Case Presentation of a patient with Mitral Stenosis for administration of Anesthesia for surgery

1. Case Discussion
Anaesthetic Management of a case of mitral stenosis
G 2P 1L 1 A 0 with 36 weeks gestation with mitral stenosis for elective
caesarean section
Speaker: Dr Bhagirath.S.N
Panelists: Dr
Akkamahadevi.P
Dr Srinivas.H.T

2. Case
Patient details
Name: Mrs. Savitha
Age: 26 years
Sex: female
I.P.No.: 236455
Chief Complaints
G2P1L1A0 with 36 weeks gestation with
Palpitations since 6 weeks
Breathlessness since 4 weeks
Fatigue since 2 weeks

3. Case………………contd. History of Presenting Illness
Palpitation Breathlessness Fatigue
Intermittent
Associated with
exertion
Relieved on rest
6 weeks duration
Gradual in onset
Progressive in
nature (NYHA II)
Aggravated on lying
down
Relieved on sitting
up
4 weeks duration
Feeling of
weakness
2 weeks duration
There was no history of haemoptysis or recurrent respiratory infections.

4. Case………………contd. Past History
No history of similar complaints in previous pregnancy.
History of Rheumatic Heart Disease since 12 years of age. Took
treatment in the form of Penicillin injections every 21 days for 8
years till age 20 and then discontinued.
No history of cyanotic spells.
No history of hypertension, Diabetes Mellitus, Tuberculosis,
Bronchial Asthma or Epilepsy.

5. Case………………contd.
No history of similar complaints in the family was noted.
Personal History
Diet: Vegetarian
Appetite: reduced.
Bowel & Bladder: Normal.
Sleep: disturbed.
Habits: None
Family History

6. Case………………contd.
A young pregnant female patient, moderately built and nourished
No pallor, icterus, cyanosis, oedema, clubbing
Pulse rate – 90/min; Weight – 58 Kgs
Blood pressure – 110/70 mm of Hg; Height – 155 cms
Respiratory rate – 16/min;
Respiratory System:
Normal Vesicular Breath Sounds heard, No added sounds.
Central Nervous System: Normal. No neurological deficits.
General Physical Examination

7. Case………………contd.
Per abdominal examination: Distended. Consistent with pregnancy. No
free fluid. No dilated veins.
Cardiovascular System:
Inspection: No deformity, Engorged superficial veins,
Scars or sinuses. No visible pulsations
Palpation: Apex beat felt in 5th intercostal space medial to left
midclavicular line, absence of left parasternal heave
Auscultation:
S1 S2 Heard. Opening Snap heard near the apex. (after S2)
Low pitched mid-diastolic murmur at apex. (no radiation)

8. Case………………contd.
G2P1L1A0 with 36 weeks gestation with Mitral Stenosis of
Rheumatic Origin without evidence of congestive cardiac failure.
Impression

9. Case………………contd.
Hb: 12.0 gm%
Differential count: Neutrophils – 71
Lymphocytes – 24
Monocytes – 02
Eosinophils – 03
Total count – 9, 800
Platelets: 2.73 lakhs/ mm3
PT INR: 1.0
BT: 3’ 00”
CT: 4’ 00”
Investigations

10. Case………………contd.
RBS: 99 mg/dl
Urea: 30 mg/dl
Creatinine: 1.1 mg/dl
Na+: 135mEq/l
K+: 4.8mEq/l
Cl-: 104mEq/l
HIV 1 & 2: Not detected
HBsAg: Not detected
Investigations

11. Case………………contd.
ECG: Sinus rhythm. Within normal limits. Heart rate: 80/min. Right axis
deviation.
2D ECHOCARDIOGRAPHY: Normal Left Ventricular systolic function
No Regional Wall Motion abnormalities
Ejection fraction: 56 %
Mitral Valve Area – 2.0 cms2
Transvalvular Pressure – 8 mm of Hg.
Chest X – Ray: Cardiomegaly. Prominent bronchovascular markings.
Management plan Regional anaesthesia for elective caesarean section
Investigations

