Anesthetic Management of a Young Adult with Severe Rheumatic Mitral and Aortic Stenosis Undergoing Double Valve Replacement: A Case Report
DOI:
https://doi.org/10.37275/bsm.v10i8.1639Keywords:
Aortic valve stenosis, Cardiopulmonary bypass, Heart valve prosthesis implantation, Mitral valve stenosis, Rheumatic heart diseaseAbstract
Background. Rheumatic heart disease remains a leading cause of valvular pathology in young adults of low- and middle-income countries. The coexistence of severe mitral stenosis (MS) and severe aortic stenosis (AS) confronts the anesthesiologist with directly opposed hemodynamic imperatives and a markedly narrowed margin of safety, particularly during separation from cardiopulmonary bypass (CPB).
Case presentation. A 41-year-old man presented with a 14-year history of exertional syncope, progressive dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Transthoracic echocardiography demonstrated severe rheumatic MS (mitral valve area 0.8 cm²) and severe rheumatic AS (aortic valve area 0.8 cm², mean gradient 56 mmHg) with preserved left ventricular ejection fraction (67%), reduced right ventricular contractility (TAPSE 17 mm), and atrial fibrillation. He underwent double valve replacement under general anesthesia using an opioid-based, hemodynamically stable induction with full invasive monitoring. Separation from CPB was complicated by two episodes of ventricular tachycardia requiring synchronized cardioversion (30 J and 20 J) and was managed with a milrinone–dobutamine–norepinephrine strategy. The patient was transferred ventilated to intensive care on inotropic and antiarrhythmic support and stabilized.
Conclusion. Combined severe MS and AS demands an individualized plan reconciling contradictory goals: adequate preload and a controlled, unhurried heart rate for MS, against maintained afterload and coronary perfusion for AS. Meticulous invasive monitoring, a stable induction, anticipation of right ventricular dysfunction, and readiness for perioperative arrhythmia are decisive for a safe outcome.
Authors
- Fauzul Nurul Azmi1*
- Pelinggo Jaya1
- Vera Muharrami2
- 1Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Riau, Pekanbaru, Indonesia
- 2Department of Anesthesiology and Intensive Care, Arifin Achmad Regional General Hospital, Pekanbaru, Indonesia
Corresponding author Fauzul Nurul Azmi — dr.fauzul@gmail.com
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