1 / 28

Mitral valve disease – Mitral Regurgitation

Mitral valve disease – Mitral Regurgitation. Mitral valve fails to close completely, causing blood to flow back into the left atrium during ventricular systole of multiple aetiology . www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Anatomy of Mitral valve apparatus.

sarila
Download Presentation

Mitral valve disease – Mitral Regurgitation

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Mitral valve disease – Mitral Regurgitation Mitral valve fails to close completely, causing blood to flow back into the left atrium during ventricular systole of multiple aetiology www.anaesthesia.co.in anaesthesia.co.in@gmail.com

  2. Anatomy of Mitral valve apparatus

  3. 45 year old women diagnosed c/o chronic mitral regurgitation posted for abdominal hysterectomy • Natural history • Pathophysiology • Preoperative assessment • Perioperative management

  4. Clinical presentation • Depends on Etiology Severity of regurgitation Left ventricular function Pulmonary hypertension Atrial fibrillation Mixed valvular lesion Coronary artery disease & Hypertension

  5. Etiopathology • Valve leaflet Rheumatic Carditis Sequlae Myxomatous Degeneration Congenital Cleft Leaflet Marfan Syndrome Infective Endocarditis HOCM Mitral valve prolapse (MVP)

  6. Etiopathology • ChordaeTendinae Rheumatic Ischemic • Papillary Muscles Ischemic • Annulus Calcification - elderly patients Dilatation - functional MR

  7. Pathophysiology

  8. Assessment of severity of MR • Symptoms severity • Presence of PHT • Physical signs of CHF • ECHO

  9. Symptoms Depends on Atrial compliance • Normal compliance – pulmonary congestion symptoms Exertionaldyspnea (NYHA ) Orthopnea Right heart failure symptoms ankle edema upper abdominal pain ascites • Increased compliance - low cardiac output symptoms easy fatigue • Palpitations (Atrial fibrillation) • Embolic symptoms or past history

  10. Ejection fraction (EF) & MR • Fraction of ventricular end diastolic volume ejected EF = EDV- ESV/EDV • Inspiteof LV dysfunction EF may be normal in range • LA acts as low resistance pathway during systole, EF overestimates LV function • LV dysfunction defined as EF< 60% (AHA Guidelines)

  11. Echocardiographic classification of MR

  12. Echocardiographic assessment of regurgitant lesions by color – flow Doppler

  13. Premedication • Standard doses of any common agents well tolerated & desirable in normal ventricular function • Poor ventricular function – doses proportional to severity of ventricular function • Usual medication on the morning of surgery • Supplemental O2 – PHT or pulmonary disease • Antibiotic prophylaxis ? IE , ? Surgical • Anticoagulation management

  14. Monitoring • Depends on LV function & procedure • Full hemodymaic monitoring – if plan for afterload reduction with vasodilators • Color- flow Doppler TEE quantify severity guides therapeutic interventions in severe lesions • Pulmonary artery pressure monitoring

  15. Anesthetic management objectives • Tailored to severity of regurgitation jet, LV function • Avoid factors exacerbating the regurgitation Bradycardia - ↑↑ LV end diastolic volume mitral annular dilatation Acute rise in SVR Excess volume expansion – dilates LV Myocardial depression • Prevent & promptly treat AF

  16. Hemodynamic goalsMaintain forward systolic flow Full, Fast & Vasodilated

  17. Preload • Augment LV preload prior to induction • Remember MR is dynamic • Excess ventricular distension →annular dilatation → worsens MR

  18. Heart rate & Rhythm • Bradycardia detrimental ↑duration of systole→ prolongs regurgitation ↑ diastolic filling→ LV distension • Sinus rhythm preferred LV filling less depends on atrial kick as compared to MS

  19. Contractility • EF underestimates LV systolic function • Avoid myocardial depression • How to manage hypotension? Manipulate volume & heart rate • Persistent hypotension → inotropic support Dobutamine Low Dose Epinephrine Milrinone

  20. Afterload • Low SVR maximizes forward cardiac output Adequate anesthetic depth Systemic vasodilators Inodilators IABP – acute MR • Alpha 1 agonists worsens MR increases SVR & reflex bradycardia • Temporary use of Ephedrine bolus preferable

  21. Pulmonary hypertension • PAP & PVR elevated in acute and chronic MR • Secondary RV dysfunction • Avoid factors increasing PVR Hypoxia Hypercapnia Acidosis High tidal volume High PEEP

  22. Factors affecting Mitral valve repair • Acute vs chronic MR • Patient’s symptom severity • Left ventricular function • Severity of mitral regurgitation • Feasibility of successessful repair • Combined valvular lesions • Complications of chronic MR

  23. Choice of agents • Preserved ventricular function – most anesthetic techniques tolerated well • Spinal, epidural anesthesia tolerated (avoid bradycardia) • Ventricular dysfunction sensitive to volatile agents opioid based anesthetic (avoid bradycardia) pancuronium with opioids useful

  24. Symptomatic patients NYHA 2,3 & 4 Indicated • Acute severe MR (class 1) • Absence of severe LV dysfunction(class1) • Severe LV dysfunction & MV repair high likely (2a) • Functional MR ,severe LV dysfunction on maximum medical therapy includes biventricular pacing (2b) (severe LV dysfunction = EF < 30% )

  25. Indications for Asymptomatic patients • Chronic severe MR and mild to moderate LV dysfunction (class1) • Chronic sever MR with normal LV function High likely successful repair (2a) New onset atrial fibrillation (2a) Pulmonary hypertension (2a) • Not indicated (class 3) Normal LV function & doubt about feasibility of repair Mild or moderate MR

  26. Mitral regurgitation complicating Pregnancy • Typically well tolerated due to favorable loading conditions increased blood volume, heart rate & low SVR • Increased risk of AF ECG monitoring during labor Acute AF – promptly control ventricular rate • Hypercoagulability , increases risk of systemic embolism Anticoagultion New onset AF, H/o embolism & Cardioversion

  27. Management of parturient • High SVR during labor – poorly tolerated Pain, Expulsive efforts & aortic compression • Prevent & treat high SVR Epidural analgesia Results in low venous return Left lateral tilt • SAB tolerated by pt’s with mild to moderate MR • Vasopressor of choice Chronotrophic effect of Ephedrine benefits

  28. Thank you www.anaesthesia.co.in anaesthesia.co.in@gmail.com

More Related