valvular heart disease and anaesthesia

Valvular Heart Disease Valvular Heart Disease and Anesthesiaand Anesthesia

Wahid AltafWahid Altaf

DefinitionDefinition::

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

IncidenceIncidence

Valvular heart disease is found in 4% of Valvular heart disease is found in 4% of patients over the age of 65 in the patients over the age of 65 in the developed world.developed world.

Valvular Heart DiseaseValvular Heart Disease

Mitral stenosisMitral stenosisMitral insufficiencyMitral insufficiencyMitral valve prolapseMitral valve prolapseAortic insufficiencyAortic insufficiencyAortic stenosisAortic stenosisPulmonary stenosisPulmonary stenosisPulmonary insufficency.Pulmonary insufficency.Tricuspid Stenosis.Tricuspid Stenosis.Tricuspid insufficency.Tricuspid insufficency.

What Information is Required?What Information is Required?

Clinical historyClinical history

Physical examPhysical exam

InvestigationsInvestigations

Common findings of the history and physical Common findings of the history and physical exam in patients with valvular disease:exam in patients with valvular disease:

A history of rheumatic fever, IV drug abuse, or A history of rheumatic fever, IV drug abuse, or heart murmur heart murmur

Decreased exercise toleranceDecreased exercise tolerance

May exhibit S/S of CHF (dyspnea, orthopnea, May exhibit S/S of CHF (dyspnea, orthopnea, fatigue, pulmonary rales, JVD, hepatic fatigue, pulmonary rales, JVD, hepatic congestion, and dependent edema)congestion, and dependent edema)

Compensatory increases in SNS tone manifest as Compensatory increases in SNS tone manifest as resting tachycardia, anxiety, and diaphoresisresting tachycardia, anxiety, and diaphoresis

Mitral StenosisMitral Stenosis

Normal: Normal: 4 - 6 cm4 - 6 cm22

Mildly stenotic: Mildly stenotic: 1.5 - 2.5 cm1.5 - 2.5 cm22

Moderately stenotic: Moderately stenotic: 1.1 - 1.5 cm1.1 - 1.5 cm22

Severely stenotic: Severely stenotic: < 1 cm< 1 cm22

Usually have symptoms when area is Usually have symptoms when area is decreased by 50%decreased by 50%

EtiologyEtiology

Delayed complication of rheumatic feverDelayed complication of rheumatic fever

66% of patients are female66% of patients are female

PathophysiologyPathophysiology

Valve leaflets thicken, calcify and become Valve leaflets thicken, calcify and become funnel-shapedfunnel-shaped

Left atrium dilates (pressure)Left atrium dilates (pressure)

Signs and symptoms:Signs and symptoms: 90% of patients present with CHF and Atrial 90% of patients present with CHF and Atrial

fibrillationfibrillation 10-15% develop chest pain10-15% develop chest pain Hoarseness caused by enlarged left atrium Hoarseness caused by enlarged left atrium

putting pressure on left recurrent laryngeal putting pressure on left recurrent laryngeal nerve nerve

Pulmonary hypertension from chronic increased Pulmonary hypertension from chronic increased pulmonary vascular resistancepulmonary vascular resistance

Hemoptysis often occursHemoptysis often occurs

Treatment:Treatment: AnticoagulationAnticoagulation Sodium restrictionSodium restriction DiureticsDiuretics Valve replacementValve replacement

Onset to incapacitation averages 5-10 years and Onset to incapacitation averages 5-10 years and

most patients die within 2-5 years of onsetmost patients die within 2-5 years of onset

Anesthesia concernsAnesthesia concerns

Maintain sinus rhythmMaintain sinus rhythm Avoid tachycardia, large increases in COAvoid tachycardia, large increases in CO Avoid both hypovolemia and fluid overloadAvoid both hypovolemia and fluid overload Avoid increases in pulmonary vascular Avoid increases in pulmonary vascular

resistanceresistance Phenylephrine is preferred over ephedrinePhenylephrine is preferred over ephedrine Epidural is preferred over spinal due to Epidural is preferred over spinal due to

gradual onsetgradual onset of sympathetic block with of sympathetic block with epiduralepidural

ManagementManagement

HRHR- keep slow to allow for diastolic filling; avoid sinus - keep slow to allow for diastolic filling; avoid sinus tachycardiatachycardia