12. Discussion
Causes: -
Palpitations
Tachyarrhythmias, Atrial fibrillation, Atrial kick
Endocrine–Pheochromocytoma, Thyrotoxicosis, Hypogylcemia
High Output states – Anemia, Pyrexia, Aortic Regurgitation,
Patent Ductus Arteriosus.
Drugs – Atropine, Adrenaline, Aminophylline, Thyroxine,
Caffeine, Tannin, Alcohol
Psychogenic – Prolonged anxiety
Idiopathic
Atrial kick -
Palpitations

13. Discussion
Cardiac causes
Atrial kick -
Palpitations
Respiratory causes Hematological
Left heart failure
Congenital heart
disease
Acquired valvular
disease
Bronchial Asthma Severe Anaemia
Acquired
valvular disease
- Dyspnea
Coronary heart
disease
Breathlessness
hypertensive
heart disease
Cardiomyopathy
Chronic obstructive
lung disease
Chronic restrictive
lung disease
Pneumonia
Pulmonary
neoplasm/ embolism
Laryngeal/ Tracheal
obstruction

14. Discussion
Past History
Atrial kick -
Palpitations
Family History Personal History
Rheumatic Heart
Disease (RHD)
RHD – Most
common cause 40%
More common in
females, typically
detected in
childhood.
Family history of
Rheumatic Heart
Disease,
Congenital
Valvular defects
may be relevant
Disturbed sleep in
Paroxysmal
Nocturnal
Dyspnoea
Acquired
valvular disease
- Dyspnea
Recurrent
respiratory tract
infection indicates
pulmonary
congestion
RHD,
Female
patient,
Childhood
history,
disturbed
sleep

15. Discussion
Oedema
Atrial kick -
Palpitations
Hepatomegaly Mitral Facies
Severe Mitral
stenosis
ultimately leads
to right heart
failure.
Seen in right
ventricular
failure and
pulmonary
hypertension.
Low Cardiac
Output in Mitral
Stenosis causes
peripheral
vasoconstriction
producing pinkish
purple patches on
cheeks.
Mitral Flush due to
vasodilatation
(vascular stasis) is
seen
Seen in fair
skinned individuals
Acquired
valvular disease
- Dyspnea
RHD,
Female
patient,
Childhood
history,
disturbed
sleep
General Physical Examination
Absent here Absent here
Edema &
Hepatomegaly
absent – mild
disease

16. Discussion
Inspection
Atrial kick -
Palpitations
No deformity of precordium. –
Precordial bulge indicates early onset and
longer duration of cardiac disease.
Acquired
valvular disease
- Dyspnea
RHD,
Female
patient,
Childhood
history,
disturbed
sleep
Cardiovascular Examination
Scar marks reveal previous surgeries
Engorged Neck Veins indicate high right heart pressures
Edema &
Hepatomegaly
absent – mild
disease

17. Discussion
Palpation
Atrial kick -
Palpitations
Tapping character of the apex beat (palpable S1) is
typical.
Acquired
valvular disease
- Dyspnea
RHD,
Female
patient,
Childhood
history,
disturbed
sleep
Cardiovascular Examination
Palpable diastolic thrill in mitral area best felt in left
lateral position in full expiration.
Parasternal heave. (absent here)
If one finds engorged superficial veins look for direction
of flow.
Absent
Parasternal
heave – mild
disease
Edema &
Hepatomegaly
absent – mild
disease

18. Discussion
Auscultation
Atrial kick -
Palpitations
S1 is sharp, short, accentuated
Acquired
valvular disease
- Dyspnea
RHD,
Female
patient,
Childhood
history,
disturbed
sleep
Cardiovascular Examination
Opening Snap after S2
Low pitched mid-diastolic rumbling murmur with
presystolic accentuation of Grade IV
intensity in mitral area without any
radiation
Murmur best heard at cardiac apex with bell of stethoscope
in left lateral position at height of expiration Absent
Parasternal
heave – mild
disease
Edema &
Hepatomegaly
absent – mild
disease
Absence of click, split, rub or murmur over other areas
Opening snap
+murmur at
apex

