Valvular Heart Disease
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1 Valvular Heart Disease Roman M. Sniecinski, MD, FASE Associate Professor of Anesthesiology Emory University School of Medicine Learning Objectives Review the major pathophysiology of the most common heart valve lesions Understand when intervention is appropriate prior to elective non cardiac surgery Learn best practices for intraoperative management of patients with valvular heart disease Background While rheumatic heart disease is now uncommon in developed countries, valvular heart disease (VHD) remains an emerging health care concern. There are currently more than 18.5 million people in the US over the age of 75, and those >65 years old represent the fastest growing segment of the population.(1) The prevalence of moderate or severe valvular degeneration is estimated to be 13 15% in this age group, making VHD an emerging epidemic. Anesthesiologists must therefore be familiar with how to manage these patients in the perioperative setting. Pre operative Evaluation Severe VHD is an active cardiac condition per the 2007 ACC/AHA perioperative evaluation guidelines.(2) It is a class I recommendation to assess and treat these conditions prior to surgery. Valve Lesion Physical Findings Severe Cut off (3,4) Pre op Issues Aortic Stenosis Systolic ejection murmur RUSB Valve Area <1.0cm 2 Asymptomatic pts with severe AS require annual Syncope Jet velocity >4 m/s echocardiogram Angina Heart failure Mean Gradient >40 mmhg May benefit from balloon valvuloplasty before Sx Mitral Stenosis Diastolic murmur apex Valve Area < 1.0cm 2 Dyspnea Palpitations Syncope (late) Rt heart failure Mean Gradient >10 mmhg PAP > 50 mmhg Asymptomatic pts with severe MS require annual echo May benefit from balloon valvuloplasty before Sx Aortic Regurgitation Diastolic flow murmur LSB Dyspnea Tachycardia (acute) Shock Widened pulse pressure Pressure Half Time <200 ms Regurgitant Fraction 50% EROA 0.3cm 2 Atrial fibrillation common Acute, severe AI almost always requires urgent surgical intervention Medical optimization for chronic patients
2 Mitral Regurgitation Pansystolic murmur apex Dyspnea on exertion Palpitations (acute) Shock Pulmonary hypertension Regurgitant Fraction 50% EROA 0.4 cm 2 (multiple others ) Acute, severe MR almost always requires urgent surgical intervention Medical optimization for chronic patients Concomitant CAD and atrial fibrillation common Most patients undergoing a surgical procedure will require pre operative antibiotics. However, it is important to note that patients with non congenital VHD, unless a prosthetic valve is already in place, do not require routine antibiotic prophylaxis for dental procedures, colonoscopies, etc.(5) Aortic Stenosis The main concern with AS patients is not necessarily the valve itself, but rather the increased pressures and concentric hypertrophy of the myocardium that occurs because of it. High left ventricular (LV) pressures are required to both fill the non compliant LV, as well as force blood past the fixed obstruction. At the same time, a high coronary perfusion pressure and long diastolic time are needed to adequately perfuse the thickened myocardium. CPP = dbp LVEDP CPP = coronary perfusion pressure; dbp=diastolic blood pressure LVEDP=left ventricular end diastolic pressure The anesthetic management must account for the LV hypertrophy and maximize the myocardial supply/demand ratio in order to prevent unwanted myocardial ischemia: Slower heart rate (unless significant aortic regurgitation is also present see below) o Maximize diastolic perfusion time and minimize systolic work load Higher blood pressure o Maximize CPP Adequate pre load o High filling pressures are required due to the diastolic dysfunction Mitral Stenosis Similar to aortic stenosis, patients with mitral stenosis have problems with LV filling. Unlike AS, however, the problem does not lie with the LV (which typically has normal function), but with the fixed obstruction to moving blood out of the left atrium (LA). The result is that while LVEDP remains normal, LA pressures become extremely high. With disease progression, pulmonary hypertension and right
3 heart failure become the predominant concerns. Inevitably, the high LA pressures also lead to left atrial enlargement, loss of sinus rhythm, and potential for LA thrombus. Anesthetic management should have the goals of maximizing LV filling without exacerbating pulmonary hypertension: Slower heart rate (sinus rhythm, if present, should be maintained) o Need time to fill the LV Judicious fluid use o Fluid overload will precipitate pulmonary edema Avoidance of increases in PA pressures o Right heart function may need to be supported with inotropes Aortic Regurgitation Acute aortic insufficiency (AI) is generally severe in nature and typically due to endocarditis, aortic dissection, or trauma. Chronic AI is usually well tolerated and asymptomatic until it becomes severe since non concentric ventricular hypertrophy is an effective compensatory mechanism. It should be remembered that patients with significant AI will have supra normal ejection fractions. Patients with normal or slightly reduced EFs usually have more advanced disease. Because most anesthetic drugs cause decreases in afterload, patients with regurgitant lesions tend to tolerate anesthesia quite well with little additional risk: Faster heart rate o Bradycardia will increase diastolic time and increase regurgitant fraction Lower afterload o Hypertension will increase regurgitant volume as well Judicious use of fluids One thing to be aware of is that aortic stenosis and aortic regurgitation are commonly found together. In this case, care should be made to maintain the patient s baseline blood pressure and heart rate.
4 Beware of mixed lesions! Mitral Regurgitation Like aortic regurgitation, mitral regurgitation typically improves under anesthesia. The caveat, however, is that one of the most common causes of mitral regurgitation is coronary artery disease and resulting ischemic cardiomyopathy. If the patient has coronary artery disease, ischemic MR may actually be exacerbated by tachycardia and lower afterload. If the underlying mechanism is fibroeleastic dysplasia, then bradycardia and hypertension will worsen the MR, potentially precipitating pulmonary edema. It is therefore important to not just treat the patient s MR, but to investigate what the underlying disease process is.
5 References 1. C W. The older population: US Census Bureau Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jr., Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Tarkington LG, Yancy CW. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation 2007;116: Zoghbi WA, Enriquez Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, Nihoyannopoulos P, Otto CM, Quinones MA, Rakowski H, Stewart WJ, Waggoner A, Weissman NJ. Recommendations for evaluation of the severity of native valvular regurgitation with two dimensional and Doppler echocardiography. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography 2003;16: Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, Iung B, Otto CM, Pellikka PA, Quinones M. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography 2009;22:1 23; quiz Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Jr., Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008;118:e
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