RhythmRhythm- sinus rhythm; if A-fib, control rate- sinus rhythm; if A-fib, control ratePreloadPreload- Maintain or slightly increase to help with left - Maintain or slightly increase to help with left

ventricular filling; excess preload may cause pulmonary ventricular filling; excess preload may cause pulmonary edemaedema

AfterloadAfterload- SVR should be maintained; avoid decreases in - SVR should be maintained; avoid decreases in SVR; avoid increases in PVRSVR; avoid increases in PVR

ContractilityContractility- Maintain to provide adequate cardiac output- Maintain to provide adequate cardiac output****epidural preferred over spinalepidural preferred over spinal

Pregnancy ConsiderationsPregnancy Considerations

Vaginal delivery: Early admission/invasive blood pressure Vaginal delivery: Early admission/invasive blood pressure monitoring/ Small top-ups for epidural/avoid iv fluids.monitoring/ Small top-ups for epidural/avoid iv fluids.

Caesarean delivery :Caesarean delivery : Spinal anaesthesia is best avoided. Spinal anaesthesia is best avoided. Careful epidural anaesthesia in class 1 and 2 patientsCareful epidural anaesthesia in class 1 and 2 patients General anaesthesia NYHA class 3 and 4 patients . Specific General anaesthesia NYHA class 3 and 4 patients . Specific

pharmacotherapy to obtund the intubation response. pharmacotherapy to obtund the intubation response. Bolus oxytocin is contraindicated in view of the risk of precipitous Bolus oxytocin is contraindicated in view of the risk of precipitous

systemic hypotension and pulmonary hypertension. systemic hypotension and pulmonary hypertension. A brief period of postoperative ventilation may be required in some A brief period of postoperative ventilation may be required in some

cases. cases.

Mitral RegurgitationMitral Regurgitation

A portion of the LV volume is ejected back A portion of the LV volume is ejected back into LA during systole because of an into LA during systole because of an incompetent valve. This leads to:incompetent valve. This leads to:Increased left atrial pressure, Increased left atrial pressure, **but the atrium**but the atrium

usually does not enlargeusually does not enlargeIncreased pulmonary artery pressureIncreased pulmonary artery pressurePulmonary edema/HTNPulmonary edema/HTNLeft ventricular hypertrophy occurs due to the Left ventricular hypertrophy occurs due to the

increased workload required to maintain volume increased workload required to maintain volume outputoutput

EtiologyEtiology

ACUTEACUTE Myocardial Myocardial

ischemia or ischemia or infarctionsinfarctions

Infective Infective endocarditisendocarditis

Chest traumaChest trauma

CHRONICCHRONIC Rheumatic feverRheumatic fever Incompetent valve Incompetent valve Destruction of mitral valve Destruction of mitral valve

annulusannulus


Reduction in forward SV due to backward flow Reduction in forward SV due to backward flow of blood into left atrium during of blood into left atrium during systolesystole (can be (can be as much as 50% of SV)as much as 50% of SV)

Left ventricle compensates by dilating and Left ventricle compensates by dilating and increasing end-diastolic volumeincreasing end-diastolic volume

Regurgitation reduces left ventricular Regurgitation reduces left ventricular afterload, but may enhance contractilityafterload, but may enhance contractility

End-systolic volume remains normal, but End-systolic volume remains normal, but eventually increases as disease progresseseventually increases as disease progresses

Signs and symptomsSigns and symptoms

Degree of atrial compliance will determine the Degree of atrial compliance will determine the clinical manifestationsclinical manifestations

Normal or reduced atrial compliance (acute MR) Normal or reduced atrial compliance (acute MR) will result in pulmonary vascular congestion and will result in pulmonary vascular congestion and edemaedemaIncreased atrial compliance (chronic MR) will Increased atrial compliance (chronic MR) will demonstrate signs of decreased cardiac outputdemonstrate signs of decreased cardiac output

Chronic weakness and fatigueChronic weakness and fatigue ““Blowing pansystolic murmur” best heard at Blowing pansystolic murmur” best heard at

the cardiac apex and often radiating to left the cardiac apex and often radiating to left axillaaxilla

TreatmentTreatment

Medical Tx: digoxin, diuretics and vasodilatorsMedical Tx: digoxin, diuretics and vasodilators

Surgical valvuloplastySurgical valvuloplastyUsually reserved for those with moderate to severe Usually reserved for those with moderate to severe symptoms (regurgitant volume 30-60% or >60%, symptoms (regurgitant volume 30-60% or >60%, respectively, of SV)respectively, of SV)