19. Substantiation Atrial kick -
Palpitations
Acquired
valvular disease
- Dyspnea
RHD,
Female
patient,
Childhood
history,
disturbed
sleep
Absent
Parasternal
heave – mild
disease
Edema &
Hepatomegaly
absent – mild
disease
Opening snap
+murmur at
apex
Childhood
history
Female
Patient
Rheumatic
Heart Disease
Edema &
hepatomegaly
absent
Palpitations Dyspnea
Absent parasternal
heave – mild disease
Opening Snap + low
pitched mid diastolic
murmur
2D – Echo – Mitral Valve 2.0 cms2,,
Transvalvular pressure 8 mm of Hg
Mitral Stenosis of Rheumatic Origin without evidence of
congestive cardiac failure.

20. Mitral stenosis at a glance

21. Anatomy

22. Anatomy
Normal Orifice: 4 – 6 Cms2
4-6 cms2
< 2.5 cms2
1.5- 2.5 cms2
1.0 – 1.5 cms2
< 1.0 cms2
Mild MS – 1.5 – 2.5 Cms2
(Dyspnea on severe exertion)
Moderate MS – 1.0 – 1.5 Cms2
(PND ± pulmonary oedema)
Severe/ Critical- < 1.0 Cms2
(Orthopnea – Class IV)
Symptoms start < 2.5 Cms2

23. Anatomy
Mitral Valve area is calculated using Gorlin’s Equation:
Area = Cardiac Output/ (DFP or SEP) (HR)
44.3 C √ΔP
DFP = Diastolic Filling Pressure
C = Empirical Constant
SEP = Systolic Ejection Period
ΔP = Pressure Gradient
HR = Heart Rate

24. Pathophysiology
Decreased LV filling
Increased left atrial
pressure and volume
Pulmonary vein pressure
Transudation of fluid into
pulmonary interstitial space
Pulmonary compliance
Work of breathing
Progressive Dyspnea
Adaptation Atrial Kick
Adaptation
Lymphatic drainage and thickening of
basement membrane
Pulmonary hypertension
Palpitations
Breathlessness Haemoptysis

25. Pathophysiology
Almost all chambers are
shown here , except…
Left Ventricle
So, are we to assume
that Left Ventricle
remains unaffected..?

26. Pathophysiology
The answer is NO. Left Ventricle is affected
Decreased filling ultimately manifests as
1. muscle atrophy
2. Inflammatory myocardial fibrosis
3. Scarring of sub valvular apparatus
4. Abnormal pattern of left ventricle contraction
5. Decreased left ventricular compliance with diastolic dysfunction
6. Right to left shift due to pulmonary hypertension

27. Aetiology
1. Rheumatic Heart Disease
2. Congenital – Parachute Mitral Valve
3. Hunter’s Syndrome
4. Hurler’s Syndrome
5. Drugs – Methysergide
6. Carcinoid syndrome
7. Amyloidosis
8. Mitral annular Calcification
9. Rheumatoid Arthritis
10. Systemic Lupus Erythematosis
11. Infective endocarditis with large vegetations.
12. Lutembacher’s Syndrome: Atrial Septal Defect (ASD) + Mitral
Stenosis (MS) rheumatic origin

28. Pathology
1. Diffuse thickening of mitral leaflets and subvalvular apparatus.
2. Commissural fusion
3. Calcification of annulus and leaflets
4. Contracture of Chordae and papillary heads
5. Usually develops over 2-3 decades.
Pathological types of Mitral Stenosis
1. Button Hole
2. Fish Mouth
3. Funnel Type

