Mitral Stenosis (MS)
Considerations
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Perioperative cardiovascular decompensation:
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Severity of valvular lesion
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High risk (especially with pregnancy)
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Hemodynamic sequelae of MS (limited ability to ↑ cardiac output)
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Atrial dilation & arrhythmias
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Pulmonary edema & CHF
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Pulmonary hypertension & RV failure
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Thrombotic events
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Associated conditions:
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Associated valvular pathologies
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Rheumatic heart disease
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Connective tissue disease (SLE, RA)
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Obstructive (carcinoid, atrial myxoma)
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Medications:
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Anticoagulation (often need bridging with heparin)
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Diuretics
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Antiarrhythmics
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Goals
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Preload: maintain (avoid overload)
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Rate: low-normal (most important goal)
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Rhythm: sinus (avoid atrial fibrillation because of ↑ HR)
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Contractility: maintain
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Afterload: maintain
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Avoid precipitants of pulmonary hypertension
Severity Grading
Pregnancy Considerations
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Goals:
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Maintain a slow heart rate
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Maintain sinus rhythm
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Aggressively treat acute atrial fibrillation
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Avoid aortocaval compression
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Maintain venous return
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Maintain adequate systemic vascular resistance
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Prevent pain, hypoxemia, hypercarbia, and acidosis (may ↑ pulmonary vascular resistance)
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Risk:
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Mild to moderate MS without severe pulmonary HTN is considered low maternal or fetal risk
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Mitral stenosis with NYHA class II-IV symptoms is considered high maternal risk
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Anesthetic options:
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Vaginal delivery
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Symptomatic patients will require invasive monitoring
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Adequate analgesia for first stage (epidural)
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Second stage should be assisted by low forceps/vacuum
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Cesarean section
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Epidural is the preferred method
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If GA required need to keep goals
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Further Reading
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Stoelting's Anesthesia and Co-Existing Disease, 7th Edition, Chapter 6: Valvular Heart Disease
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Chestnut's Obstetric Anesthesia, Sixth Edition, Chapter 41: Cardiovascular Disease