Anesthesia Considerations 

Mitral Stenosis (MS)

 

 

Considerations

 

• Perioperative cardiovascular decompensation:

  • Severity of valvular lesion

  • High risk (especially with pregnancy)

• Hemodynamic sequelae of MS (limited ability to ↑ cardiac output)

  • Atrial dilation & arrhythmias

  • Pulmonary edema & CHF

  • Pulmonary hypertension & RV failure 

  • Thrombotic events

• Associated conditions:

  • Associated valvular pathologies

  • Rheumatic heart disease 

  • Connective tissue disease (SLE, RA)

  • Obstructive (carcinoid, atrial myxoma)

• Medications:

  • Anticoagulation (often need bridging with heparin)

  • Diuretics

  • Antiarrhythmics

 

 

Goals 

 

• Preload: maintain (avoid overload)

• Rate: low-normal (most important goal)

• Rhythm: sinus (avoid atrial fibrillation because of ↑ HR)

• Contractility: maintain

• Afterload: maintain 

• Avoid precipitants of pulmonary hypertension  

 

 

Severity Grading

     

 

 

 

 

 

 

 

Pregnancy Considerations

 

• Goals: 

  • Maintain a slow heart rate

  • Maintain sinus rhythm

  • Aggressively treat acute atrial fibrillation

  • Avoid aortocaval compression

  • Maintain venous return

  • Maintain adequate systemic vascular resistance 

  • Prevent pain, hypoxemia, hypercarbia, and acidosis (may ↑ pulmonary vascular resistance)

• Risk: 

  • Mild to moderate MS without severe pulmonary HTN is considered low maternal or fetal risk

  • Mitral stenosis with NYHA class II-IV symptoms is considered high maternal risk

• Anesthetic options: 

  • Vaginal delivery

    • Symptomatic patients will require invasive monitoring 

    • Adequate analgesia for first stage (epidural)

    • Second stage should be assisted by low forceps/vacuum

  • Cesarean section

    • Epidural is the preferred method

    • If GA required need to keep goals

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Further Reading 

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

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