Mitral stenosis is a chronic mechanical obstruction of the left ventricular inflow caused by narrowing of the mitral valve orifice. This document discusses the anesthetic considerations for a patient with mitral stenosis undergoing non-cardiac surgery. It covers the pathophysiology of mitral stenosis, preoperative evaluation and optimization of the patient, and intraoperative anesthetic goals of maintaining normal hemodynamics while avoiding tachycardia, changes in preload or afterload, and worsening of pulmonary hypertension.

1. ANAESTHETIC CONSIDERATIONS
IN MITRAL STENOSIS PATIENT
FOR NON CARDIAC SURGERIES
SPEAKER: Dr.Vamshidhar (JR3)
Dr. Prashanthi (SR)
Moderator: Dr.Aruna mam (A.P)
DEPARTMENT OF ANAESTHESIOLOGY
ESIC MEDICAL COLLEGE ,HYDERABAD

2. Mitral Stenosis
 Mitral valve is present between LA & LV
 Normal mitral valve orifice area (MVA): 4-6cm2
 Decrease in Mitral valve orifice area leading to chronic & fixed
mechanical obstruction to LV filling is termed as MS.

3. Natural History- untreated MS
•
•
•
•
Progressive, lifelong disease
Usually slow & stable in the early years
Progressive acceleration in the later years
20-40 year latency from rheumatic fever to symptom onset in developed
countries
After symptoms-- additional 10 years before disabling
symptoms
•

4. Causes
• Rheumatic Heart disease
• SLE
• Carcinoid syndrome
• Active Infective Endocarditis
• Left atrial myxoma
• Congenital mitral stenosis
• Massive Annular Calcification

5. Pathology
Obstruction at the level of the mitral valve
Calcification of the valve apparatus
Thickening, fusion and contracture of the chordae and papillary heads
Increased rigidity of the valve leaflets
Thickening and commissural fusion of the mitral valve leaflets.

6. pathophysiology
Obstruction at the level of the mitral valve
raised left atrial pressure » enlargement of left atrium
pulmonary hypertension Atrial fibrillation
right heart failure

9. Rheumatic mitral stenosis
 More common in females (2/3rdof all pts)
 Symptoms occur two decades after onset of Rheumatic fever Age of
presentation
 Earlier in 20s-30s or 40s-50s (slower progression)
 Isolated MS in 40% cases of RHD
 Remaining 60% cases associated with other valvular diseases-
MR/AR

10. Rheumatic fever- Jones criteria
Major criteria
•
•
•
•
•
Carditis
Arthritis
Subcutaneous nodules
Chorea
Erythema marginatum
•
•
•
•
Minor Criteria
Clinical
Fever
Arthralgia
P/H rheumatic fever / RHD
Laboratory
• Acute phase reactants:
leucocytosis, ESR, CR
proteins
Prolonged PR interval

11. RF - Essential criteria
• Evidence for recent streptococcal infection as indicated by
– Increased anti streptococcal antibody titers
– Positive throat cultures
– Recent scarlet fever

12. • Valve area > 1.5 cm2usually does not produce symptoms at rest
• Dyspnoea in patients with mild MS usually precipitated by
– Exercise
– Emotional stress
– Fever, Infection
– Anaemia
– Pregnancy
– Atrial fibrillation with rapid ventricular response
– Thyrotoxicosis

13. Symptoms
 Dyspnoea
 PND
 Orthopnea Palpitations Fatigue
 Chest pain
 Cough
 Hemoptysis
 Abdominal discomfort
 hoarseness

14. signs
• Mitral facies
• Raised JVP
• Parasternal heave
• Tenderness right hypochondrium
• Ascites
• Diastolic murmur
• Accentuated 1st heart sound (wide, loud, split first heart sound, an S3
sound, and a soft systolic ejection murmur in pregnants)
• Opening snap
• Embolic events may be present in 20% of cases (mostly cerebral,
pulmonary)

15. General examination
• Mitral facies
‘Pink purple patches on the cheeks, cyanotic skin changes from low
cardiac output’
• Pulse – low volume pulse
• Blood pressure

