valvular heart disease v6
TRANSCRIPT
-
8/8/2019 Valvular Heart Disease v6
1/43
Moderated by
Dr. Chitra
Presented by
Mukesh kumar sah
Anaesthesia for Valvular Heart Disease
-
8/8/2019 Valvular Heart Disease v6
2/43
Contents
DefinitionDefinition
Types of VHDTypes of VHD
General Evaluation ofGeneral Evaluation of
PatientsPatients
History TakingHistory Taking
New York AssociationNew York Association
Functional ClassificationFunctional Classification
of Heart Diseaseof Heart Disease
Physical ExaminationPhysical Examination
Common ComplicationsCommon Complications
Laboratory EvaluationLaboratory Evaluation
Special StudiesSpecial Studies
PrePre--medicationmedication
Anti Coagulation ManagementAnti Coagulation Management
Special Valvular DisordersSpecial Valvular Disorders
Mitral Stenosis (MS)Mitral Stenosis (MS)
Mitral Regurgitation (MR)Mitral Regurgitation (MR)
Mitral Valve ProlapseMitral Valve Prolapse
-
8/8/2019 Valvular Heart Disease v6
3/43
Definition Valvular Heart Disease (VHD)
An acquired or congenital
disorder of a cardiac valve
characterized either by
Stenosis (obstruction) or
Regurgitation (backward
flow of blood)
-
8/8/2019 Valvular Heart Disease v6
4/43
Common Types of Valvular Heart Diseases
Mitral Stenosis
Mitral Regurgitation
Tricuspid Stenosis
and Regurgitation
Pulmonary Stenosis
and Regurgitation
Mitral Valve Prolapse
Aortic Stenosis
Idiopathic Hypertrophic
Subaortic AS
Aortic Regurgitation
lkjadsflkjasdfk
-
8/8/2019 Valvular Heart Disease v6
5/43
General Evaluation of Patients
Key Considerations
Severity of Lesion
Its Hemodynamic significance
Residual ventricular function
Presence of secondary effects on Pulmonary,Renal and Hepatic functions
Concomitant Coronary Artery Disease (CAD)
-
8/8/2019 Valvular Heart Disease v6
6/43
History Taking
Key Considerations
Age
History of rheumatic fever, i/v drug abuse
Symptoms related to ventricular function
Exercise Tolerance
Fatigueability
Pedal edema
Shortness of breath (dyspnoea), when lying flat (orthopnoea), or at
night (paroxysmal nocturnal dyspnoea)
Chest pains and neurological symptoms as some valvular lesions
a/s with thromboembolic phenomenon
-
8/8/2019 Valvular Heart Disease v6
7/43
History Taking
Prior procedures such as valvotomy or valve replacement and
their effects
Review of medications to evaluate efficacy and exclude
serious side effects. Commonly used agents
Digoxin
Diuretics
Vasodilators
ACE inhibitors
Anti-arrhythmics
Anticoagulants
-
8/8/2019 Valvular Heart Disease v6
8/43
New York Heart Association - Functional
Classification of Heart Disease
Useful for grading clinical severity of heart failure and
estimating prognosis
Description Grade
Asymptomatic except during severe exertion 1
Symptomatic with moderate activity 2
Symptomatic with minimal activity 3
Symptomatic at rest 4
-
8/8/2019 Valvular Heart Disease v6
9/43
Physical Examination
Abnormal Pulse with possible type of disorder
Pulse Abnormality Possible Disorder
Low Volumic Pulse Mitral Stenosis (MS)
Water Hammer PulseMitral Regurgitation (MR),
Aortic Regurgitation (AR)
Slow Rising Pulse Aortic Stenosis (AS)
Irregular Rate and Rhythm Atrial Fibrillation (AF)
-
8/8/2019 Valvular Heart Disease v6
10/43
Physical Examination
Search for signs of congestive heart failure
Right sided
Jugular Venous Distension
Hepatospleenomegaly
