgically corrected.
  • 104.
    VALVULAR HEART DISEASE REFERENCES • Stoelting’sTextbook of Coexisting diseases • Miller’s Textbook of Anaesthesia • Kaplan’s Textbook of Cardiac anaesthesia • Practical Approach to Cardiac Anaesthesia(Henseley & Martin) • Harrison’s Textbook of Internal Medicine • Davidson’s Textbook Of Medicine
  • 105.