Anesthesia Considerations 

Mitral Regurgitation (MR)

 

 

Considerations

 

• ↑ risk of perioperative cardiac complications (MI/CHF)

• Hemodynamic alterations associated with MR:

  • Left atrial volume overload & ↓ forward cardiac output (CO)

  • Potential for LV dysfunction (from overload)

  • Potential for arrhythmias (atrial fibrillation commonly) due to LA dilatation

  • Potential for pulmonary hypertension leading to RV dysfunction

• Acute MR: sudden LA & LV overload without compensatory hypertrophy leading to decreased forward CO & simultaneous pulmonary congestion

• Comorbid disease:

  • Coronary artery disease

  • Atrial fibrillation

  • Other valvular lesions (MS, AI)

  • Connective tissue diseases (SLE, RA, Marfan’s)

  • Endocarditis

• Management of medical therapy:

  • ACE inhibitors, beta-blockers, digoxin, calcium channel blockers

 

 

Goals

 

• Maintain forward flow & ↓ regurgitant fraction:

  • Preload: maintain preload but avoid overload (↑ risk for CHF)

  • Rate: high-normal rate (80-100bpm) & avoid bradycardia (longer diastole = more regurgitation)

  • Rhythm: sinus rhythm preferred but not as critical as stenotic lesions 

  • Contractility: maintain or enhance contractility to improve forward flow & reduce regurgitant fraction by constricting mitral valve annulus 

  • Afterload: reduce afterload to enhance forward flow 

• Avoid ↑ in pulmonary vascular resistance to mitigate right heart failure (avoid hypoxia, hypercarbia, acidosis, pain)

 

 

Pregnancy Considerations 

 

• Goals:

  • Prevent an ↑ in SVR

  • Maintain a normal to slightly elevated heart rate

  • Maintain sinus rhythm

  • Aggressively treat acute atrial fibrillation

  • Avoid aortocaval compression

  • Maintain venous return

  • Prevent an ↑ in central vascular volume

  • Avoid myocardial depression during general anesthesia

  • Prevent pain, hypoxemia, hypercarbia, & acidosis (may ↑ PVR)

• Monitoring:

  • Invasive monitoring rarely required unless severe mitral regurgitation 

• Anesthetic options:

  • Epidural preferred for vaginal delivery or cesarean section 

  • If GA used, give attention to the maintenance of adequate heart rate & ↓ afterload

  • Acute atrial fibrillation must be treated promptly & aggressively; hemodynamic instability warrants the immediate performance of cardioversion

 

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Further Reading 

• Stoelting's Anesthesia and Co-Existing Disease, 7th Edition, Chapter 6: Valvular Heart Disease

• Chestnut's Obstetric Anesthesia, 6th Edition, Chapter 41: Cardiovascular Disease