29. Common symptoms
1. Dyspnoea
2. Orthopnea
3. Paroxysmal Nocturnal Dyspnea
4. Palpitation
5. Fatiguability
6. Haemoptysis
7. Recurrent Bronchitis
8. Cough
9. Chest pain
10. Right hypochondrial Pain (hepatomegaly)

30. Conditions simulating mitral stenosis
1. Left Atrial Myxoma
2. Cortriatriatum
3. Ball valve thrombus of left atrium
4. Diastolic flow murmurs across normal mitral valve as in VSD,
PDA, severe MR
5. Carey-Coomb’s murmur of mitral valvulitis
6. Tricuspid stenosis
7. Austin-Flint murmur

31. Complications
1. Acute left heart failure and acute pulmonary edema
2. Pulmonary hypertension
3. Right Ventricular failure
4. Atrial Fibrillation
5. Atrial Flutter
6. Ventricular or atrial premature beats
7. Embolic manifestations
8. Haemoptysis
9. Infective Endocarditis
10. Recurrent Broncho-pulmonary infections
11. Complications arising from enlarged left atrium:
Hoarseness of voice – left recurrent laryngeal nerve due to enlarged
left atrium (Ortner’s Syndrome)
Dysphagia – Oesophageal compression
12. Jaundice, Cardiac cirrhosis.

32. Diagnosis
One needs to assess anatomy of Mitral Valve Leaflet in terms of
1. Thickening
2. Calcification
3. Mobility
4. Extent of involvement and subvalvular apparatus
One also needs to assess extent of stenosis
1. Mitral Valve area
2. Transvalvular pressure gradient
Also to be assessed are
1. Cardiac chamber dimension 2. Pulmonary hypertension
3. Ventricular function 4. Associated valvular disease
5. Examination of Left Atrial Thrombus

33. Diagnosis
Assess extent of calcification
1. Disappearance of Opening snap especially if calcification is more.
Assessment of X-Ray (P-A View)
1. Left Atrial Enlargement – Mitralisation of heart
2. Straightening of Left Heart Border
3. Elevation of Left mainstem Bronchus
4. Evidence of Mitral Calcification, Evidence of Pulmonary edema, Pulmonary
Vascular Congestion.
5. Kerley’s B lines
Assessment of X-Ray (RAO view)
1. Oesophagus is pushed or curved backward by enlarged left atrium.

34. Diagnosis
Assessment of ECG
1. Broad notched “P” Waves signifying atrial enlargement.
2. Atrial Fibrillation (f- waves replacing p-waves)
3. Right Ventricular Enlargement
2D – Echocardiography Doppler study
1. Chamber Enlargement 1. To know the speed and direction of blood flow.
2. Valve pathology
3. Valve movement
4. Mitral Orifice
Blood Examination
1. TC and DC 2. ESR
3. ASO Titre

35. Treatment
1. Mild Mitral stenosis – Diuretics
Restriction of physical activity
Salt-restricted diet
2. When in Atrial Fibrillation – Digoxin (0.25 mg tablet)
β- Blockers
Calcium Channel Blockers
Control of heart rate is paramount, because tachycardia impairs left ventricular
filling and further increases left atrial pressure.
3. Anticoagulation – Warfarin to normalise INR

36. Treatment
4. Surgery if Pulmonary hypertension develops
Percutaneous balloon valvotomy
Surgical commisurotomy
Valve reconstruction
5. Valve replacement
Starr-Edwards ball valve
Bjork-Shiley disc valve
Porcine bio-prosthesis
6. Prophylaxis against recurrence of rheumatic fever
Inj. Benzathine Penicillin 1.2 million units.

