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MITRAL STENOSIS & REGURGITATION Pathophysiology & Anesthetic considerations for non-cardiac surgery. Presenter: Dr Prashant Kumar. University College of Medical Sciences & GTB Hospital, Delhi. Mitral Stenosis. Mitral valve is present between LA & LV

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Mitral stenosis regurgitation pathophysiology anesthetic considerations for non cardiac surgery

MITRAL STENOSIS & REGURGITATIONPathophysiology & Anesthetic considerations for non-cardiac surgery

Presenter: Dr Prashant Kumar

University College of Medical Sciences & GTB Hospital, Delhi

Mitral stenosis

Mitral Stenosis

  • Mitral valve is present between LA & LV

  • Normal mitral valve orifice area (MVA): 4-6cm2

  • MVA <2.5cm2 leads to symptoms

  • Decrease in Mitral valve orifice area leading to chronic & fixed mechanical obstruction to LV filling is termed as MS.



  • Rheumatic Heart disease

  • SLE

  • Carcinoid syndrome

  • Active Infective Endocarditis

  • Left atrial myxoma

  • Congenital mitral stenosis

  • Massive Annular Calcification

Rheumatic mitral stenosis

Rheumatic mitral stenosis

  • More common in females (2/3rd of all pts)

  • Symptoms occur two decades after onset of Rheumatic fever

  • Age of presentation

    • Earlier in 20s-30s

    • Now in 40s-50s (slower progression)

  • Isolated MS in 40% cases of RHD

    • Remaining 60% cases associated with other valvular diseases- MR/AR

Patho physiology


  • Immunological disorder initiated by Group A beta hemolytic streptococcus.

  • Antibodies produced against streptococcal cell wall proteins & sugars react with connective tissues & heart; result in rheumatic fever and symptoms like

    • Carditis

    • Arthritis

    • Subcutaneous nodules

    • Chorea

    • Erythema marginatum

Presenter dr prashant kumar

  • Chronic cardiac & valvular inflammation leads to cardiac & valvular pathology

  • Valvular pathology

    Rheumatic fever involving mitral valves

    Valve leaflet thickening and fusion of commissures

    Increased rigidity of valve leaflets

    Thickening, fusion and contracture of chordae & papillary heads

    Leaflet calcification (long standing MS)

    Progressive reduction in mitral valve orifice area

    Mitral Stenosis

Presenter dr prashant kumar

Mechanical obstruction to left ventricular diastolic filling

Adaptative ↑ in LAP to maintain LV filling


LA enlargement ↑ in pulmonary venous pressure → ↑ in pulmonary arterial pressure*

Atrial fibrillationTransudation of fluid into pulmonary interstitial space

Thrombus formation

Systemic thrombo-embolism ↓ed pulmonary compliance ↑Work of breathing

Progressive dyspnoea on exertion/rest

Acute conditions like AF, Pregnancy, Pain, sepsis

(↑ HR/CO)

Acute ↑ in LAP

Pulmonary edema

↑ in pulmonary arterial pressure*--------→ Pulmonary arterial hypertrophy (Pulmonary HTN)

RV hypertrophy and dilatation

RV failure

Effect of ms on left ventricle

Pressure gradient between LA & LV

Effect of MS on left ventricle

Effect of heart rate

Effect of heart rate

  • Gorlin formula

    Valve area = Transvalvular flow rate (ml/s)

    K x PG1/2

    (PG: Transvalvular pressure gradient, mmHg)

    (K is a hydraulic-pressure constant =38)

  • Tachycardia shortens diastole more proportionately than systole

  • Decreases the overall time for transmitral flow,

  • In order to maintain CO, the flow rate per unit time must increase

  • Pressure gradient increase proportionate to square of flow rate

  • ↑LAP → Pulmonary venous congestion and symptoms.

  • So, patients with MS do not tolerate tachycardia.

Effect of atrial fibrillation in ms

Effect of Atrial fibrillation in MS

  • Increased chances of thrombus formation & systemic thrombo-embolism

  • Normally effective atrial contraction is important in LV diastolic filling

    • In presence of AF

      • Loss of effective atrial contraction

      • ↑ed ventricular rate (↓ed diastolic filling time)

        Impaired LV filling (↓ed LV preload)

        decreased cardiac output



  • Clinical presentation

    • Dyspnea, fatigue, orthopnea, PND, cough, hemoptysis,.

    • 10% patients have anginal type chest pain not attributable to CAD

    • Systemic thromboembolism (first symptom in 20% cases).