Pedal Edema
Left sided
S3 gallop
Pulmonary rales
Cardiomegaly
Neurologial deficits secondary to embolic phenomenon to be seen
-
8/8/2019 Valvular Heart Disease v6
11/43
Physical Examination
Auscultatory findings confirm the valvular dysfunction
S1
Closure of mitral and
tricuspid valves
S2
Closure of aortic and
pulmonic valves
S1 S2
Diastole
Systole
Diastole
S1
Closure of mitral and
tricuspid valves
S2
Closure of aortic and
pulmonic valves
S1 S2
Diastole
Systole
Diastole
-
8/8/2019 Valvular Heart Disease v6
12/43
Common Complications
Acute and Chronic Heart Failure
Spontaneous Bacterial Endocarditis
Arrhythmias - AF
Thromboembolism-stroke, TIA
Abnormal heart structure
-
8/8/2019 Valvular Heart Disease v6
13/43
Laboratory evaluation
Hemogram Anemia
Blood Glucose Exclude DM
Lipid Profile Risk factor for IHD
S.electrolytes Low K+ f/o diuretics
Urine R/M, s.creatinine BUN Renal Function Tests
S.bilirubin, SGOT, SGPT LFT( Right Heart Failure)
Arterial Blood Gases In Patients with Pulmonary Symptoms
PT and aPTT Reversal of Anti Coagulants
Chest X Ray Cardiac sizePulmonary Vascular Congestion
ECG
Rhythm and Conduction Abnormalities
RVH/LVHST-Segment ChangesSigns of digoxin toxicity (prolonged PRinterval and arrhythmias)
-
8/8/2019 Valvular Heart Disease v6
14/43
Special Studies
For Diagnosis and Prognosis
Echocardiography
Radionucleotide ongiography
Cardial catheterization
Following things should be analyzed
Which valvular abnormality is most important hemodynamically?
What is the severity of that lesion?
Degree of ventricular impairment?
Hemodynamic significance of other identified abnormalities
Any evidence of CAD
-
8/8/2019 Valvular Heart Disease v6
15/43
Pre-medication
Patients with Normal Ventricular Functions
Standard doses of any of used agents
Patients with Poor Ventricular Functions
Doses to be reduced in proportion to severity of ventricular
impairment
Supplemental O2
Pulmonary Hypertension
-
8/8/2019 Valvular Heart Disease v6
16/43
Pre-medication
Antibiotic Prophylaxis
The risk of infective endocarditis in patients with Valvular Heart Disease following
bacteremic events including dental, oropharyngeal or nasopharyngeal, gastrointestinal or
genitourinary surgery any I & D is well established
Prophylaxis should follow general guidelines recommended by the American heart
association For Dental, Oral Respiratory Tract or Esophageal Procedures
Standard General Prophylaxis
Amoxicillin - Dosage: Adults - 2 gms, Children 50 mg/kg; Mode: Orally 1 hr before
Procedure
Inability to take Oral Medication
Ampicillin Dosage: Adults - 2 gms, Children 50 mg/kg; Mode: i/m or i/v 30 mins
before procedure
For Genitourinary or Gastrointestinal Procedures
For High Risk Patients
Ampicillin + Gentamycin ( Dosage: 1. 5 mg/kg, Mode i/m or i/v 30 mins before
procedure), six hours later Ampicillin (Dosage: Adults 1 gm children 25 mg/kg, Mode:
i/m or i/v ) or Amoxicillin (Dosage: Adults 1 gm, Children 25 mg/kg, Mode: Orally)
For High Risk Patients Allergic to Ampicillin
Vancomycin (Dosage: Adults 1 gm, Children 20 mg/kg) + Gentamycin ( adults &
children 1.5 mg/kg, Mode: i/m or i/v, within 30 mins before starting procedure)
-
8/8/2019 Valvular Heart Disease v6
17/43
Pre-medication
Anticoagulation Management
Patients receiving anticoagulants can have their drug regimen interrupted 1-3 days
