This presentation is about valvular heart disease and anaesthetic implications.. Thankyou!

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
• An acquired or congenital disorder of a cardiac
valve characterized by stenosis (obstruction)
or regurgitation (backward flow) of blood

3. 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

4. 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.

5. 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.

6. 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

7. VALVULAR HEART
DISEASE
VALVULAR HEART DISEASE

8. 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

9. 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

10. 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.

11. 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

12. 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

13. VALVULAR HEART
DISEASE
• Serum electrolytes
• Renal function tests
• Coagulation profile
• ABG- significant pulmonary symptoms

14. 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

15. VALVULAR HEART
DISEASE
ENDOCARDITIS PROPHYLAXIS-
AHA GUIDELINES

16. 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

17. 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)

18. VALVULAR HEART
DISEASE
ANTIBIOTIC REGIMENS

19. 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

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 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

22. 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

23. 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

24. VALVULAR HEART
DISEASE
MAJOR VALVULAR LESIONS
• LT SIDED
• RT SIDED

25. VALVULAR HEART
DISEASE
MITRAL VALVE DISEASE

26. VALVULAR HEART
DISEASE
Mitral stenosis
ETIOLOGY
Almost always rheumatic in origin
Elderly - heavy calcification
Rarely -
• Congenital mitral stenosis
• Rheumatoid arthritis

27. 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

28. 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

29. 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.

30. 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.

31. 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

32. 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

33. VALVULAR HEART
DISEASE

34. 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

35. 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

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 GRID IN 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 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)

41. 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

42. 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

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 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.

45. 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.

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
• 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.

48. 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.

49. 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

50. 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

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
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

53. VALVULAR HEART
DISEASE
ANAESTHETIC GRID IN MR
LV PRELOAD HR RHYTHM CONTRACTILITY SVR PVR
Maintai
n
higher
rate
Maintain
sinus
rhythm
Maintain ↓ ↓

54. VALVULAR HEART
DISEASE
INDUCTION OF ANESTHESIA
• With an intravenous induction drug.
• Dosing adjusted to prevent ↑SVR & ↓HR
• muscle relaxant - Pancuronium modest ↑in heart rate

55. 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. .

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 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

58. VALVULAR HEART
DISEASE
• Maybe anatomical 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
• Midsystolic click+/- 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
• cerebral embolic 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 of anaesthesia-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 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

65. 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

66. 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.

67. 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

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 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

70. 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

71. 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

72. 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)

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 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

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 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.

78. 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

79. VALVULAR HEART
DISEASE
ANAESTHETIC GRID IN AS
LV PRELOAD HR RHYTHM CONTRACTILITY SVR PVR
↑ Avoid
↓ or↑
Maintain
sinus
rhythm
Maintain
constant
↑ Maintain
constant

80. 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

81. 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

82. 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

83. VALVULAR HEART
DISEASE
MAINTENANCE
• Neuromuscular blocking 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
• 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

87. 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.

88. 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.

89. VALVULAR HEART
DISEASE
CLINICAL FEATURES
Symptoms Mild 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 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

92. 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

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 GRID IN AR
LV PRELOAD HR RHYTHM CONTRACTILITY SVR PVR
↑ ↑ Maintain
sinus
rhythm
Maintain ↓ Maintain
constant

95. 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.

96. 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

97. 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.

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 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

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
• 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

102. 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.

103. 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.

104. 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

105. VALVULAR HEART
DISEASE
THANK YOU