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Anaesthesia in the patient with valvular heart disease
A narrow valve (stenosis) needs a slow, full heart with preserved systemic resistance; a leaking valve (regurgitation) needs a slightly fast, full heart and a low systemic resistance that moves blood forward.
Why it matters in the exam
The exam presents a patient with severe aortic stenosis, mitral stenosis, aortic or mitral regurgitation, or HOCM before non-cardiac surgery, and asks which heart rate, which volume and which drug for hypotension are suitable. It also asks whether spinal anaesthesia is allowed in severe aortic stenosis, what defines severe stenosis, and when endocarditis prophylaxis is given.
In severe aortic stenosis (valve area below 1.0 cm², mean gradient above 40 mmHg or velocity above 4 m/s) the hypertrophied ventricle depends on atrial contraction and on a good diastolic pressure for coronary perfusion; hypotension or tachycardia starts a cycle of ischaemia. In mitral stenosis left ventricular filling is slow, so tachycardia and fast atrial fibrillation raise left atrial and pulmonary pressure. In regurgitation, a slow heart rate lengthens diastole and increases the leak.
In HOCM anything that makes the ventricle smaller worsens outflow obstruction: hypovolaemia, tachycardia, vasodilators and inotropes. So hypotension is treated with fluids and phenylephrine, not with ephedrine or dobutamine. Endocarditis prophylaxis under the European guidelines is given only to high-risk patients (prosthetic valve, previous endocarditis, certain congenital heart lesions) and only for certain dental procedures.
Key points
- Stenosis = slow, full, resistance preserved; regurgitation = slightly fast, full, low resistance.
- Severe aortic stenosis: area below 1.0 cm², gradient above 40 mmHg, velocity above 4 m/s.
- Phenylephrine for hypotension in stenosis and HOCM.
- HOCM — avoid hypovolaemia, tachycardia, vasodilators and inotropes.
- Endocarditis prophylaxis only for high risk.
Summary table
| Condition | Heart rate | Volume and resistance | Drug for hypotension |
|---|---|---|---|
| Aortic stenosis | Low-normal, sinus rhythm | Volume preserved; resistance preserved | Phenylephrine |
| Mitral stenosis | Low, control atrial fibrillation | Careful volume; avoid hypoxia and acidosis (pulmonary pressure) | Phenylephrine |
| Aortic or mitral regurgitation | Normal-high, avoid bradycardia | Volume preserved; low resistance | Ephedrine; vasodilators as needed |
| HOCM | Low | Full volume; resistance preserved | Phenylephrine and fluids; no inotropes |
| Endocarditis prophylaxis | — | — | High risk only, and only for certain dental procedures |
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Sources
- ESC/EACTS Guidelines for the management of valvular heart disease, 2021 — Severity criteria and non-cardiac surgery
- Miller's Anesthesia, 9th edition (2020) — Anesthesia for Cardiac Surgical Procedures; Valvular Heart Disease
- Morgan & Mikhail's Clinical Anesthesiology, 7th edition (2022) — Anesthesia for Patients with Cardiovascular Disease
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.