From the Guidelines
A patient with mitral stenosis can be considered fit for laparoscopic cholecystectomy if they have non-significant mitral stenosis (valve area >1.5 cm2) and are asymptomatic, or if they have significant mitral stenosis with a systolic pulmonary artery pressure <50 mmHg, as stated in the 2017 ESC/EACTS guidelines for the management of valvular heart disease 1. The decision to proceed with surgery depends on the severity of stenosis, presence of symptoms, and overall cardiac function.
- Patients with mild to moderate mitral stenosis who are asymptomatic or well-controlled on medications can generally undergo surgery with appropriate precautions.
- However, patients with severe stenosis (valve area <1.5 cm²), symptoms of heart failure, pulmonary hypertension, or atrial fibrillation may need valve intervention before elective surgery. Preoperative management should include:
- Echocardiography to assess stenosis severity
- Optimization of heart rate control (typically with beta-blockers like metoprolol 25-100mg twice daily)
- Appropriate anticoagulation management if the patient is on warfarin Intraoperatively, careful hemodynamic monitoring is essential, maintaining normal sinus rhythm, avoiding tachycardia, and ensuring adequate preload while preventing fluid overload. The anesthesiologist should be prepared to manage potential complications like atrial fibrillation or pulmonary edema. The pneumoperitoneum required for laparoscopy can increase afterload and decrease venous return, potentially worsening mitral stenosis physiology, so minimizing insufflation pressures is advisable when possible, as suggested by the 2014 ESC/ESA guidelines on non-cardiac surgery: cardiovascular assessment and management 1. Additionally, the 2019 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population recommend that laparoscopic approach should always be attempted at first except in case of absolute anesthetic contraindications and septic shock 1.
From the Research
Assessment of Mitral Stenosis
To determine if a patient with mitral stenosis is fit for a laparoscopic cholecystectomy, it's essential to assess the severity of the mitral stenosis and its hemodynamic consequences.
- Echocardiography, particularly transthoracic echocardiography (TTE), is the primary imaging modality used to diagnose and assess the severity of mitral stenosis 2, 3, 4.
- The severity of mitral stenosis should be defined by valve areas, mean Doppler gradients, and pulmonary pressures, rather than a single value 4.
Treatment Options for Mitral Stenosis
The treatment options for mitral stenosis include percutaneous mitral balloon valvuloplasty (PMBV) or surgery 5, 4.
- PMBV is the treatment of choice for patients with suitable valve morphology, while surgery is recommended for those with suboptimum valve morphology or contraindications to PMBV 5, 4.
- In some cases, mitral valve stenosis may occur after MitraClip treatment, requiring surgical correction 6.
Pre-Surgical Evaluation
Before undergoing a laparoscopic cholecystectomy, the patient's mitral stenosis should be evaluated to determine the risk of surgery.
- A thorough echocardiographic assessment, including TTE and possibly transesophageal echocardiography, should be performed to evaluate the severity of mitral stenosis and valve morphology 2, 3, 4.
- The patient's overall cardiac function and any potential contraindications to surgery should also be assessed 5, 4.