preoperatively
Warfarin stopped 3 days prior to Surgery and restart 2-3 days post operation
If thromboembolic risk deemed high, stopped the day before surgery and reversed
with vit K or fresh frozen plasma, i/v heparin therapy then initiated 12-24 hrs post-op
once surgery hemostasis is adequate
Incidence of thromboembolic complications increases with
Prior history of embolism and the presence of thrombus
Atrial fibrillation
Prosthetic mechanical valve
Caged ball mechanical prosthesis (starr edwards) highest (mitral or
tricuspid)
Tilting disc valves ( ST Judes) Intermediate
Bioprosthesis ( porcine or bovine tissue valves) lowest
-
8/8/2019 Valvular Heart Disease v6
18/43
Special Valvular Disorders Mitral Stenosis
Etiology
Delayed complication of Rheumatic fever
66% of patients are females
Stenotic process begins after minimum period
of 2 years following acute disease and results
from progressive fusion and calcification of
value leaflets
Symptoms develop after 20 30 years when
orifice reduced to less than 2 cm2
Usually have symptoms when
areas reduced by 50%
Particulars Dimensions
Normal Aperture 4 6 cm2
Mildly Stenotic 1.5 2.5 cm2
Moderately Stenotic 1.1 1.5 cm2
Severe Stenotic < 1 cm2
Less than 50% patients Isolated MS
Remaining - Also have MR
Upto 25% rheumatic involvement of AV (AS or AR)
-
8/8/2019 Valvular Heart Disease v6
19/43
Pathophysiology
Valve leaflets thicken, calcify
and become funnel shaped
(Fish Mouth Valve)
Restriction of blood flow
through the Mitral value results
in a transvalvular pressure
gradient That depends on CO,
HR (diastolic time) and
presence of normal Atrial kick
-
8/8/2019 Valvular Heart Disease v6
20/43
Pathophysiology
Increase in either HR or CO
Supraventricular
Tacchycardias (AF)
Higher flow across Valve
Higher Transvascular
Pressure GradientLA Dilates
Blood Flow Statis
Formation of
Thrombi
Elevation in Left Atrial
Pressure
Transmitted to
Pulmonary Capillaries
If PCP > 25 mmHg
Transudation of Capillary
Fluid
Chronic PulmonaryVascular Changes
Irreversible Increase in
Pul. Vascular Resistance
Pulmonary Hypertension
Reduced Lung
Compliance
Ch. Dyspnoea
Rt. Ventricular Failure
Dilatation of RVTR or PR
Pulmonary Edema
-
8/8/2019 Valvular Heart Disease v6
21/43
Diagnosis
Clinical manifestations
Chronic dyspnoea
Embolic events common in patients with MS and AF.
Dislodgement of clots from left atrium results in systemic
emboli most commonly cerebral, pulmonary emboli,
pulmonary infarction, hemoptysis and recurrent bronchitis
Chest pain occurs in 10-15% of patients - emboli in coronary
circulation or acute right ventricular pressure overload
Hoarseness due to compression of left recurrent laryngeal
nerve by enlarged left atrium
-
8/8/2019 Valvular Heart Disease v6
22/43
Diagnosis
Physical findings
On palpation
Low volume pulse
Tapping apex
On auscultation
Opening Snap heard in expiration medial to cardiac apex,
follows S2 by 0.05 to 0.12 sec
OS followed by low pitched, rumbling, diastolic murmur heard
best at apex with pt. in left lateral recumbent position
S1 S2
Opening snap
-
8/8/2019 Valvular Heart Disease v6
23/43
Diagnosis
Laboratory Evaluation
Chest X Ray
Straightening of left border of heart
Prominence of main pulmonary artery
Dilatation of upper lobe pulmonary veins
Backward displacement of esophagus by enlarged lt.
