Influence of Severe Valvular Disease on Haemodynamic Performance

Created on Tue, 06/30/2015 - 17:03
Last updated on Wed, 05/16/2018 - 00:42

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This is a table of suggestions for the haemodynamic optimisation of patients with severe valvular disease, or some other sort of severe structural or functional derangement of cardiac function

Lesion Preload Rate Rhythm Contractility Afterload
Aortic stenosis

High preload.

Keep them well filled.

Avoid GTN

Minimise propofol

Keep it SLOW.

50-70 is best.

Sinus is best.

It is critically important to avoid AF.

Keep it high.

Avoid beta-blockers.

Keep the diastolic high.

Noradrenaline is a good choice

Aortic regurgitation

High preload.

Keep them well filled.

Avoid GTN

Minimise propofol

Keep is FAST.

90 is best.

Don't worry too much about it. AF is OK.

Keep it high.

Avoid beta-blockers.

Consider dobutamine.

Keep the blood pressure low.

Use calcium channel blockers or sodium nitroprusside.

Mitral stenosis

Careful high preload.

Keep them filled - but just enough.

Carefully titrate vasodilators

Keep it NORMAL.

...maybe 70?

It is critically important to avoid AF

Not as important;

Consider milrinone

(for PA pressures and RV contractility)

Not as important.

Keep it normal.

Vasopressors wont help.

Avoid hypoxia and high PEEP (for RV afterload)

Mitral regurgitation

Experiment.

Find the magic preload volume.

Keep it FAST.

90 is best.

Don't worry too much about it. AF is OK.

Keep it high.

It is all-important.

Use dobutamine,

or some mix of dobutamine/milrinone

Keep it low.

It is very important.

Use sodium nitroprusside.

GTN may not be as helpful.

Tricuspid stenosis

High preload.

Keep them filled.

Keep it SLOW.

50-70 is best.

It is critically important to avoid AF

Keep it high.

Use milrinone.

Don't worry too much about afterload. It plays little role.

Tricuspid regurgitation

High preload.

Keep them filled.

Keep it FAST.

90 is best.

They have AF.

Just live with it.

Keep it high.

It is all-important.

Use dobutamine,

or some mix of dobutamine/milrinone

Don't worry too much about LV afterload. It plays little role.

Avoid high PA pressures; keep PEEP low and avoid hypoxia

Pulmonic stenosis

High preload.

Keep them filled.

Experiment.

Find the magic heart rate.

AF is not ideal, but they all have AF.

Just live with it.

Keep it high.

It is all-important.

Use milrinone

Forget about PA pressures.

Maintain a high diastolic.

HOCM with LVOT obstruction

High preload.

Keep them well filled.

Avoid GTN

Minimise propofol

Keep it slow.

50-70 is best.

Sinus is best.

It is critically important to avoid AF.

Keep it LOW.

Use beta-blockers.

Avoid inotropes.

Keep the diastolic high.

Vasopressin or phenylephrine (or metaraminol)

Avoid beta-agonists.

Individually, these problems are all interesting enough to merit their own chapters.

 

References

Moore and Martin's chapter on valvular disease in "A Practical Approach to Cardiac Anaesthesia" is a must-read

(in general, that book is awesome)