In summary, 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.
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)