37. Anaesthetic Management

38. Hemodynamic
Parameters
Change in normal
pregnancy
Change during
Labour & delivery
Change during
postpartum
Blood volume Increased by 40 % - 50% Increased Decreased (auto
diuresis)
Heart rate Increased by 10 – 15
beats/ min
Increased Decreased
Cardiac Output Increased by 30% - 50 % Additional 50 % Decreased
Blood Pressure Decreased by 10 mm of
Hg
Increased Decreased
Stroke Volume Increased in first and
second trimester
Increased (300 –
500
ml/contraction)
Decreased
Systemic Vascular
Resistance
Decreased Increased Decreased

39. Maternal mortality associated with heart disease in pregnancy
Group 1: Mortality < 1%
Atrial septal defect
Ventricular septal defect; PDA
Pulmonary/tricuspid disease
Tetralogy of Fallot, corrected; Bioprosthetic valve
Mitral stenosis, NYHA class I and II
Group 2: Mortality 5–15%
2A Mitral stenosis NYHA class III–IV; Aortic stenosis
Coarctation of aorta, without valvular involvement
Uncorrected Tetralogy of Fallot
Previous myocardial infarction
Marfan syndrome with normal aorta
2B Mitral stenosis with atrial fibrillation
Artificial valve
Group 3: Mortality 25–50%
Primary pulmonary hypertension or Eisenmenger
syndrome
Coarctation of aorta, with valvular involvement
Marfan syndrome with aortic involvement

40. Mortality: 0 point-5%,1 point-27%,>1 point-75%
CARPREG Score

41. Anaesthetic Management
Principle involved:
Cardiac Output
Decrease in cardiac output
Hypotension
Tachycardia
Reduced ventricular
filling
Vicious cycle
Increased
ventricular filling
Trendelenburg'
s position,
Autotransfusio
n due to
uterine
contraction
Precipitation of
CHF
1
2
3

42. Anaesthetic Management
Principle involved:
1. Prevent decrease in cardiac output, as hypotension because of this causes
reflex tachycardia, which in turn reduces ventricular filling further
compromising cardiac output.
2. Avoid hypotension for the same reason listed above. If hypotension ensues,
treat with Ephedrine or Phenylephrine.
3. Avoid precipitating Congestive Heart Failure due to factors such as
Trendelenburg’s position
Autotransfusion due to uterine contraction leading to
increased central blood volume.
4. Avoid precipitation of Right Ventricular Failure
Hypercarbia
Hypoxemia
Lung Hyperinflation
Increase in lung water
If Right Ventricular Failure exists, treat with inotropes and pulmonary vasodilators.

43. Anaesthetic Management
Preoperative Medication
1. Decrease anxiety (decreases tachycardia)
2. Drugs used to control heart rate to be continued till day of surgery
3. Hypokalemia if present secondary to diuretic therapy to be addressed
4. If intended surgery is a minor surgery, continue anticoagulant therapy
5. If intended surgery is a major surgery, discontinue anticoagulant therapy.
Induction of Anaesthesia
1. Avoid Ketamine – Increases heart rate, blood pressure
2. Avoid Atracurium – Increased histamine release causes hypotension which
manifests as tachycardia.

44. Anaesthetic Management
Maintenance of Anaesthesia
1. Drugs should have minimal effects on hemodynamic pattern
2. Balanced anaesthesia with N2O/ Narcotic/ Volatile anaesthetic
3. N2O causes insignificant pulmonary vasoconstriction. It is significant only if
pulmonary hypertension exists. So, one needs to treat pulmonary
hypertension preoperatively.
4. Cardiac stable muscle relaxants are to be used. (preferably avoid Pancuronium)
5. Avoid lighter planes of anaesthesia (To avoid tachycardia)
6. Fluid Management:
Avoid Hypervolemia - -> Worsens pulmonary edema
Avoid Hypovolemia - -> Sacrifices already decreased left ventricular filling,
which further decreases Cardiac output. Hypovolemia secondary to blood
loss and vasodilatory effects of anaesthesia ought to be avoided.

45. Anaesthetic Management
Monitoring
1. Transesophageal Echocardiography
2. Intra-arterial pressure
3. Pulmonary artery pressure to be monitored
4. Left atrial pressure
Principle:
1. Ensure adequacy of cardiac function
intravascular fluid volume
ventilation
oxygenation
A word of caution regarding Pulmonary artery pressure monitoring: -
When measured too frequently, the risk of pulmonary artery rupture is far too
high.

