Preoperative evaluation and anaesthetic management of a 35 year-old female patient with a prosthetic mitral valve scheduled
for MTP with laparoscopic tubal ligation

Preoperative Assessment and optimisation

In patients with mechanical heart valve the anesthetic management addresses the following areas of concern

assessment of cardiac function 

• residual pathology

• infective endocarditis

• anticoagulation status

• preparation for reversal of anticoagulation if needful

• neurological evaluation for detection of microthrombi

The cardiac function is assessed with history of dyspnea,orthopnea and easy fatiguability, rhythm abnormality, chest rales, and distended jugular vein.
the labs needed would be ECG,CHEST RADIOGRAPH AND 2D ECHO
CARDIAC CATHETERISATION may provide additional information
the prosthetic valve can br mechanical or bioprosthetic
The prosthetic valve can be heterograft composed of porcine or bovine tissues mounted on metal supports or homografts which are preserved human aortic valves
they last less than the mechanical valve for 10 to 15 years and have less thrombogenic potential so long term anticoagulation is not necessary

Assessment of prosthetic heart valve with 2D ECHO for ring stability and leaflet motion while TEE provides higher resolution images.MRI for prosthetic valve regurgitation or paravalvular leak. CAG can be done for transvalvular pressure gradients and prosthetic valve area.

COMPLICATIONS WITH PROSTHETIC VALVE

• VALVE THROMBOSIS
• SYSTEMIC EMBOLISATION
• STRUCTURAL FAILURE
• HEMOLYSIS
• PARAVALVULAR LEAK
• ENDOCARDITIS

MANAGEMENT OF ANTICOAGULATION

           ANTICOAGULATION BEFORE SURGERY
                                      
                                   ⬇
INCREASED RISK OF VENOUS AND ARTERIAL THROMBOEMBOLISM

                                                             

⬇                                                               ⬇
              MINOR SURGERY.                                                                        MAJORSURGERY
                  ⬇
        CONTINUE ANTICOAGULATION IF    MINIMAL BLOOD LOSS                                                                                                                                                                                                           

                                                                                                                                                                                                            

                                                        

                                            ⬇

                                                                                  

                                           WARFARIN or clopidogrel or any of the newer anticoagulants are discontinued 1 to 5 DAYS prior to surgery

                                                                                   

                                                          ⬇

                                                                                  
                                        

              

      REPLACED WITH IV  UNFRACTIONATED  

                             HEPARIN OR LMWH

                                                                                         

                                                                 ⬇         
                                           TILL 1 DAY BEFORE   

                                             SURGERY 
                                                                                            
 RESTARTED  1 DAY POST SURGERY IF RISK OF BLEEDING IS REDUCED

ELECTIVE SURGERY IS AVOIDED IN THE FIRST MONTH AFTER AN ACUTE EPISODE OF THROMBOEMBOLISM

ANTICOAGULATION IS IMPORTANT IN PARTURIENTS IN VIEW OF HYPERCOAGULABLE STATE BUT WARFARIN IS AVOIDED AND LMWH IS CONTINUED TILL DELIVERY 

DOSE ASPIRIN THERAPY CAN BE GIVEN IN CONJUCTION WITH HEPARIN THERAPY