Anaes · Cardiac anaesthesia
Anaesthesia for valve surgery
Also known as Anaesthesia for valve surgery · Aortic stenosis anaesthesia · Mitral repair SAM
Haemodynamic goals for AS, AR, MS, MR; TOE assessment; CPB and cardioplegia nuances; prosthesis checks and post-repair SAM risk.
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Target exams
Red flags
- Spinal/epidural hypotension is dangerous in critical AS.
- New severe paravalvular leak or stuck leaflet needs immediate surgical attention.
- SAM/LVOTO worsens with inotropes and hypovolaemia — think differently.
- Never treat SAM with pure inotropes and hypovolaemia as if it were pump failure.
- Inadequate ACT before full CPB risks circuit thrombosis.
Meet the patient
A 78-year-old with critical aortic stenosis and a recent syncopal episode is listed for an aortic valve replacement. After induction, the mean arterial pressure drops to 50 mmHg. The registrar reaches for an inotrope — but this is a fixed-output ventricle that needs preload and afterload, not squeezing. One wrong drug and the coronary perfusion collapses against the hypertrophied wall.[1]
The question that decides this patient's next two minutes is the question that decides every valve case: what does this lesion need to maintain coronary perfusion — preload, afterload, or rate? Match the haemodynamics to the lesion table, prove the ACT before bypass, survey the prosthesis and ventricle with TOE after CPB, and for SAM after mitral repair, fill, squeeze, slow, and stop pure inotropes.[2]
References3ShowHide
- [1]Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery N Engl J Med, 2017.PMID 29130845
- [2]Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists J Am Soc Echocardiogr, 2013.PMID 23998692
- [3]Levy JH, et al. What's fishy about protamine? Clinical use, adverse reactions, and potential alternatives J Thromb Haemost, 2023.PMID 37062523