46. Anaesthetic Management
Post Operative
1. Assess postoperative risk of pulmonary oedema and right heart failure and
manage accordingly.
2. Avoid pain as pain begets hypoventilation which leads to respiratory acidosis,
hypoxemia which manifests as raised heart rate and pulmonary vascular
resistance.
3. After Major thoracic or abdominal surgery, the decreased pulmonary
compliance and increased work of breathing requires mechanical ventilation.

47. Anaesthetic Management
Category 1 - Immediate threat to life of woman or fetus(baby needs to be removed
in 30 min. of making the decision to do LSCS
Category 2 - Maternal or fetal compromise, not immediately life threatening(some
time can be spent for resuscitation)
Category 3 - Needing early delivery but no maternal or fetal compromise
Category 4- At a time to suit the woman and maternity team

48. Anaesthetic Management
Anesthetic techniques available are
1. Regional anaesthesia (Sub Arachnoid Block, Epidural, Combined Spinal
Epidural)
2. General Anaesthesia
Sub Arachnoid Block: subarachnoid causes rapid onset of extensive sympathetic
blockade with intense vasodilatation sudden hypotension and severe tachycardia.
Epidural Block: epidural anaesthesia might not be an ideal technique as it requires
slow induction, delay in the onset of action which may not be possible in an
emergency situation. Moreover large volume of local anesthetic is needed for
adequate blockade.
Combined Spinal Epidural: Combined spinal and epidural will be the technique of
choice.CSE offers rapid onset and improved analgesia It offers ability to use low
dose spinal with room for post operative analgesia

49. Anaesthetic Management
Why our choice is right..?
1. Rapid onset of spinal block
2. Ability to modify / top-up / prolong anaesthesia with epidural component
3. Spread of spinal anaesthetic can be altered with injection of saline into the
epidural space (compression effect of dural sac)
4. Option for post-operative analgesia
5. Reduces need for conversion to general anaesthetic in event of spinal failure
6. Able to use lower dose spinal and modify if required, potentially reducing
spinal induced hypotension
7. Advantageous in cardiac conditions
8. Arguably advantageous in pre-eclampsia

50. Anaesthetic Management
Why our choice is right..?
9. Can produce a denser block than either technique in isolation
10. Airway pressures are not altered and avoids hyperventilation
11. Minimal autonomic blockade , hence no sudden decrease in Systemic
Vascular resistance
12. Better maintenance of uterine blood flow improving the fetal outcome
13. Auto transfused blood during the third stage of labor is well accommodated
14. Improved microvascular blood flow prevents DVT
15. Allows early ambulation and return of bowel movements

51. Anaesthetic Management
Procedure per se
Preparation:
1. All resuscitation equipments and drugs , anaesthesia machine, O2 delivery
system, Equipments for G.A. , Suction apparatus are kept ready
2. Patient is given aspiration prophylaxis in the form of 0.3ml SODIUM CITRATE
30ml orally, H2 receptor blocker and antiemetic given
3. Record baseline vitals
4. Secure two wide bore cannulae and infuse 60-75ml/hr of crystalloid
5. Administer infective endocarditis prophylaxis
6. Monitors- SpO2, ECG, NIBP, and urine output
7. Reassure the patient
8. Informed consent is obtained explaining the maternal and fetal risk
9. Adequate Compatible blood

52. Anaesthetic Management
Procedure per se
CSE is performed in lateral decubitus position under strict aseptic precautions
Epidural space is identified with 18 G Tuohy needle using LOR with saline. Spinal
needle is introduced through the Tuohy needle and subarachnoid block is
performed.20-30 μg of Fentanyl along with 2.5 -5mg of 0.5% Bupivacaine is given.
This is followed by insertion of epidural catheter through which 3 ml of 2%
Xylocaine with epinephrine is given.
Post operative analgesia is maintained as shown in the table below
Drug Initial Injection Continuous Infusion
Bupivacaine 10-15 mL of a 0.25%-0.125% solution 0.0625%-0.125% solution at 8-15 mL/hr
Ropivacaine 10-15 mL of a 0.1%-0.2% solution 0.5%-0.2% solution at 8-15 mL/hr
Fentanyl 50-100 µg in a 10-mL volume 1-4 µg/mL