16. Examination
Inspection
•Engorged vein in neck Palpation:
Tapping apex beat
Palpable S1
Parasternal heave
Palpable S2 Diastolic
thrill
•
•
•
•
•
Auscultation:
• S1 is short, sharp , accentuated
(loud, snapping)
S2 audible
Opening snap after S2
A2 to OS interval inversely
proportional to severity
Diastolic rumble: length
proportional to severity
In severe MS with low flow- S1,
OS & rumble may be inaudible
• Mid diastolic murmer

17. MID DIASTOLIC MURMER:
• It is a decrescendo diastolic filling rumble occurring in the first rapid
filling phase.
• It is low pitched rough rumbling in character.
• length of the murmur correlates with severity of murmer.
• best heard just medial to apex in left lateral position during expiration
• It is introduced with prominent OS, associated with Loud S1, presystolic
• accentuation and a diastolic thrill.
• Left lateral position, hand grip exercise, amyl nitrate inhalation - Enhance
MDM
• Valsalva maneuver -Diminishes the murmur.

18. Features of PHT
Palpation:
• Parasternal heave
• Palpable S2
Auscultation:
• ESM over pulmonary area
• SM which increases on inspiration
heard along the left sternal border
-Functional TR
• Graham Steel murmur –
pulmonary Regurgitation

19. Complications
 Atrial dysrhythmias
 Systemic embolization (10-25%)
 Risk of embolization is related to age, presence of atrial
fibrillation, previous embolic events
 Congestive heart failure
 Pulmonary infarcts (result of severe CHF)
 Endocarditis
 Pulmonary infections

20. Normal mitral valve
• MVA > 4 cm2(4- 6 cm2)
• Diastolic mitral valve flow of 150- 200 ml/ sec/ diastole
• Diastolic transvalvular pressure gradient of less than 2 mmHg

21. Assesment of severity
>2.5 cm2 None
1.5-2.5 cm2 (Mild) Dyspnoea on severe exertion
1-1.5 cm2 (Moderate) PND +/- Pulmonary edema
<1 cm2 (Severe/ critical MS) Orthopnoea
A) According to Valve area & Symptoms
B) Severity of MS is on A2- OS interval
Grading Interval
Mild MS (LAP 15 mm Hg) 0.08- .12 sec
Moderate MS (LAP 20 mm Hg) 0.04- 0.08 sec
Severe MS (LAP 25 mm Hg) 0.04 sec

22. C) According to gradient across Valve
Normal valve mean gradient is 0 mmHg.
Mild MS <5 mmHg
Moderate MS 5-15mmHg
Severe MS >15 mm Hg

24. LEFT VENTRICULAR FUNCTION
 Known as fixed cardiac output state which means SV cannot be increases with
increasing heart beat
 LV contractility and function usually normal in early stages,but LV dysfunction
occurs in late stages
 As stenosis worsens flow restriction limits LV filling and LV preload
 In addition there is increased afterload due to vasoconstriction due to reflex
vasoconstriction in response to low cardiac output
 LV dysfunction occurs due to LV muscle atropy as a result of chronic underfilled
states
 There is shift of interventricular septum towards left due to right ventricular
hypertrophy

25. INVESTIGATIONS
 Complete blood count
 Blood grouping and cross matching
 Liver function test
 Renal function test and electrolytes—effect of diuretics and digoxin
 Chest X-ray:
• Normal in early stages
• Mitralization of left heart border
• LA enlargement: Double density sign
• RV enlargement
• Pulmonary edema
• Calcified valve, splaying of carina

26. ECG:
May be normal
• P-mitrale:
 Classic broad M-shaped P wave in lead II (LA enlargement)
 P-wave may be more than 120 msec in duration
 Biphasic P-waves may be seen in lead V
Right axis deviation, RBBB due to right ventricular hypertrophy
Atrial fibrillation

27. • Echocardiography:
• Area of mitral valve
• Assessment of mitral valve anatomy-Wilkins score
• Size of LA
• Presence of LA thrombus
• Pressure gradient between left atrium and ventricle
• Severity of associated lesions like mitral regurgitation
• Staging of the disease and to decide intervention of choice based on Wilkins
score
• Ventricular function
• Doppler echocardiography –
• Pressure gradient across mitral valve
• Pulmonary artery pressure
• Left ventricular function