ManagementManagement

HRHR- - maintain or increase; maintain or increase; avoid bradycardiaavoid bradycardia which worsens which worsens regurgitant flowregurgitant flow

RhythmRhythm- - sinus rhythmsinus rhythm

PreloadPreload- - Maintain or slightly increaseMaintain or slightly increase; an; an elevated preload elevated preload will cause an increase in regurgitant flow, and low preload will cause an increase in regurgitant flow, and low preload causes inadequate cardiac outputcauses inadequate cardiac output

AfterloadAfterload- - DecreaseDecrease to improve forward cardiac output; to improve forward cardiac output; avoid sudden increases in SVRavoid sudden increases in SVR

ContractilityContractility- - Maintain or increaseMaintain or increase to decrease left to decrease left ventricular volumeventricular volume

**spinal & epidurals well tolerated, but bradycardia must be avoided****spinal & epidurals well tolerated, but bradycardia must be avoided**

Anesthesia concernsAnesthesia concerns

Avoid slow heart rate (ideally 80-100 bpm)Avoid slow heart rate (ideally 80-100 bpm) Avoid increase in afterloadAvoid increase in afterload WATCH IV FLUIDSWATCH IV FLUIDS

excess fluids will dilate the LV and worsen regurgitationexcess fluids will dilate the LV and worsen regurgitationNeed adequate volume to maintain forward SVNeed adequate volume to maintain forward SV

Preload reduction with vasodilators and diuretics Preload reduction with vasodilators and diuretics Minimize drug-induced myocardial depressionMinimize drug-induced myocardial depression Spinal and epidural are well tolerated (avoid Spinal and epidural are well tolerated (avoid

bradycardia)bradycardia) Give prophylactic antibioticsGive prophylactic antibiotics

Anesthetic ConsiderationsAnesthetic Considerations

Prevent peripheral vasoconstrictionPrevent peripheral vasoconstriction

Avoid myocardial depressantsAvoid myocardial depressants

Treat acute atrial fibrillation immediatelyTreat acute atrial fibrillation immediately

Maintain a normal or slightly elevated heart Maintain a normal or slightly elevated heart raterate

Monitor PCW pressure or intensity of Monitor PCW pressure or intensity of murmurmurmur


No specific recommendations for the No specific recommendations for the management of mitral regurgitation during management of mitral regurgitation during labour and delivery. labour and delivery. Prior to labour symptoms may be Prior to labour symptoms may be managed with diuretics and vasodilators.managed with diuretics and vasodilators. During labour, regional anaesthesia is During labour, regional anaesthesia is usually well tolerated. However, in usually well tolerated. However, in complicated NYHA class 3-4 cases, complicated NYHA class 3-4 cases, general anaesthesia may be required.general anaesthesia may be required.

Mitral Valve ProlapseMitral Valve ProlapseAnesthetic ConsiderationsAnesthetic Considerations

Avoid decreases in preloadAvoid decreases in preload

Continue antiarrhythmic therapyContinue antiarrhythmic therapy

With MVP and moderate to severe mitral With MVP and moderate to severe mitral insufficiency the same considerations as insufficiency the same considerations as listed for mitral insufficiency alone applylisted for mitral insufficiency alone apply

Aortic StenosisAortic Stenosis

Aortic Valve AreaAortic Valve Area

Normal 2.6 - 3.5 cm2Normal 2.6 - 3.5 cm2

Mild 1.2 – 1.8 cm2Mild 1.2 – 1.8 cm2

Moderate 0.8 – 1.2 Moderate 0.8 – 1.2 cm2cm2

Significant 0.6 .0.8 Significant 0.6 .0.8 cm2cm2

Critical < 0.6 cm2Critical < 0.6 cm2

LV-Aortic GradientLV-Aortic Gradient

Mild 12 – 25 mmHgMild 12 – 25 mmHg

Moderate 25 – 40 Moderate 25 – 40 mmHgmmHg

Significant 40-50 Significant 40-50 mmHgmmHg

Critical > 50 mmHgCritical > 50 mmHg

EtiologyEtiology

congenital bicuspid aortic valve (2%).congenital bicuspid aortic valve (2%).

Rheumatic heart disease.Rheumatic heart disease.

Valve Calcification.Valve Calcification.


Obstruction of left ventricular ejection.Obstruction of left ventricular ejection.

Concentric hypertrophy of left ventricular Concentric hypertrophy of left ventricular muscle.muscle.