53. Anaesthetic Management
1. If Hypotension occurs- vasopressors are used.
2. After the baby is delivered Oxytocin in minimal dose as slow infusion is given
3. Arrhythmias should be treated appropriately.
4. Blood loss should be assessed and replaced accordingly.
5. Immediate post partum period mandates meticulous care as mortality is very
high in these patients with Pulmonary artery hypertension.
6. Post operative pain management reduces Cardiovascular-stress response and
prevents Deep Vein Thrombosis.

54. Anaesthetic Management
Myths and Worries about Regional anaesthesia
1. Preloading is mandatory and hazardous--CVP guided fluid management
negates overloading and maintains adequate cardiac output
2. Regional Anaesthesia is associated with sudden fall in BP. Local anaesthetic
with Opioid combination intrathecally followed by epidural to titrate the
desired level of block does not produce rapid fall in BP.
3. Delay in performing the actual procedure: this doesnt happen with expert
hands
4. The complications of CSE-like total spinal, LA toxicity, epidural hematoma and
abscess are negligible with senior anesthesiologists

55. Anaesthetic Management
Controversies about CSE:
Risk of epidural catheter through the dural hole
Perceived increase in neurotrauma
Contraindications to Regional Anaesthesia
• Active heavy bleeding
• Uncorrected coagulopathy (e.g. HELLP syndrome (Hemolysis, Elevated
Liver Enzymes, Low Platelets) associated with pre-eclampsia)
• Thrombocytopenia
• Systemic sepsis
• Local sepsis at site of insertion
• Patient refusal

56. Anaesthetic Management
Guidelines for general anaesthesia
General anesthesia has the advantages of speed of induction, control of the
airway, and superior hemodynamics.
Anaesthetic Goals:
1. Maintain the heart rate around 80-100 b/min .
2. Maintain Left Atrial Pressure high enough to take advantage of the increased
preload reserve.
3. Avoid pulmonary artery hypertension by treating hypercarbia, hypoxemia, and
acidemia.
4. Aggressively treat pulmonary artery hypertension with vasodilator therapy to
avoid RV failure. If RV failure does occur, inotropic support of the RV and
pulmonary vasodilation may be necessary. The presence of PAH is the major
factor that increase the mortality.

57. Anaesthetic Management
Guidelines for general anaesthesia
5. Avoid factors which depress the myocardium:(inhalation agents and drugs)
6. Maintain awareness of potential for LV rupture.
7. Aggressive treatment of arrhythmias if they occur
8. Avoid profound changes in SVR
9. Attenuate pressor response(intubation, extubation, light plane of anesthesia)
10. Adequate analgesia and adequate muscle relaxation guided by Neuro
muscular monitoring
11. Aspiration prophylaxis
12. Blood loss assessment and prompt replacement

58. Anaesthetic Management
Guidelines for general anaesthesia

59. Anaesthetic Management
Guidelines for general anaesthesia
Other advantages are
1. Rapidly established
2. Better hemodynamic stability
3. Prevention of aspiration as the airway is isolated
4. High FiO2 -which will reduce PVR
5. Ventilation controlled to avoid hypercarbia-which will increase PVR
6. FRC is increased by controlled ventilation
7. Ventilation of atelectatic areas –better V/Q
8. Sinus rhythm can be maintained. In case of SVT and Ventricular arrhythmias
promptly reverted by cardioversion

60. Anaesthetic Management
Guidelines for general anaesthesia
Other advantages are
9. Peak airway pressure can be kept <20 cms H2O
10. Elective post operative ventilation to tide over the CCF that may be possible
after parturition
11. Effective management of Pulmonary oedema - IPPV with PEEP, liberal use of
high dose morphine