28. Cardiac catherization:
• Not routinely done in mitral stenosis cases
Indicated when:
 Noninvasive tests are inconclusive
 Discrepancy between noninvasive tests and clinical assessment of
severity
Uses of catheterization in mitral stenosis:
 For calculation of MVA using Gorlins equation
 PCWP increases to 30-50 mm Hg when mitral valve area 1 to 1.2 cm2
 Valvular diastolic pressure gradients 5-25 mm Hg, if severe MS

29. GORLIN’S EQUATION
The relationship between cardiac output, valvular area & transvalvular
gradient can be expressed by the Gorlin equation:

31. PREOPERATIVE
ASSESSMENT
 Take detailed history and examination (general and systemic)
 Assess the functional status based on NYHA classification
 Look for AF
 Recognition of compensatory mechanisms for maintaining cardiac output
 Evaluate patients hemodynamic state.
 The presence of associated major organ system disease /comorbids.
 Drug history/ current medication

32. Patient on anticoagulants
 Anticoagulants can be continued in minor surgeries where minimal
bleeding is expected.
 Oral anticoagulation should be discontinued at least 3-5 days before any
major surgery.
 UFH or LMWH in prophylactic doses is substituted preoperatively.
 A dose of UFH should be given 3-6 h preoperatively in patients and should
be restarted as soon as possible post operatively (preferably within 12 h).
 Warfarin is restarted 24 hours postoperatively or when patients can start
oral intake.
 In emergency surgery, the affect of warfarin needs to be neutralized by
FFP along with vitamin K.

33. Atrial fibrillation
Sinus rhythm/control of ventricular rate
1. Digoxin: (loading dose 0.25mg iv over 15 minutes followed by 0.1mg
every hour till response occur or total dose of 0.5-1.0mg. Monitor
ECG, BP, CVP; HR <60bpm- Stop)
2. CCB (verapamil/diltiazem: 0.075-0.15mg/kg IV)
3. β-blocker (esmolol: 1mg IV)
4. Amiodarone:loading:150mg IV bolus over
15mins,
infusion 1mg/min IV for 6hrs
f/b 0.5mg/min for next 18 hrs
5. Cardioversion in hemodynamic unstable patients

34. Pulmonary HTN/Edema/RVF
1. Oxygen
2. Diuretic
Loop diuretics
High dose deleterious Combine with vasodilator
3. Digitalis
4. Morphine (0.1mg/kg)
5. Vasodilators (NTG): Pulmonary vasodilation (↓PAP)
0.5–10 μg/kg/min S/E: systemic hypotension
6. Nesiritide
 Recombinant BNP
 Arterial & venous dilatation
 Controls dyspnoea in Acute heart failure
7.Myofilament calcium sensitizer (Levosimendan)
Inodilators (↑es myocardial contractile strength,
dilatation of systemic, pulmonary & coronary artery)

35. 8. Inotropic agents
Dobutamine
9. Inodilators
Amrinone Milrinone

36. CLINICAL RISK ASSESMENT
 Clinical risk scores are calculated from the patient’s history and the results of
routinely performed preoperative investigations.
 Lee’s Revised Cardiac Risk Index (RCRI) is the most widely used risk score in
non-cardiac surgery and has been incorporated into ACC/AHA guidelines.
 One point is allocated for each risk factor
 The incidence of major cardiac complications was 0.4%, 0.9%, 7%, and 11% for
patients with a score of 0, 1, 2, or ≥3, respectively.

37. Functional status
 Functional status or exercise capacity may be expressed in term of
metabolic equivalents (METS; i.e. multiples of resting energy
expenditure).
 The ability to perform more than 4 METS (walking up two flights of
stairs, heavy housework, running a short distance) without symptoms is
considered in both the ESC and ACC/AHA guidelines to be associated
with acceptable perioperative risk.

38. Sedatives and anxiolytics:
 Prevention of tachycardia is very important as it worsens the left ventricular
filling by decreasing diastolic time.
 Elimination of anxiety avoids tachycardia, but excessive sedation may lead to
respiratory depression and hypercarbia and acidosis, resulting in elevated
pulmonary vascular resistance.
 So, sedative premedication like benzodiazepines must be used judiciously in
titrated doses.
Antibiotic prophylaxis:
 This patient would need antibiotic prophylaxis for her surgery which would
include good gram-positive and gram-negative cover.
 Drug can be given as per institutional protocol.
 Only high-risk group should receive prophylaxis against infective endocarditis.
 Patients with a prosthetic heart valve or prosthetic material used for valve repair.
 Patients with a past history of infective endocarditis patients with cardiac valvulopathy after
cardiac transplantation
 Specific patients with congenital heart disease.