Decreased compliance of left ventricle Decreased compliance of left ventricle making it difficult to fill.making it difficult to fill.

Anesthesia concerns:Anesthesia concerns:

Maintain normal sinus rhythm, heart rate Maintain normal sinus rhythm, heart rate and intravascular volumeand intravascular volume

Optimal heart rate 70-80 bpmOptimal heart rate 70-80 bpm WATCH OUT FOR VASODILATIONWATCH OUT FOR VASODILATION Treat hypotension with phenylephrineTreat hypotension with phenylephrine Mild to moderate AS may tolerate spinal or Mild to moderate AS may tolerate spinal or

epidural (epidural preferred)epidural (epidural preferred) Spinal and epidural contraindicated in Spinal and epidural contraindicated in

severe ASsevere AS High risk of myocardial ischaemiaHigh risk of myocardial ischaemia

Peri-operative Care.Peri-operative Care.

SymptomaticSymptomatic patients for elective non-cardiac patients for elective non-cardiac surgery should have aortic valve replacement surgery should have aortic valve replacement first as they are at great risk of sudden death first as they are at great risk of sudden death perioperatively (untreated severe symptomatic perioperatively (untreated severe symptomatic stenosis has a 50% one year survival).stenosis has a 50% one year survival).Asymptomatic patients for major elective surgery Asymptomatic patients for major elective surgery associated with marked fluid shifts (thoracic, associated with marked fluid shifts (thoracic, abdominal, major orthopaedic) with gradients abdominal, major orthopaedic) with gradients across the valve > 50 mmHg should have valve across the valve > 50 mmHg should have valve replacement considered prior to surgery.replacement considered prior to surgery. Asymptomatic patients for intermediate or minor Asymptomatic patients for intermediate or minor surgery generally do well if managed carefully.surgery generally do well if managed carefully.

Haemodynamic goalsHaemodynamic goals

(Low) normal heart rate(Low) normal heart rate

Maintain sinus rhythmMaintain sinus rhythm

Adequate volume loadingAdequate volume loading

High normal systemic vascular resistanceHigh normal systemic vascular resistance

(Phenylepherine / Metarminol)(Phenylepherine / Metarminol)

Effective analgesia.Effective analgesia.

Postoperative ManagementPostoperative Management

Have a low threshold for admission to Have a low threshold for admission to ICU / HDUICU / HDU

Meticulous attention must be paid to fluid Meticulous attention must be paid to fluid balance and post operative pain balance and post operative pain managementmanagement

Infusions of vasoconstrictors may be Infusions of vasoconstrictors may be required to maintain haemodynamic required to maintain haemodynamic stabilitystability

Pregnancy considerationsPregnancy considerations

Caesarean section: Caesarean section: General anaesthesia with the aid of invasive General anaesthesia with the aid of invasive

haemodynamic monitoring. Aggressive maintenance haemodynamic monitoring. Aggressive maintenance of systemic blood pressure with vasopressors (e.g. of systemic blood pressure with vasopressors (e.g. phenylephrine).phenylephrine).

Spinal anaesthesia is generally contraindicated.Spinal anaesthesia is generally contraindicated. There are reports of the successful management of There are reports of the successful management of vaginal delivery under carefully introduced and limited vaginal delivery under carefully introduced and limited epidural analgesia, but this should be restricted to very epidural analgesia, but this should be restricted to very experienced hands. experienced hands.

Aortic regurgitation Aortic regurgitation

Etiology:Etiology:

Rheumatic heart disease.Rheumatic heart disease.

Endocarditis.Endocarditis.

Aortic dissection Aortic dissection

Connective tissue disorders Connective tissue disorders

ManagementManagementHRHR- Avoid sudden decreases; an increase (10-15 beats) - Avoid sudden decreases; an increase (10-15 beats)

causes shortening of diastolic phase which decreases causes shortening of diastolic phase which decreases the regurgitant fraction and increases cardiac outputthe regurgitant fraction and increases cardiac outputRhythmRhythm- sinus rhythm preferred- sinus rhythm preferredPreloadPreload- increase to maximize forward cardiac output - increase to maximize forward cardiac output

and maintain blood pressureand maintain blood pressureAfterloadAfterload- decrease afterload to favor forward cardiac - decrease afterload to favor forward cardiac

output (keep moving forward); avoid sudden increase output (keep moving forward); avoid sudden increase in afterloadin afterload

