Optimal Hemodynamic Goals

Mitral Valve Stenosis

• Etiology/Risk Factors
  • Most common cause is rheumatic heart disease
• Pathophysiology
  • Non‐compliant mitral valve requiring excess pressure from the left atrium to open leading to left atrial hypertrophy which can lead to:
    • ↑ Risk of atrial fibrillation
    • ↑ Risk of thrombosis
    • Hoarseness secondary to impingement on the left recurrent laryngeal nerve
  • ↓ CO
  • Pulmonary HTN
  • Pulmonary edema
  • Dyspnea
  • Murmur is low‐pitched diastolic rumble heard best at apex
• Treatment
  • Regular follow‐up and monitoring
  • Diuretics
  • β‐blockers
  • Calcium channel blockers
  • Anticoagulants
  • Valve replacement
• Primary Concerns
  • Anesthetics further decreasing CO
  • Maintaining diastolic kick
  • Volume status
  • Current anticoagulation status
  • For management of pulmonary HTN see page 180
• Evaluation
  • Consider cardiology consult
  • Consider preoperative ECG
  • Consider echocardiogram
  • Consider PT/PTT/INR
  • Establish DASI/METs on pages 67–68
  • Evaluate for pulmonary edema
• Anesthesia Management
  • Discuss anticoagulation management with surgeon
  • Continue β‐blockers and CCBs
  • Careful titration of anesthetics as they can decrease cardiac contractility and CO
  • Optimize atrial kick of diastole
    • Relatively low heart rate
    • Maintain normal sinus rhythm
  • Avoid tachycardia
    • Ketamine
    • Catecholamines (stress)
    • Anticholinergics
  • Avoid excessive fluids
  • Avoid Trendelenburg position

Mitral Valve Regurgitation

• Etiology/Risk Factors
  • Genetic
  • Congenital malformation
  • Rheumatic fever
  • Papillary muscle dysfunction
  • Previous MI
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