  • Physical examination

    • Low volume pulse

    • Sign & Symptoms of right sided heart failure - engorged neck veins, enlarged tender liver

Presenter dr prashant kumar

  • Mitral facies

    ‘Pink purple patches on the cheeks, cyanotic skin changes from low cardiac output’

  • Cardiac auscultation

    • Opening snap

    • Rumbling diastolic murmur best heard at apex radiating to the axilla

    • Loud S2: pulmonary hypertension

  • Presenter dr prashant kumar


    Broad notched P wave (left atrial enlargement)

    Atrial fibrillation

    Presenter dr prashant kumar

    Chest X-ray

    Normal to ↑ed cardiac shadow

    Straightening of the left heart of border and elevation of left main bronchus (left atrial enlargement)

    mitral calcification

    Evidence of pulmonary edema/ HTN

    LAA: Left atrial appendages, MPA: Main pulmonary artery, LPA: left pulmonary artery, RPA: Right pulmonary artery, Ao- Aortic knuckle (Ao)

    Presenter dr prashant kumar

    • Echocardiography

      • Anatomy/size of mitral valve & its appendages

      • severity of MS (area of orifice)

      • Size & function of ventricles

      • Estimation of pulmonary artery pressure

    • Cardiac catheterization and invasive measurement

      • Are almost never necessary

      • Reserved for situations ECHO sub-optimal/conflict with clinical presentation

    Severity of ms

    Severity of MS



    “Symptomatic MS (progressive dyspnoea on exertion, exertional pre-syncope, heart failure) is an active cardiac condition & pt should undergo evaluation & treatment before non cardiac surgery”

    • Emergency surgery

      Mild / Moderate MS

      • High risk

      • Continue medication

      • Proceed with surgery

    • Severe MS

      • Very high risk consent

      • Post- op ventilatory consent

    Presenter dr prashant kumar

    • Pre-operative Optimization of patient

      • Atrial fibrillation

        Sinus rhythm/control of ventricular rate

        1.Digoxin (emergent IV digitalization:- loading dose 0.25mg iv over 15 minutes followed by 0.1mg every hour till response occur or total dose of 0.5-1.0mg. Monitor ECG, BP, CVP; HR <60bpm- Stop)

        2. CCB (verapamil/diltiazem: 0.075-0.15mg/kg IV)

        3. β-blocker (esmolol: 1mg IV)

        4. Amiodarone (loading: 100mg IV, infusion: 1mg/min IV for 6 hrs. 0.5mg/min for next 18 hrs)

        5. Cardioversion in hemodynamic unstable patients

    Presenter dr prashant kumar

    • Pulmonary HTN/Edema/RVF

      1. Oxygen

      2. Diuretic

      Loop diuretics

      High dose deleterious

      Combine with vasodilator

      3. Digitalis

      4. Morphine (0.1mg/kg)

    Presenter dr prashant kumar

    (Pre-operative Optimization of patient> Pulmonary HTN/Edema/RVF continued…)

    5. Vasodilators (NTG)

    Pulmonary vasodilation (↓PAP)

    Start from small dose (0.5–10 μg/kg/min)

    S/E: systemic hypotension

    6. Nesiritide

    Recombinant BNP (Brain natriuretic peptide)

    Arterial & venous dilatation

    Controls dyspnoea in Acute heart failure

    7. Myofilament calcium sensitizer (Levosimendan)

    Inodilators (↑es myocardial contractile strength, dilatation of systemic, pulmonary & coronary artery)

    Presenter dr prashant kumar

    (Pre-operative Optimization of patient> Pulmonary HTN/Edema/RVF continued…)

    8. Inotropic agents




    9. Inodilators



    Presenter dr prashant kumar

    • Elective surgery

      • Mild/ moderate MS

        • Proceed with surgery after evaluation

        • Continue medications

      • Severe MS

        • Cardiology referral/surgical correction

        • Patients taken in optimized condition

    Management of anesthesia anesthetic goals

    Management of Anesthesia Anesthetic goals

    Pre medication

    Pre medication

    • To decrease anxiety & any associated likelihood of adverse circulatory responses produced by tachycardia

    • Drug to control heart rate

    • Antibiotics (prophylaxis for infective endocarditis is no longer recommended) (Ref: Miller’s Anesthesia, 7th edition)



    Standard non-invasive







    Symptomatic pts or major surgery

    Standard non-invasive

    Serial ABG

    Invasive monitoring



    Echocardiography (TTE/TEE)

    Cardiac catheterization


    Intra operative management

    Intra-operative management

    Presenter dr prashant kumar

    Non-opioid induction agents

    Muscle relaxants

    Muscle Relaxants

    Post operative




    Pain relief: multimodal including neuroaxial opioids

    Intravenous fluids



    Pulmonary congestion/edema


    Heart failure


    New york heart association functional classification of patients with heart disease

    New York Heart Association functional classification of patients with heart disease

    Congestive heart failure

    Congestive Heart Failure

    • Diuretics: loop diuretics (furosemide 20-40mg IV); S/E: Hypokalemia

    • Digoxin:

    Therapeutic plasma concentration level: 0.5-2.0ng/ml

    Presenter dr prashant kumar

    Clinical manifestation of digitalis toxicity

    • Plasma level > 3ng/ml

    • Extra Cardiac: Anorexia, nausea, vomiting & abdominal pain (CTZ stimulation)

    • Cardiac: any type of atrial or ventricular arrhythmia, delayed conduction through AV Junction.