ContractilityContractility- maintain- maintain****most patients tolerate spinal or epidural provided intravascular volume is most patients tolerate spinal or epidural provided intravascular volume is

maintainedmaintained

TreatmentTreatment

Once symptomatic, death can occur within Once symptomatic, death can occur within 5 years unless lesion is surgically repaired5 years unless lesion is surgically repaired

Digitalis, diuretics and afterload reduction Digitalis, diuretics and afterload reduction (ACE inhibitors) for chronic (eventual (ACE inhibitors) for chronic (eventual surgical repair)surgical repair)

Inotropes (dopamine, dobutamine) and Inotropes (dopamine, dobutamine) and vasodilator for severe, chronic aortic vasodilator for severe, chronic aortic regurgitation (requires surgery)regurgitation (requires surgery)

Anesthetic considerationsAnesthetic considerations

Maintain normal heart rate Maintain normal heart rate

Increased frequency of conduction abnormalities, Increased frequency of conduction abnormalities, consider pacingconsider pacing

Keep SVR lowKeep SVR low Avoid myocardial depressionAvoid myocardial depression

Maintain or slightly increase preloadMaintain or slightly increase preload Give prophylactic antibioticsGive prophylactic antibiotics Most patients will tolerate spinal or epidural, Most patients will tolerate spinal or epidural, provided provided

intravascular volume is maintainedintravascular volume is maintained

Peri-operative CarePeri-operative Care

Asymptomatic Patients- tolerate surgery well.Asymptomatic Patients- tolerate surgery well.

Patients with low functional capacity- Consider valve Patients with low functional capacity- Consider valve replacement surgery first.replacement surgery first.

Haemodynamic goals Haemodynamic goals High normal heart rate – around 90 bpmHigh normal heart rate – around 90 bpm Adequate volume loadingAdequate volume loading Low systemic vascular resistanceLow systemic vascular resistance Maintain contractilityMaintain contractility

Spinal/Epidural well tolerated.Spinal/Epidural well tolerated.

Pregnancy considerationsPregnancy considerations

During labour, epidural analgesia During labour, epidural analgesia improves forward flow, and is therefore the improves forward flow, and is therefore the anaesthetic of choice in patient’s requiring anaesthetic of choice in patient’s requiring an operative delivery. an operative delivery.

Pulmonary StenosisPulmonary Stenosis

• Haemodynamic management: Maintain right Haemodynamic management: Maintain right ventricular preload, left ventricular afterload and ventricular preload, left ventricular afterload and right ventricular contractility. right ventricular contractility.

• Avoid hypothermia, hypercarbia, acidosis,Avoid hypothermia, hypercarbia, acidosis, hypoxia and high ventilatory pressures. hypoxia and high ventilatory pressures.

• Spinal anaesthesia may be associated with an Spinal anaesthesia may be associated with an uncontrolled reduction in right ventricular uncontrolled reduction in right ventricular preload and should therefore be avoided in preload and should therefore be avoided in severe cases.severe cases.


Spinal anaesthesia may be associated Spinal anaesthesia may be associated with an uncontrolled reduction in right with an uncontrolled reduction in right ventricular preload and should therefore ventricular preload and should therefore be avoided in severe cases.be avoided in severe cases.

Endocarditis prophylaxisEndocarditis prophylaxis

Consider prophylaxis for all patients with Consider prophylaxis for all patients with valvular lesions.valvular lesions.Three main questions:Three main questions:

Which patients have a high risk?Which patients have a high risk? Which procedures cause "significant" Which procedures cause "significant" bacteraemia?bacteraemia? Which antibiotics are active against Which antibiotics are active against these bacteria?these bacteria?

Prophylaxis for valvular heart Prophylaxis for valvular heart disease.disease.

Prophylaxis against infective endocarditis is recommended for the following patients:

Patients with prosthetic heart valves and patients with a history of infective

endocarditis. (Level of Evidence: C) Patients with congenital cardiac valve malformations, particularly those with

bicuspid aortic valves, and patients with acquired valvular dysfunction (e.g., rheumatic heart disease). (Level of Evidence: C)

Patients who have undergone valve repair. (Level of Evidence: C)

Patients who have hypertrophic cardiomyopathy when there is latent or resting obstruction. (Level of Evidence:C)

Patients with MV prolapse (MVP) and auscultatory evidence of valvular regurgitation and/or thickened leaflets on echocardiography.* (Level of Evidence: C)