atrium
Kerly B lines in lower and mid lung fields
ECG
Right axis deviation and RVH
Tall and peaked P wave
Echo - most sensitive and specific
-
8/8/2019 Valvular Heart Disease v6
24/43
Treatment
Medical management is primarily supportive
Limitation of physical activity
Anticoagulation ( with history of emboli, AF, old age)
Na+ restriction
Diuretics
Digoxin only in patients with AF and a rapid ventricular response
Beta blockers to control Heart Rate
Valve replacement
Valvuloplasty or Percutaneous transeptal ballon valvuloplasty Valve replacement surgery recurrent MS following valvuloplasty
-
8/8/2019 Valvular Heart Disease v6
25/43
Anaesthetic Management
Objectives Heart Rate - Keep slow to allow for diastolic filling. Avoid sinus
tacchycardia
Rhythm Sinus rhythm
Preload maintain or slightly increase to help with ventricular
filling
Afterload SVR should be maintained, avoid decreases in SVR,
avoid increase in PVR
Contractility maintain to provide adequate CO
Monitoring
Direct intraarterial pressure
ECG-notched p wave
Pulmonary artery Pressure-prominent a wave and decreased y
decent
-
8/8/2019 Valvular Heart Disease v6
26/43
Anaesthetic Management
Choice of agents
Regional Anaesthesia
Epidural is preferred over spinal due to gradual onset of
sympathetic block with epidural
General anaesthesia
Ketamine poor induction agent for GA because of sympathetic
stimulation
Pancuronium induced tachycardia to be avoided
Volatile agents produce undesirable vasodilatation or precipitatejunctional rhythm with loss of an effective Atrial kick
Halothane most suitable because it reduces Heart Rate and is least
vasodilating
NO2 avoided as causes increase in PVR
-
8/8/2019 Valvular Heart Disease v6
27/43
Anaesthetic management
Intra-op tacchycardia
Deepening anaesthesia with opioid or b-blockers
(esmolol, proponalol)
In case of AF
control rate with diltiazem or digoxin
Sudden supraventricular tachycardia - cardioversion
As vasopressor - phenylephrine preferred over ephedrine
as former lacks b-agonist activity
Acute hypertension or afterload reduction done under
hemodynamic monitoring
-
8/8/2019 Valvular Heart Disease v6
28/43
Mitral Regurgitation
A portion of LV volume is ejected back into
LA during systole because of an incompetent
valve
Etiology
Acute
Myocardial ischemia / infarction
( papillary muscle dysfunction or
rupture of a chorda tendenae)
Infective endocarditis
Chest trauma
Chronic Rheumatic fever
Congenital or developmental
abnormality of valve
Dilatation, destruction or calcification
of mitral annulus
-
8/8/2019 Valvular Heart Disease v6
29/43
Pathophysiology
Reduction in forward SV due to backward flow of blood into left
atrium during systole ( can be as much as 50% of SV)
Left ventricle compensates by dilating and increasing end diastolic
volume
Regurgitation reduces left ventricular afterload but which may
enhance contractility
End systolic volume remains normal but eventually increases as
disease progresses
With time, patients with Chronic MR develop eccentric left ventricular
hypertrophy and progressive impairment in contractility
-
8/8/2019 Valvular Heart Disease v6
30/43
Volume overload of LA
Volume overload of LV
Mitral regurgitation
LA dilationNormal LA
pressuresLV filling Fiber size
Stroke volume
Cardiac output and BP
maintained
Contractility
BP and CO
Reflexive arteriolar
constriction
SVR
Regurgitation
LA pressure Pulmonary
congestion
Early Late
-
8/8/2019 Valvular Heart Disease v6
31/43
Pathophysiology
The regurgitant volume passing
through the mitral valve is
dependant on the
Size of the mitral valve orifice
Heart rate (systolic time)
Lt. ventricular lt. atrial
pressure gradient during
systole
Systemic vascular
resistance
Lt. atrial compliance
-
8/8/2019 Valvular Heart Disease v6
32/43
Diagnosis
Clinical manifestations
Depend on degree of atrial compliance
Normal or reduced compliance (acute MR) pulmonary venous congestion and edema,
