Perioperative Anesthesia Management in Secondary Mitral Regurgitation and Heart Failure

Abstract

This chapter provides an overview of the anesthesia and perioperative intensive care management of patients undergoing surgery for secondary mitral regurgitation (SMR).Evidence-based medicine has led to an unprecedented growth in the scientifi c approach to decision making in the belief that it will translate into benefi ts for patients to decrease their risk and improve outcomes (Cheng and Martin, Semin Cardiothoracic Vasc Anesth 9:1-4, 2005). However, clinicians must apply innumerable, complex, and dynamic interventions to the perioperative care of these challenging patients, interventions that are adjusted to achieve a number of physiologic and clinical goals by selecting, titrating, and timely applying many pharmacologic and nonpharmacologic therapies. In doing so clinicians are of course driven by the available evidence, but also by inductive pathophysiologic reasoning, local culture and policies, resource and technology availability, various concerns, beliefs, bias, and random events. While it is clear that outcome of major surgery is affected greatly by surgical prowess and volume (Birkmeyer et al., N Engl J Med 349:2117-2127, in addition, part of the variance in surgical mortality relates to factors beyond surgical skills, namely to all of that complex activity that is the perioperative medicine (Grocott and Pearse Br J Anaesth 108:723-726, 2012). Therefore, albeit only a few nonsurgical interventions have randomized evidence to support their effect in reducing mortality in patients undergoing cardiac surgery (CS) (Landoni et al., Acta Anaesthesiol Scand 5:259-266, 2011), it is believed that perioperative medicine matters.Perioperative management of patients with SMR is accordingly outlined in the text hereafter, with a main focus on hemodynamics along with hints stemming from an integrative approach of the heart interacting with other organ systems. An extensive review of the body of knowledge relevant to the cardiac anesthesiologist and of all the challenges and details of anesthesia and perioperative management in cardiac surgical candidates is beyond the scope of this chapter and can be found in reference cardiac anesthesia and CS texts. Preoperative and intraoperative echocardiographic imaging, as well as minimally invasive mitral valve (MV) surgery and percutaneous Mitra Clip procedures are covered elsewhere in this book