61. Anaesthetic Management
Guidelines for general anaesthesia
The possible complications that can be anticipated
1. failed intubation
2. Aspiration( more common in unprepared case)
3. Hypoxia and hypocarbia -effect on fetus
4. Hypertensive crisis
5. Arrhythmia-hypoxia, hypercarbia, inhalational agents, Drugs
6. Use of poly pharmacy and anaphylaxis
7. Awareness
8. Uterine atony with inhalation agents

62. Anaesthetic Management
Guidelines for general anaesthesia
The possible complications that can be anticipated
9. Need for adequate post op. Analgesia
10. Neonatal depression
11. Delayed recovery
12. Anesthetic drug interaction with cerebrovascular drugs(Ca channel blockers
and Magnesium)
13. Increased incidence of PONV
14. Prolonged stay ICU

63. Outlines of Management
1. Pre-conceptual counseling- NYHA III and IV are advised corrective cardiac
before pregnancy. It is advisable for certain cardiac diseases where pregnancy
is to be avoided
They have to be registered, interviewed regarding functional difficulties, regular follow ups
starting from early pregnancy. It is advisable to manage them in higher centers where
multidisciplinary support is available(Multidisciplinary approach: management by a team of
specialists apart from obstetricians that includes the cardiologist(failure prevention,
arrhythmia management), CT surgeon(emergent cardiac surgery), neonatologist(preterm
baby) anesthesiologist(pain relief-epidural, mechanical Ventilation if necessary)
2. Correct factors which will burden the cardiac lesion like anemia, obesity,
Hypertension, arrhythmia
3. Prevention of Infection

64. Outlines of Management
4. Optimization of Heart rate with pharmacological agents
5. Pregnancy is a hypercoagulable state, which increases the risk of
thromboembolic events, especially in the cardiac patient with a prosthetic
heart valve, valvular heart disease, or heart failure. Anticoagulant therapy
should be considered in these high-risk patients to prevent thromboembolism
or thrombus formation.
6. IE prophylaxis -(as per the ACOG guidelines- some of the drugs recommended
by ACC/AHA are not recommended for pregnant patients)
7. Monitors- other than the ASA standards recommendation- Advanced
monitors like invasive arterial pressure, CVP -, PCWP and TEE are
recommended. They should be continued in the post partum period upto 72
hrs at least

65. Outlines of Management
8. Planning the mode of delivery-vaginal delivery is better tolerated(less blood
loss, less catecholamine), Pain relief during Labor - recommended, shortening
the second stage- outlet forceps, episiotomy.
9. Large boluses of Oxytocics should be avoided as they cause profound
hypotension. Ergometrine better avoided. PGF2 alpha and mesoprostol are
used cautiously.
10. If planned for Cesarean section choice of anesthetic should be directed to keep
the haemodynamic stable (as near normal Systemic vascular resistance,
Preload, Afterload as possible)Adequate replacement of blood loss.
11. All patients with cardiac disease should be kept in High dependency unit and
monitored after the delivery for a minimum period of 72hrs
12. Plan and Advise cardiac surgery in the second trimester if is warranted in the
interest of the mother's well being

66. When to give Infective Endocarditis Prophylaxis..?

67. How to give Infective Endocarditis Prophylaxis..?

68. References
Miller’s Anaesthesia ,
7th Edition, Vol 1
Clinical Anesthesia by
Paul.G.Barash
Morgan’s Clinical
Anaesthesiology
Kaplan’s Cardiac
Anesthesia

69. References
Harrison’s Internal
Medicine 17th Edn
A Practice of
Anesthesiology
by Churchill
Wylie
Stoelting’s Anesthesia
& co-existing
disease
CMDT 2010

70. References
Bedside Clinics in
medicine - Kundu
A Manual of
Practical
Medicine by
Alagappan
Circulation Journal

71. References
Indian Journal of
Anaesthesiology