Mitral Valve Replacement / Repair
Patient phenotype
Severe mitral regurgitation (degenerative, functional, ischemic) or stenosis (rheumatic — declining incidence). Often AF, pulmonary hypertension, dilated LA. EF preserved early in MR (eccentric hypertrophy compensates), drops late.
Procedure
Median sternotomy or right mini-thoracotomy approach. Cardiopulmonary bypass + cardioplegic arrest. Repair preferred (annuloplasty + leaflet repair) over replacement. Replacement: mechanical (lifelong anticoagulation) or bioprosthetic (limited durability). 3-5 hours.
Anesthetic plan
GETA + standard cardiac monitoring + TEE (mandatory for repair quality assessment). High-dose opioid (fentanyl 10-25 mcg/kg) + benzodiazepine + low-dose volatile classic, though fast-track with lower-dose opioid + dex increasingly common.
Setup
- ·A-line pre-induction (radial preferred)
- ·Large-bore central line (3-port introducer + PA catheter or CVC)
- ·PA catheter — debated but often used for pulmonary HTN assessment
- ·TEE probe — surgeon + anesthesia review pre + post repair
- ·Cell saver
- ·External defibrillation pads
- ·Vasopressor + inotrope infusions: NE, epi, milrinone, vasopressin
Biggest concerns by phase
MR vs MS hemodynamic goals — opposite
MR: 'fast, full, forward' — afterload reduction (low SVR), avoid bradycardia, normal-to-high preload. MS: maintain SVR, slow HR (longer diastole for filling), avoid tachycardia, maintain sinus. AF + new RVR in MS = catastrophe.
Pulmonary hypertension assessment
Severe MR/MS → secondary pulmonary HTN → RV strain. RV failure during/after CPB = leading cause of separation difficulty. PA pressures, RV function on TTE/TEE noted preop. Have iNO, milrinone, epi ready for RV support.
Avoid hemodynamic disasters at induction
MR: avoid bradycardia + high SVR (worsens regurgitation). MS: avoid tachycardia + fluid overload (worsens pulmonary edema). Slow titration. Etomidate often preferred in low-EF.
TEE-guided repair quality
Pre-CPB TEE confirms diagnosis + measurements. Post-CPB TEE assesses repair: residual regurgitation grade, mean gradient (replacement), LV function, RV function, presence of SAM (systolic anterior motion — repair complication).
Separation from CPB + RV failure
RV in pulmonary HTN often fails coming off CPB. Strategy: minimize PVR (avoid hypoxia, hypercarbia, acidosis, high airway pressure), iNO 20-40 ppm, milrinone (PDE3 inhibitor — inotrope + pulmonary vasodilator), epinephrine for inotropy. Consider mechanical RV support (RVAD, ECMO) if refractory.
SAM (systolic anterior motion) post-repair
Anterior leaflet pulled into LVOT after repair → dynamic LVOT obstruction. Treatment: increase preload + afterload, decrease contractility (stop epi, start beta-blocker). Surgical revision if persistent.
Anticoagulation transition + ICU disposition
Heparin reversed with protamine — watch for hypotension/anaphylaxis. Mechanical valve = warfarin lifelong + heparin bridge. Bioprosthetic = ASA + 3 mo warfarin (variable). Extubation goals: hemodynamically stable, normothermic, neurologically intact, low chest tube output.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
62-year-old F, severe degenerative MR, EF 60%, mod pulmonary HTN (PAS 55), AF on warfarin (held 5 days, INR 1.2), planned mitral repair. Walk through your hemodynamic goals + induction plan.
What an examiner probes for
- ▹Names MR-specific goals: forward flow, low SVR, normal HR
- ▹Discusses PA HTN + RV failure prevention
- ▹Plans induction without bradycardia or SVR spikes
- ▹Reviews TEE role pre + post repair
- ▹Anticipates post-bypass RV support (iNO, milrinone)
Sources
- Miller's Ch 67
- Kaplan's Cardiac Anesthesia 7e
- ACC/AHA Valvular Heart Disease 2020
Anatomy reference
Sourced reference images. 4 matches for "heart mitral valve cardiac".
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