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

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 

 

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