signs of right sided heart failure
Increased compliance (chronic MR) signs of
decreased cardiac output
Most patients exhibit features of both
-
8/8/2019 Valvular Heart Disease v6
33/43
Diagnosis
Physical Findings
Hyperdynamic Apex
On auscultation
Wide splitting of S2 ( pre mature closure of
aortic valve)
Blowing pan systolic murmur best heard at theapex and often radiating to left axilla
S1S2
-
8/8/2019 Valvular Heart Disease v6
34/43
Diagnosis
Laboratory Evaluation
Chest X Ray
Left Atrial Enlargement
Pulmonary Venous Congestion
Kerly B Lines
ECG
Left Atrial Enlargement may be present
ECHO
To know the cause and degree of left ventricular function
-
8/8/2019 Valvular Heart Disease v6
35/43
Treatment
Medical Treatment
Digoxin, Diuretic and Vasodilators
Surgical Valvuoplasty
Usually reserved for those with symptomatic MR
moderate(Regurgitant Volume 30 to 60% S V)
severe (Regurgitant Volume more than 60% S V)
-
8/8/2019 Valvular Heart Disease v6
36/43
Anaesthetic Management Objectives
Heart Rate avoid slow heart rate (ideally 80 to 100 beats per
minute), faster rate decreases regurgitant volume
Rhythm maintain sinus rhythm
Preload - Excess fluid will dilate the left ventricle and worsen
regurgitation. Need adequate volume to maintain forward stroke
volume. Pre load reduce with Vasodilators and diuretics
Afterload Decreases are beneficial
Contractility minimize drug induced myocardial depression
Monitoring
Pulmonary Artery Pressure
Intraarterial pressure
ECG
Color flow Doppler TEE
-
8/8/2019 Valvular Heart Disease v6
37/43
-
8/8/2019 Valvular Heart Disease v6
38/43
Mitral Valve Prolapse (MVP)
Also known as Systolic Click Murmur Syndrome, Barlows
Syndrome, Sloppy Valve Syndrome or Billowing Mitral Leaflet
Syndrome
Relatively common abnormality - present in 5% of general
population ( 15% of women)
Etiology
Sporadic
Familial
Connective tissue disorder
Marsan Syndrome
Esler Danlos Syndrome
Osteogenesis Imperfecta
-
8/8/2019 Valvular Heart Disease v6
39/43
Mitral Valve Prolapse (MVP)
Pathology
myxomatous degeneration of valve leaflets. Mitral annulus may
be dilated.
Posterior mitral leaflet most commonly affected MVP causes stress on papilary muscles Dysfunction and
Ischemia of papilary Muscles More stress on diseased mitral
valve
Often associated with MR
Prolapse accentuated by maneuvers that decrease ventricularvolume (preload) like standing ,Valsalva
Prolapse diminished by maneuvers that increase ventricular
volume (preload) like squatting and isometric exercises
-
8/8/2019 Valvular Heart Disease v6
40/43
Mitral Valve Prolapse - Diagnosis
Clinical Manifestations - Majority of patients areasymptomatic. In small percentage progressive myxomatosis
degeneration
Arrthymias (psVT, VT) Palpitation, Light Headedness,
Syncope
Chest pain
Embolic events (TIA)
Infective endocorditis
Florid MR
Sudden death
-
8/8/2019 Valvular Heart Disease v6
41/43
Mitral Valve Prolapse - Diagnosis
Physical Findings
On Auscultation
Mid or late systolic click 0.14 seconds after S1 with or without a
late apical systolic murmur
Laboratory Evaluation
Chest X Ray
ECG usually normal or inverted or biphasic T waves or ST segment
changes inferiorly
Paroxymal supra ventricular tachycardia common
Echo systolic prolapse of mitral valve leaflets in to left atrium.
-
8/8/2019 Valvular Heart Disease v6
42/43
Anaesthetic Treatment
based on their clinical course
Most patients are asymptomatic and need only a/b prophylaxis
Patients with systolic murmur at risk for infective
endocarditis
Ventricular arrthymia may occur in intra-op / respond to
lidocaine or beta blockers
Relatively deep anaesthesia with a volatile agent usually
decreases incidence of intraop arrthymia
Hypovolemia and factors that increase ventricular emptying
increased sympathetic tone or decreased afterload should
be avoided
Phenylephrine preferred over ephedrine if there is need of
vasopressors
-
8/8/2019 Valvular Heart Disease v6
43/43
Thank You!