Anesthetic management for laparoscopic cholecystectomy in a patient with severe mitral regurgitation and severely depressed cardiac function

Pallavi Butiyani, MD1, Jalpesh Kapuriya2
1Academic Head; 2DNB Student

Department of Anesthesiology, Noble Hospital, Pune – 411013, Maharashtra, (India)

Correspondence: Dr Jalpesh Kapuriya, Room No. 306, Boys Hostel, Noble Hospital, Hadapsar, Pune – 411028, Maharashtra, (India); E-mail: pallavibutiyani@gmail.com
ABSTRACT
Severe mitral valve disease in an elderly patient, may exhibit serious hemodynamic disturbance and pose a great challenge to the anesthesiologist. During laparoscopy, positive pressure pneumoperitonium with carbon dioxide insufflation has additional deleterious effects on hemodynamic stability. This case report describes successful management of a patient with severe mitral regurgitation scheduled to undergo laparoscopic cholecystectomy. It highlights the importance of adequate optimization, perioperative monitoring and use of preemptive regional anesthesia.
Keywords: Laparoscopic cholecystectomy; Rheumatic heart disease; Mitral regurgitation
Citation: Butiyani P, Kapuriya J. Anesthetic management for laparoscopic cholecystectomy in a patient with severe mitral regurgitation and severely depressed cardiac function. Anaesth Pain & Intensive Care 2018;22(2):231-233
Received – 29 July 2017, Reviewed – 7 October, 12 December 2017, Corrected –9 March, 20 February 2018, Accepted 21 9 March 2018

INTRODUCTION
Severe valvular disease is a high risk clinical predictor for anesthesia and/or surgery and identified in 2007 ACA/AHA guidelines for perioperative cardiovascular evaluation for noncardiac surgery.1 Laparoscopic surgery in patients with severe valvular disease with compromised cardiac function may lead to high probability of intraoperative cardiac failure.2 Therefore, standard literatures often consider patients with cardiac dysfunction a relative contraindication for laparoscopic surgery. We successfully managed anesthesia for a patient with severe mitral regurgitation scheduled to undergo laparoscopic cholecystectomy.

CASE REPORT
A 65 year old male with symptomatic gall bladder polyp was scheduled for laparoscopic cholecystectomy. He was a diagnosed case of hypertension and rheumatic heart disease (RHD) with mild mitral stenosis (MS) but severe mitral regurgitation (MR). He presented with dyspnea of NYHA grade III. Radial pulse was irregularly irregular with a holosystolic murmur on auscultation. Echocardiography showed RHD, mild MS with severe MR, moderate tricuspid regurgitation (TR) and pulmonary hypertension (PHT), dilated left atrium (LA) and left ventricle (LV) with severe hypokinesia, and LVEF of 20-25%. He was on diuretics, telmisarton, diltiazem, digoxin, warfarin / ecosprine. Preoperative lab reports showed Hb-7.1, PT-54.2 and INR-3.2. He was transfused with 2 units of PCV and 6 units of FFP. This corrected the PT to 14.7 and INR to 1.15. He was posted for laparoscopic cholecystectomy with ASA grade III risk. Informed consent was obtained.

Inside operating room, standard monitors were connected, emergency drugs and defibrillator were kept ready. He showed atrial fibrillation (AF) with a basal heart rate of 106/min, BP 130/74 mmHg, and SpO2 95% on room air. Right radial artery and right internal jugular vein were cannulated. After 3 min of preoxygenation, he was induced with etomidate 10 mg, fentanyl 50 µg and vecuronium 4 mg. 2% Lignocaine 3ml was administered IV. Within 3 min the heart rate rose to 130/min (AF), with BP 102/66 mmHg, yet satisfactory levels of SpO2 100% (FiO2 - 50%) and EtCO2 45 mmHg. Anesthesia was maintained with O2 and air and 1% sevoflurane. USG guided right sided subcostal TAP block using 20 ml of 0.2% ropivacaine was given just after induction.

Pneumoperitoneum was created slowly with maximum pressure of 10 mmHg. However, 4-5 min after pneumoperitoneum, AF worsened with HR 150-160/min with BP of 130/88 mmHg. Immediately, inj amiodarone150 mg bolus was administered. Since heart rate couldn’t be controlled, Diltiazem bolus 0.25 mg/kg was given. Within 3-4 min, the HR and BP returned to 86/min and 112/67 mmHg respectively with EtCO2 35 mmHg. Diltiazem infusion started at 5 mg/h to maintain the HR. Further course of 75 min was uneventful. Patient was reversed with neostigmine and glycopyrrolate and extubated.

After extubation, he became dyspneic and could not maintain oxygen saturation. ABG done at this point showed CO2 retention with PaCO2 of 80 mmHg and pH of 7.18. He was put on noninvasive ventilation for 6 hours and ABG corrected to PaCO2 42 mmHg and pH 7.37. He was observed in ICU for one day and was discharged on 3rd post operative day.

DISCUSSION
We report a case of RHD with mild MS and severe MR in AF for Laparoscopic cholecystectomy which was successfully and uneventfully managed.

Patients with severe MR who have poor hemodynamic reserve are challenge for anesthesiologist. Although, many patients undergo safe intraoperative course of noncardiac surgery, their perioperative course is often complicated by tachyarrhythmias, AF which results in extraordinarily high morbidity and mortality especially in those with pre-existing AF and lower LVEF.The primary goal in such cases is to maintain a heart rate of 80 to 100 beats / min, reduce the afterload and to offer adequate depth of anesthesia. These patients require intensive care in the post-op period.3,4
This patient in addition to severe MR also had moderate TR with PHT. His long standing hypertension might have resulted in higher systolic driving pressures; which in turn causes exaggeration of regurgitation factor. The echocardiography revealed an LVEF of 20 to 25%. However, ejection fraction indices are poorly correlated with systolic functions. Hence, LVEF may be overestimated echocardiographically.

Role of laproscopic surgery in patients with cardiac dysfunction is controversial. Current evidence show that laparoscopic surgery can be successfully performed on NYHA grade III and IV patients.5 This patient was subjected to laparoscopic procedure, which offered him all benefits including lesser pain, stress and morbidity.

This patient exhibited severe tachycardia of 160 / min 4-5 min after pneumoperitoneum. MR could become detrimental with marked increase in systemic vascular resistance and tachycardia associated with pneumoperitoneum.6 Higher intra-abdominal pressures of 8-10 mmHg along with CO2 insufflation contributed to the acute episode of AF.

This was effectively and promptly controlled with diltiazem within a span of 3-4 min. Diltiazem prevents forward movement of calcium ions through slow channels in myocardial and vascular smooth muscle cells. It is a negative inotrope and it reduces vascular resistance.

Epidural analgesia would help in reduction in afterload but its role in presence of severely depressed LVEF is questionable and may lead to excessive hypotention. We chose Subcostal TAP block for perioperative pain. This reduced the requirement of anesthetics and opioids without causing much effect on hemodynemics. Also, use of invasive monitoring helped us to assess and judiciously control the intraoperative hemodynamic derangement and thus facilitated IV fluid management and appropriate use of ventilators.7  Trans-esophageal echocardiography (TEE) would be ideal in monitoring filling pressure but it was not available in our institute.

CONCLUSION
Laparoscopic surgeries can be safely done in patients with severe MR with severely depressed LVEF. However, preoperative optimization of cardiac status, administration of balanced anaesthesia, proper intraoperative monitoring and low pressure pneumoperitoneum are essential steps to patient safety. The chances of life threatening complications are rare and can be easily managed in the hospital with adequate cardiac support.

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