Severe mitral regurgitation for free-flap surgery58-year-old woman, 64 kg, for elective free-flap breast reconstruction, about 8 hours

The patient

The examiner asks

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1. Consider

   What are the key issues?

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   • A 58-year-old with severe primary MR having a long elective free flap. Patient
   • Primary MR is a valve lesion; I need her recent LV size, EF and PA pressure. Disease
   • Her EF of 52% already counts as impaired in severe MR.
   • Her PA systolic of 45 shows the leak is raising left atrial and lung pressures.
   • Eight hours, big fluid shifts, and a flap that needs flow rather than vasoconstriction. Surgery
   • No endocarditis prophylaxis; this is not a dental procedure. Disease

2. Prepare

   What is her cardiac risk, and how do you prepare her?

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   • Urgency: elective, so there is time to deal with her valve first. Stem trigger
   • Active cardiac condition? Yes: severe MR is a severe valve lesion. Disease
   • Risk score: none of the RCRI items, so RCRI 0.
   • Functional capacity: two flights without symptoms, over 4 METs.
   • Decision: cardiology decides on repair first; her surgery can follow soon after a successful repair.
   • Withhold lisinopril for 24 hours; omit furosemide that morning.
   • Arterial line and cardiac output monitoring; milrinone, amiodarone and a checked defibrillator ready. Crisis

3. Plan

   What are your haemodynamic goals?

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   • Her heart rate normal to slightly fast; slowing lets more blood leak back. Disease
   • Afterload low: smooth depth, no pressure surges; anaesthetic vasodilation helps her.
   • Preload slightly up, but no overload into her dilated ventricle.
   • No hypoxia, hypercapnia or acidosis, so her pulmonary resistance stays low.
   • Vasopressors are discouraged in free flaps; hypo- and hypervolaemia both threaten the flap. Surgery
   • If flap and BP conflict, I keep her rate up and add an inodilator rather than a pressor. Disease
   • Sinus rhythm matters; any arrhythmia is controlled quickly.

4. Crisis

   Five hours in, she develops AF at 160/min, BP 74/40. What do you do?

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   • Tachycardia algorithm: AF at 160 with BP 74/40 in severe MR, so unstable. Crisis
   • Unstable with a pulse: call for help, warn the surgeon, synchronised cardioversion now.
   • She is anaesthetised: confirm depth, then start at 200 J or more.
   • If AF returns: amiodarone 300 mg over an hour, as she is hypotensive.
   • Her branch: no diltiazem or verapamil while her pressure is low.
   • Low output after sinus returns: milrinone 0.3–0.7 mcg/kg/min, no bolus, noradrenaline holding pressure.
   • Monitored bed after; anticoagulation decision with cardiology. After surgery