      • Atrial tachycardia with AV block is most common arrhythmia

      • Ventricular fibrillation is most frequently cause of death.

        Treatment of digitalis toxicity

    • Stop further dose

    • Correction of hypokalemia, hypomagnesemia, arterial hypoxemia

    • Drugs

      • Phenytoin (0.5-1.5mg/kg IV over 5min), lidocaine (1-2mg/kg IV), atropine (35-70µg/kg IV) for cardiac dysarrhythmia

      • Digiband (digoxin specific antibodies, Fab portion, IV preparation 40mg vial)

    • Insertion of a temporary artificial transvenous cardiac pacemaker

    Anticoagulant therapy

    Anticoagulant therapy

    • Management of Patients on warfarin

      • Emergency surgery

        • Discontinue warfarin

        • Give vitamin K 0.5 – 2.0 mg IV

        • FFP 15 ml/kg repeat if necessary

        • Accept for surgery if INR <1.5

    • Elective surgery

      • Stop 3 days preoperatively

      • monitor INR daily

      • Give heparin when INR <1.5

    Presenter dr prashant kumar

    • Stop heparin 6 hours prior to surgery

    • Check INR

    • Accept for surgery if INR <1.5

    • Restart heparin post-operatively as soon as possible

    • Both to be given for 2 – 3 days, stop heparin if INR 1.5 – 2.0.

    Presenter dr prashant kumar

    • Management of Patients on Heparin

      • Emergency surgery

        • Consider reversal with IV protamine 1 mg for every 100 IU of heparin

      • Elective Surgery

        • Stop heparin 6 hours prior to surgery

        • Check INR, accept for surgery if INR <1.5

        • Restart heparin in post-op as soon as possible

          If patient is on LMWH, we rarely need to stop it.

    Summary of ms

    Summary of MS

    • Is a low & fixed cardiac output condition

    • Stress condition like pregnancy, labour & sepsis, condition become worst- CHF, pulmonary edema, AF

    • Patients may be on diuretics, digitalis & anticoagulant therapy

    • Peri-operatively these patients have to be managed as per medications & guidelines

    • Tachycardia has to be avoided at any cost

    • Pulmonary vasculature resistance has to be reduced

    • Preload & afterload both should be maintained

    • NYHA I & II :- Epidural block or GA

    • NYHA III & IV :- GA preferred over epidural block

    Mitral regurgitation

    Mitral Regurgitation

    Presenter dr prashant kumar

    • Retrograde flow of blood from LV to LA through incompetent mitral valve during systolic phase


      • MR is almost always (90%) associated with MS in RHD

      • Degenerative processes of leaflets and chordal structures

      • Infective endocarditis

      • Mitral annular calcification

    Presenter dr prashant kumar

    • Functional

      Structurally normal leaflets and chordae tendineae

      • Ischemic heart disease (Ischemic MR)

      • Idiopathic dilated cardiomyopathy

      • Mitral annular dilatation

    Pathophysiology of mr

    Pathophysiology of MR

    Mitral regurgitation

    Systolic (Retrograde) ejection into LA

    Acute Chronic

    Volume overload in LA & LV ↓ed LV afterload (into LA)

    ↑ed LA, LV Pressure↑ed LA/LV size/ compliance

    Pulmonary edema ↓ed Cardiac outputLA dilatation↓ed contractility

    AF ↓ CO

    Pulmonary congestion

    Acute mr

    Acute MR

    Sudden onset MR

    Sudden increase in LV preload

    Enhanced LV contractility ↑ed LAP (acute)

    (LV size: N) (LA size: N)

    Ejection into LA & ↑ed Pulm vascul pressure

    systemic circulation

    ↓ cardiac outputPulmonary congestion/edema

    Chronic compensated mr

    Chronic compensated MR

    • Slow development of MR

      Chronic LV overloading

      Eccentric LV hypertrophy LA dilatation

      ↑LV radius, ↑ed wall tensionMaintenance of LAP

      Maintenance of LV systolic function Change in LV compliance

      (LVEDP maintained)