40. DVT prophylaxis:
 If the patient is active with normal lifestyle, chances of preoperative DVT are less.
 Patients with severe MS with restricted lifestyle should be screened for DVT
preoperatively and put on prophylaxis in perioperative period.
 If epidural catheter insertion is planned confirm that there is a gap of minimum
12 hours between LMWH and epidural catheter placement as per ASRA
guidelines

41. medications to continue intra operatively
• Diuretics- Evaluate fluid status
Check electrolytes on day of surgery
• Drugs to control AF :Digoxin, beta blockers, Amiodarone
• Patients on pulmonary vasodilators :sildenafil,bosentan
• Watch serum potassium- in patients receiving digoxin and
diuretics
• Warfarin- switch to heparin perioperative for better control. Titrate to
APTT 1.5-2 times normal.
• Continue post op.
• Management of anticoagulation perioperatively should balance
risks of bleeding with the risk of thrombosis and systemic
embolization
Regarding medications

42. Anesthetic goals
Heart rate/
rhythm
Sinus rhythm, control
ventricular rate (70-
90bpm)
Avoid tachycardia
Preload Normal or increased Avoid under-load/
overload
After-load Maintain normal after
load
Avoid sudden
increase/reduction in
afterload
Avoid cardio-
depressant drugs
Contractility Usually LV systolic
function: N
But may be reduced in
long history
Normal oxygenation,
acid base status
Pulmonary HTN/RV
dysfunction
Avoid hypoxia,
hypercarbia, acidosis

43. Premedication
• There is no ideal technique or drug. Any technique can be used as long
as the hemodynamic goals are met.
• Adequate dose prevents anxiety and tachycardia.
• While overdose cause hypoventilation & hypotension(↑pvr &↓c.o.)
exacerbate pulmonary hypertension.
 Morphine 0.1-0.2mg/kg
 Clonidine 30ug iv 30 min before surgery
 Benzodiazepenes can be given (reduce dose of
morphine)
 Fentanyl: 1mic/kg
Anticholinergics- avoided as they increase heart rate

44. •
POSITION:Avoid Trendelenburg position to avoid increasing central blood
volume
Class Drug Dose (mg/kg) Rout
e
BZPs Diazepam 0.1-0.15 PO,IM
Lorazepam 0.03-0.06 PO,IM
Midazolam 0.03-0.07 IM
Opioids Morphine 0.2 IM
Meperidine 1.0-1.5 IM

45. Induction
• Etomidate best for hemodynamic stability .
• Any intravenous induction drug except ketamine(H.R.)
• Should be double diluted and given slowly.
• Midazolam,Narcotic( morphine 0.5mg/kg or Fentanyl 5-10 ug/kg)
• Avoid Propofol- direct and indirect effects on ventricular preload
• Beta blockers,lignocaine, dexmeditomidine can be used to
attenuate the intubation response during laryngoscopy
• Moderate to severe MS generally have slow circulation that
prolongs the brain arm circulation time

46. Muscle relaxants
 Avoid histamine releasing NMBA like Atracurium,Cicatracurium,
Mivacurium, Pancuronium
 Steroidal Group like Vecuronium, Rocuronium - preferred
relaxants.
 Succinylcholine can be used in anticipated difficult airway as
it is not an absolute contraindication.

47. Non-opioid induction agents
Thiopenton
e
Propofol Etomidate Ketamine BZP
MAP   ↔  
HR   ↔  
CO   ↔  
SVR   ↔/↓  
PVR ↔ ↔/↓ ↓ ↑ ↔
contr ↓ ↔/ ↓ ↔ ↔/↑ ↔

48. Muscle Relaxants
Pan Vec Roc Atra Miv Sc
h
MAP  -    
HR  -    
CO  -    -
SVR - - -   -
Histamine - - - + + -

49. Maintainence
 A balanced anesthesia that includes low concentrations of a volatile
anesthetic is desirable.
 Avoid halothane- arrythmogenic
 Isoflurane(tachycardia), Sevoflurane(ideal).
 Nitrous oxide – Increases PVR . Best avoided in PAH
 Vasodilator therapy ( NTG/ Nitroprusside 0.5-1 ug/kg/min)-
desirable in severe PAH
 Intraoperative fluid replacement must be carefully titrated
 Reversal- slowly to help ameliorate any drug-induced tachycardia
caused by the anticholinergic drug in the mixture.

