mitral valve prolapse

Question 1

34 year old female with history of MVP is scheduled for shoulder scope in sitting position. otherwise healthy and takes no meds. does she need further cardiac eval?

Answer 1

as she is otherwise healthy and asymptomatic, i would not require further testing. i would preform focused H&P to illicit s/s of CHF or ischemia, such as angina, orthopnea, DOE, exercise intolerance, peripheral edema, pulmonary rales, S3 gallop, systolic ejection click, murmur. if she reported significant symptoms, i would consider echo to identify mitral regurgitation and presence/absence of PFO (increased risk of air embolism during sitting surgery)

if she had significant regurgitation, syncope, chest pain, or CHF, further testing may be warranted.

Question 2

after induction she is placed in sitting position, BP drops to 63/38 and HR is 90. what is the cause?

Answer 2

uncompensated decrease in BP with movement into head-up position. general anesthesia blunts normal autonomic responses.

however, i would consider other factors like hypovolemia, excessive anesthesia (myocardial depression, systemic vasodilation), dysrhythmias and acute mitral regurgitation/decreased CO. this can occur may experience worsened prolapse with increased emptying of the LV (tachycardia, increased contractility, decreased SVR, hypovolemia, upright posture)

finally i would consider less likely causes such as myocardial ischemia, tension ptx, air embolism.

Question 3

how would you treat this patient?

Answer 3

1. inform surgeon
2. return patient to supine
3. evaluate EKG
4. auscultate chest for bilateral vent and new murmurs
5. 100% FiO2
6. fluid bolus
7. alpha1 agonist (phenylephrine) to get constriction but no tachycardia
8. reduce anesthetic if necessary

avoid: agents that increase contractility and accentuate mitral regurgitation

if remained unstable i would perform TEE