What is the appropriate anesthetic plan for a patient with rheumatic heart disease, taking into account the specific valve lesions, presence of atrial fibrillation, and anticoagulation therapy?

Anesthetic Management for Rheumatic Heart Disease

For patients with rheumatic heart disease undergoing anesthesia, the critical priorities are maintaining hemodynamic stability through careful heart rate control, ensuring therapeutic anticoagulation with vitamin K antagonists (not NOACs), and preventing acute decompensation of valve lesions through meticulous fluid management and avoidance of tachycardia or bradycardia extremes.

Preoperative Anticoagulation Management

Patients with Atrial Fibrillation and/or Mitral Stenosis

• Vitamin K antagonist (warfarin) is mandatory for all RHD patients with moderate-to-severe mitral stenosis, regardless of atrial fibrillation status, with target INR 2.5 (range 2.0-3.0) 1, 2
• NOACs are absolutely contraindicated in rheumatic mitral stenosis—this is a critical safety issue that cannot be overlooked 3
• For patients with atrial fibrillation and RHD, warfarin remains the only acceptable anticoagulant (Class I, Level C recommendation) 3, 1

Perioperative Bridging Strategy

• For patients on therapeutic warfarin requiring surgery, bridge with unfractionated heparin IV or therapeutic-dose LMWH subcutaneously 4
• Stop warfarin 5 days before surgery and initiate bridging anticoagulation when INR falls below 2.0
• Discontinue UFH 4-6 hours before surgery or LMWH 24 hours before surgery
• Resume therapeutic anticoagulation postoperatively as soon as hemostasis is secure 4

Special Consideration: Left Atrial Thrombus

• If preprocedural TEE reveals left atrial thrombus, postpone elective surgery until thrombus resolution is documented 1, 4
• Administer warfarin with higher intensity target INR 3.0 (range 2.5-3.5) until repeat TEE confirms resolution 1, 5
• This typically requires 4-12 weeks of therapeutic anticoagulation before reassessment 4

Hemodynamic Goals by Valve Lesion

Mitral Stenosis (Most Common in RHD)

• Maintain slow heart rate (60-80 bpm) to maximize diastolic filling time across the stenotic valve 6
• Avoid tachycardia at all costs—this is the most dangerous hemodynamic derangement in mitral stenosis
• Maintain sinus rhythm if present; atrial fibrillation occurs in 40-75% of RHD patients and significantly worsens hemodynamics 7
• Preserve adequate preload but avoid fluid overload
• Maintain systemic vascular resistance (SVR) in normal range

Mitral Regurgitation (Present in 87% of RHD Patients)

• Maintain normal-to-slightly elevated heart rate (80-100 bpm) to reduce regurgitant fraction 6
• Reduce afterload (SVR) to favor forward flow
• Avoid bradycardia which increases regurgitant volume per beat
• Maintain adequate preload but monitor for pulmonary edema

Combined Lesions (Most Common Presentation)

• Three-valve disease (MR+MS+TR) occurs in 30% and four-valve disease (MR+MS+TR+AR) in 28% of RHD patients 6
• For mixed mitral disease, the stenotic component typically dominates hemodynamic management
• Prioritize heart rate control in the 70-85 bpm range as a compromise
• Use invasive monitoring (arterial line, central venous pressure) for complex multi-valve disease

Anesthetic Technique Selection

Regional vs. General Anesthesia

• Neuraxial anesthesia carries significant risk in patients with severe mitral stenosis due to sudden afterload reduction and inability to compensate with increased cardiac output
• For patients with severe MS, general anesthesia with controlled hemodynamics is preferred over spinal/epidural
• If regional anesthesia is chosen, use incremental epidural dosing rather than single-shot spinal to allow gradual hemodynamic changes
• Maintain therapeutic anticoagulation status when considering neuraxial techniques—follow institutional protocols for timing relative to INR 3

Induction and Maintenance

• Avoid agents causing significant tachycardia (ketamine, pancuronium, atropine in large doses)
• Etomidate or high-dose opioid technique preferred for hemodynamic stability in severe valve disease
• Beta-blockers or calcium channel antagonists should be continued perioperatively for rate control in patients with atrial fibrillation 3
• Maintain adequate depth of anesthesia to prevent sympathetic surge

Intraoperative Monitoring

Essential Monitoring

• Invasive arterial blood pressure monitoring is strongly recommended for all patients with moderate-to-severe RHD
• Five-lead ECG to detect ischemia and monitor rhythm (atrial fibrillation present in 49% of RHD patients) 6
• Central venous pressure monitoring for complex valve disease or poor ventricular function
• Transesophageal echocardiography when available for major surgery—provides real-time assessment of valve function and ventricular filling 6

Hemodynamic Management

• Treat acute atrial fibrillation with rapid ventricular response immediately with IV beta-blockers (esmolol, metoprolol) or calcium channel antagonists (diltiazem) 3
• For hypotension in mitral stenosis, use pure alpha-agonists (phenylephrine) to maintain SVR without increasing heart rate
• Avoid ephedrine in mitral stenosis due to tachycardia
• Digoxin may be used for rate control but has limited acute utility (36% of RHD patients receive digoxin chronically) 6

Management of Congestive Heart Failure

• 89% of RHD patients present with congestive heart failure—assume decompensated status until proven otherwise 6
• Diuretics are used in 96% of RHD patients; continue perioperatively and monitor electrolytes closely 6
• Maintain euvolemia through careful fluid management with CVP or TEE guidance
• Have inotropic support readily available (dobutamine preferred over dopamine to avoid tachycardia)

Critical Perioperative Pitfalls

Avoid These Common Errors

• Never use NOACs in rheumatic mitral stenosis—this is contraindicated even with atrial fibrillation 3, 1
• Never allow sustained tachycardia in mitral stenosis—this rapidly precipitates pulmonary edema and hemodynamic collapse
• Never perform neuraxial anesthesia in anticoagulated patients without appropriate timing protocols 3
• Never assume bioprosthetic valves eliminate anticoagulation needs—many RHD patients with bioprosthetic mitral valves still require warfarin due to atrial disease 3
• Never discontinue rate-control medications perioperatively in patients with atrial fibrillation 3

High-Risk Scenarios Requiring ICU Care

• Severe mitral stenosis (valve area <1.0 cm²) with pulmonary hypertension
• Multi-valve disease with NYHA Class III-IV symptoms
• Recent decompensated heart failure within 30 days
• Subtherapeutic anticoagulation with documented left atrial thrombus
• Emergency surgery in patients requiring anticoagulation bridging

Postoperative Management

• Resume therapeutic anticoagulation as soon as surgical hemostasis permits 4
• Continue heart rate control medications throughout recovery period 3
• Monitor closely for atrial fibrillation with rapid ventricular response—this is a common postoperative complication
• Maintain strict fluid balance to prevent pulmonary edema in patients with mitral stenosis
• Target INR 2.5 (range 2.0-3.0) for standard RHD patients; INR 3.0 (range 2.5-3.5) if left atrial thrombus was present 1, 5