50. INTRA OPERATIVE
MANAGEMENT
 Rate/rhythm: sinus rhythm should be maintained.
 A low normal heart rate (<70 beats/min) is critical regardless of the rhythm
to allow sufficient diastolic time for ventricular filling.
 Preload:Aim for normovolemia, - fluid boluses can worsen pulmonary
oedema.
 Fluids should be judiciously administered as to keep the right heart and PA
pressures low.
 Afterload: maintenance is very crucial.
 Any decrease in afterload is detrimental as it can lead to severe hypotension
and decreased coronary perfusion pressures.
 Avoiding hypoxia, hypercarbia, and acidosis as it can lead to increased PVR
which may lead to acute right ventricular decompensation.

51.  Contractility: Aim to maintain adequate myocardial contractility.
 In case of LV failure, augmentation of RV contractility is required.
 Phosphodiesterase III inhibitors(amrinone/milrinone) or dobutamine may be
used when signs of increased PVR are seen.
 Phosphodiesterase inhibitors can reduce afterload therefore should be used
cautiously.
 Intra op hypotension can be treated with phenyl ephrine.
 Marked increase in central blood volume is associated with over transfusion
and head down position

52. • Monitoring
• ECG, BP, Spo2, capnography, temperature
• Invasive monitoring-
-Direct arterial pressure
-CVP- measure loading conditions and means of transfusing
inotropes/dilators
-Pulmonary artery catheter-
- Monitor Pulmonary Artery Pressure ( PAP)- useful in PAH
- Helpful for confirming the adequacy of cardiac function, intravascular fluid
volume, ventilation, and oxygenation.
- PCWP reflect LA pressure but not LVEDP because of mitral stenosis.

53. REGIONAL ANAESTHESIA
Peripheral nerve blocks(US guided) very safe and should be used wherever
possible.
Central Neuraxial anesthesia:
Subarachnoid block can be preferred for infraumbilical and lower limb
procedures in mild disease
CSEA
Graded epidual
Continuous intrathecal
Possibility of exaggerated hypotension with central neuraxial blockade to be
remembered who are on beta blockers and diuretics.
In severe ms , central neuraxial blocks are contraindicated.
For mild-moderate
disease

54. • Strict monitoring
• Anticoagulation need to be started as soon as the risk of post operative
bleeding has been diminished
• Inotropic support and vasodilator therapy should be continued for
prolonged ( 24-48 hrs) in patients with severe PAH.
• in patients with LV dysfunction May require a period of mechanical
ventilation - avoid Pain and hypoventilation(PVR)
• ANALGESIA:
• Multimodal analgesia is preferred.
• Relief of postoperative pain with neuraxial opioids useful
Post operative management

55. Post-operative Complication
• Pulmonary congestion/edema
• Thrombo-embolism
• Heart failure

56. MS in pregnancy
The main cardiovascular changes in pregnancy which worsen features of mitral
stenosis are:
1. Increase in blood volume by 30–50% starting at end of 1st trimester to peak at
20–24 weeks. This increases pulmonary capillary hydrostatic pressure thereby
increasing risk of pulmonary edema.
2. Decrease in systemic vascular resistance.
3. Increase in heart rate by 10–20 beats/min—reduces diastolic filling time of LV.
4. the transvalvular gradient increases significantly.
This also raises LA pressure substantially to give rise to symptoms.
5.During pregnancy, the patient’s symptomatic status will generally increase by 1
New York Heart Association class.

57. 6. During labor and delivery, there is sympathetic stimulation causing
tachycardia and further increase in cardiac output. Also there is sudden
rise in venous return to the heart due to auto-transfusion and IVC
decompression. This may lead to decompensation.
7. Enlarged atrial dimension predispose to atrial arrythmias including
atrial fibrillation.
8.Pregnancy also induces changes in haemostasis which contribute to
increased coagulability and thromboembolic risk

58. Anaesthetic goals
Pregnancy associated change
Haemodynamic goal
measures

59. Cesarean section
Advantages:
 Avoids hemodynamic consequences of labour.
Choice of anesthesia for CS depends on:
 Severity of MS
 Emergency/Elective
 Hospital facilities-Invasive monitors,Ventilator,ICU,cardiac
facilities,Surgeons.