No prophylaxis requiredNo prophylaxis required Prophylaxis against infective endocarditis is not recommended for the

following patients: Patients with MVP without MR or thickened leaflets on echocardiography.*

(Level of Evidence: C) Patients with physiological, functional, or innocent heart murmurs, including

patients with aortic valve sclerosis as defined by focal areas of increased echogenicity and thickening of the leaflets without restriction of motion and a peak velocity less than 2.0 m per second. (Level of Evidence: C)

Patients with echocardiographic evidence of physiologic MR in the absence of

a murmur and with structurally normal valves. (Level of Evidence: C) Patients with echocardiographic evidence of physiological tricuspid

regurgitation (TR) and/or pulmonary regurgitation in the absence of a murmur and with structurally normal valves. (Level of Evidence: C)

Prophylaxis recommended Prophylaxis not recommendedProphylaxis recommended Prophylaxis not recommended

Dental proceduresDental procedures with mucosal bleeding without mucosal bleedingwith mucosal bleeding without mucosal bleeding

Respiratory tractRespiratory tract tonsillectomy / adenoidectomy intubation of the tracheatonsillectomy / adenoidectomy intubation of the trachea flexible bronchoscopyflexible bronchoscopy

Gastrointestinal tractGastrointestinal tract procedures damaging the intestinal mucosa endoscopyprocedures damaging the intestinal mucosa endoscopy surgery or endoscopy of the biliary tractsurgery or endoscopy of the biliary tract sclerotherapy of oesophageal varicessclerotherapy of oesophageal varices

Urogenital tractUrogenital tract surgery of the prostate hysterectomy*surgery of the prostate hysterectomy* cystoscopy vaginal delivery*, Caesarean sectioncystoscopy vaginal delivery*, Caesarean section dilatation of the urethra bladder catheterization (in the dilatation of the urethra bladder catheterization (in the absence of infection)absence of infection) * consider prophylaxis in high risk * consider prophylaxis in high risk patientspatients

Antibiotic regimensAntibiotic regimens

1. Dental, Oral, Respiratory Tract, or Oesophageal Procedure1. Dental, Oral, Respiratory Tract, or Oesophageal Procedure

Standard: Amoxicillin 2.0 g (child: 50 mg/kg) per os 1 h preoperativelyStandard: Amoxicillin 2.0 g (child: 50 mg/kg) per os 1 h preoperatively Ampicillin 2.0 g (child 50 mg/kg) iv 30 min preoperativelyAmpicillin 2.0 g (child 50 mg/kg) iv 30 min preoperatively

* Alternative: Clindamycin 600 mg (child 20 mg/kg) per os* Alternative: Clindamycin 600 mg (child 20 mg/kg) per os or Cefalexin per os or Cefazolin iv or Erythromycin per osor Cefalexin per os or Cefazolin iv or Erythromycin per os

2. Gastrointestinal or Genitourinary Procedure2. Gastrointestinal or Genitourinary Procedure

High-risk patient:High-risk patient:

Standard: Ampicillin + Gentamicin (2.0 g + 1.5 mg/kg) iv,Standard: Ampicillin + Gentamicin (2.0 g + 1.5 mg/kg) iv, after 6 h, Ampicillin 1.0 g iv or Amoxicillin 1.0 g per osafter 6 h, Ampicillin 1.0 g iv or Amoxicillin 1.0 g per os * Alternative: Vancomycin + Gentamicin (1.0 g+ 1.5 mg/kg,* Alternative: Vancomycin + Gentamicin (1.0 g+ 1.5 mg/kg, infuse over 1-2 h directly preoperatively, child: 20 mg/kg + 1.5 mg/kg)infuse over 1-2 h directly preoperatively, child: 20 mg/kg + 1.5 mg/kg)

Moderate-risk patient:Moderate-risk patient:

Standard: Amoxicillin per os or Ampicillin ivStandard: Amoxicillin per os or Ampicillin iv * Alternative: Vancomycin (1.0 g) iv infuse over 1-2 h directly preoperatively* Alternative: Vancomycin (1.0 g) iv infuse over 1-2 h directly preoperatively

Anaesthesia for a patient with valvular Anaesthesia for a patient with valvular heart disease can be challenging.heart disease can be challenging.

The aim of anaesthesia is to keep the The aim of anaesthesia is to keep the diseased heart within its "optimal working diseased heart within its "optimal working conditions"conditions"

valvular heart disease and anaesthesia

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