      After load/CO: maintained

      Gradual decline in LV systolic function

      Decompensated phase

    Decompensated phase

    Decompensated phase

    Progressive LV dilatation

    Mitral annular dilatation↑ed wall stress/afterload

    Increased regurgitationdeteoration in LV syslolic

    & diastolic function

    ↑ed LAP

    Atrial enlargement Pulmonary congestion/edema/HTN

    Atrial FibrillationRV dysfunction/failure

    Pathophysiology of ms with mr

    Pathophysiology of MS with MR


    Obstruction of blood flow systolic (retrograde) ejection into LA

    from LA to LV during diastole

    Volume overload in LA Volume overload in LV

    ↓ed LV filling↑ LAP LV dysfunction

    ↓ed CO

    ↓ed COLA dilatation


    (LV size/function: N)

    RV dysfunction

    Mr ms




    • Clinical presentation

      • Fatigue, dyspnoea, orthopnoea/Systemic thrombo-embolism

    • Physical examination

      • Arterial pressure: N/↓

      • Pulse (Water Hammer pulse- ↓DBP, ↑ SBP)

      • Signs of RVF like ↑ JVP

      • Systolic thrill at apex (hyperdynamic circulation)

    • Cardiac auscultation

      • Holosystolic murmur

      • S1 is absent, soft or buried in the systolic murmur

    Presenter dr prashant kumar


    Non-specific findings

    Atrial fibrillation

    LA enlargement/LV hypertrophy

    Chest X-ray

    Left heart chamber enlargement

    Pulmonary congestion

    Presenter dr prashant kumar

    • Echocardiography

      • Diagnosis/mechanism/severity of MR/MS

      • Impact on cardiac chamber size, pressure & function

      • Pulmonary artery pressure

      • Presence of thrombus

    • Cardiac catheterization with left ventriculography

      • invasive

      • Reserved for pts in whom ECHO is sub-optimal

    Presenter dr prashant kumar

    Severity of MR

    Management of anesthesia

    Management of Anesthesia

    Problems to be anticipated:

    • Pulmonary congestion/ edema

    • Atrial fibrillation/ thrombo-embolism

    • LV dysfunction: ↓ CO

    • Acute  in afterload following ET intubation & surgical stimulation  acute decompensation of LV

    • Bradycardia -  time for retrograde blood flow

    • Drug induced myocardial depression

    Presenter dr prashant kumar

    Anesthetic goals in MR Primary goals- Maintain forward systemic flow- Decrease the regurgitant fraction- Optimize RV function

    Anesthetic goals in ms and mr

    Anesthetic Goals in MS and MR

    Technique of anesthesia in mr

    Technique of anesthesia In MR

    Regional vs General Anesthesia in MR

    • Peripheral nerve blocks

      • Safe

      • Avoid intravascular drug injections (ultrasound/nerve stimulator guided blocks)

    • Central neuraxial blocks

      • Preload: ↓HR: ↔/ ↑/ ↓, Contractility: ↔

        Afterload: ↓Pulmonary vasculature: ↔

      • Mild/ Moderate MR (NYHA class I & II): SAB and epidural are well tolerated (avoid bradycardia)

      • Severe MR (NYHA class III & IV): Prefer GA over SAB and epidural



    Standard non-invasive







    Symptomatic pts or major surgery

    Standard non-invasive

    Serial ABG

    Invasive monitoring



    Echocardiography (TTE/TEE)

    Cardiac catheterization


    Management of ga

    Management of GA

    Presenter dr prashant kumar

    Non-opioid induction agents

    Muscle relaxants1

    Muscle Relaxants



    Narcotic oxygen relaxant technique

    Use of N2O – declined

    Summary of mr

    Summary of MR

    • 90% of Rheumatic MR are associated with MS

    • LV has to deal with large volume- only a fraction goes to systemic circulation

    • Patient may present with CHF, pulmonary edema & LV dysfunction

    • Patients may be on diuretics, digitalis & anticoagulants- to be managed as per patients condition and guidelines.

    • Bradycardia has to be avoided at any cost

    • Systemic vascular resistance (afterload) should be kept slightly low

    • Preload should me maintained

    • NYHA I & II :- neuraxial block or GA

    • NYHA III & IV :- GA preferred over neuraxial block



    • Valvular heart disease poses challenge during anesthesia

    • We should know pathophysiology of each valvular heart diseases

    • Most of the time, valvular heart diseases occur in combination

    • Our aim is to maintain normal cardiac output & tissue perfusion by regulating heart rate/rhythm, preload, afterload, myocardial contractility.

    • Use of regional anesthesia is not contraindicated in theses patients, but proper patients selection & precaution are must.



    • Kaplan’s Cardiac Anesthesia; 5th edition

    • Miller’s Anesthesia; 7th edition

    • Clinical Anesthesia; Barash, Cullen, Stoelting, 5th edition

    • Stoelting’s Anesthesia & Co-existing Disease; 5th edition

    • Harrison’s Internal Medicine; 17th edition

    • Wylie & Churchill- Davidson’s A Practice of Anesthesia; 7th edition

    • Clinical Anesthesia; Morgan 4th edition

    Thank you

    Thank you

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