60. Neuraxial block
 A single-shot spinal anesthesia is contraindicated in severe stenosis
because of uncontrolled hypotension.
 ↓ SVR
 ↓ cardiac preload
 reflex tachycardia
 In mild –moderate cases spinal anesthesia with 1ml 0.5% bupivacaine and
10-20mcg fentanyl along with epidural block or use of spinal catheter .
 Small boluses of phenylephrine (25-50mcg) are effective in avoiding
precipitous hypotension.

61. EPIDURAL BLOCK
 Epidural alone can be used in mild to moderate MS .
 A well-controlled, individualized epidural neuraxial block using
incremental graded dosing of local anesthetic in the hands of
experienced anesthesiologists with invasive monitoring of arterial & CVP
may be beneficial even for the most severe cardiac disease.
 Sensory level to be achieved with titrated doses of LA .
 Optimize fluid status
 Avoid adrenaline in the epidural test dose

62. Advantages of graded
epidural analgesia
 Total dose can be titrated to the desired sensory level.
 Slower onset - allows the maternal CVS to compensate for the
occurrence of sympathetic blockade  Low risk of hypotension &
Low risk of↓ uteroplacental perfusion .
 Segmental blockade spares the lower extremity “muscle pump,” aiding
in venous return.
 ↓ incidence of thrombo-embolic events.

63. GENERAL ANAESTHESIA
 A beta blocker and an adequate dose of opioid like fentanyl should be
administered before or during the induction of general anaesthesia.
 Esmolol has a rapid onset and short duration of action, better choice in
controlling tachycardia however foetal heart rate should be monitored
 Modified rapid sequence induction using etomidate, remifentanyl and
succinylcholine/rocuronium is an ideal choice in severe stenosis with
pulmonary hypertension.
 Maintenance of anaesthesia can be carried out with oxygen and air,
isoflurane, opioids and vecuronium.
 With associated severe pulmonary hypertension, nitrous oxide can be omitted.

64.  After delivery of the foetus, oxytocin 10–20 u in 1,000 ml of crystalloid
should be administered at a rate of 40–80 ml/min.
 An infusion of oxytocin can lower the SVR as well as elevate the pulmonary
vascular resistance, resulting in a drop in cardiac output.
 Care must be taken during its administration.
 Methylergonovine produces severe hypertension, tachycardia and increased
pulmonary vascular resistance hence avoided
Avoid drugs that cause tachycardia
 Atropine
 Ketamine
 Pancuronium

65. Labor analgesia
 Epidural, blocks  ↑ INR  Contraindicated
 Entonox pulmonary pressures ↑
 IV opioids ( remifentanyl) are the choice

66. APPENDICECTOMY
Common in 2nd and 3rd trimester
In pregnancy appendix lies above the iliac crest.
Concerns:
 CO2 insufflation- hypercarbia risk of pulmonary hypertension
 Elevated intraabdominal pressure lowers venous return &
uteroplacental blood flow

67. Laparoscopic surgery
• Less post op pain
• Early mobilization lesser
thromboembolic events.
• Lesser incidence of infection
• Decreased rate of fetal
depresion due to less narcotic
use
• Technically difficult after 26
wks
• Trochar insertion
difficulty/Trauma
• ↑intra abdominal pressure 
utero placental blood flow↓,
Fetal hypotension,
• Risk of uterine
irritationuterine
manipulation,cautery
• Fetal acidosis due to CO2
narcosis.
Disadvantages

68. Summary of MS
• Is a low & fixed cardiac output condition
• Stress condition like pregnancy, labour & sepsis, condition become worst- CHF,
pulmonary edema, AF
• Patients may be on diuretics, digitalis & anticoagulant therapy
• Peri-operatively these patients have to be managed as per medications &
guidelines
• Tachycardia has to be avoided at any cost
• Pulmonary vasculature resistance has to be reduced
• Preload & afterload both should be maintained
• Use of regional anesthesia is not contraindicated in theses patients, but proper
patients selection & precaution are must.

69. Thank you