Valvular heart disease and anaesthesia

1. Valvular Heart Disease Valvular Heart Disease
and Anesthesiaand Anesthesia
Wahid AltafWahid Altaf

2. DefinitionDefinition::

An acquired or congenital disorder of a An acquired or congenital disorder of a
cardiac valve characterized by stenosis cardiac valve characterized by stenosis
(obstruction) or regurgitation (backward (obstruction) or regurgitation (backward
flow) of bloodflow) of blood

5. IncidenceIncidence
Valvular heart disease is found in 4% of Valvular heart disease is found in 4% of
patients over the age of 65 in the patients over the age of 65 in the
developed world.developed world.

6. Valvular Heart DiseaseValvular Heart Disease
Mitral stenosisMitral stenosis
Mitral insufficiencyMitral insufficiency
Mitral valve prolapseMitral valve prolapse
Aortic insufficiencyAortic insufficiency
Aortic stenosisAortic stenosis
Pulmonary stenosisPulmonary stenosis
Pulmonary insufficency.Pulmonary insufficency.
Tricuspid Stenosis.Tricuspid Stenosis.
Tricuspid insufficency.Tricuspid insufficency.

7. What Information is Required?What Information is Required?
Clinical historyClinical history
Physical examPhysical exam
InvestigationsInvestigations

8. Common findings of the history and physical Common findings of the history and physical
exam in patients with valvular disease:exam in patients with valvular disease:
A history of rheumatic fever, IV drug abuse, or A history of rheumatic fever, IV drug abuse, or
heart murmur heart murmur
Decreased exercise toleranceDecreased exercise tolerance
May exhibit S/S of CHF (dyspnea, orthopnea, May exhibit S/S of CHF (dyspnea, orthopnea,
fatigue, pulmonary rales, JVD, hepatic fatigue, pulmonary rales, JVD, hepatic
congestion, and dependent edema)congestion, and dependent edema)
Compensatory increases in SNS tone manifest as Compensatory increases in SNS tone manifest as
resting tachycardia, anxiety, and diaphoresisresting tachycardia, anxiety, and diaphoresis

9. Mitral StenosisMitral Stenosis
Normal: Normal: 4 - 6 cm4 - 6 cm
22
Mildly stenotic: Mildly stenotic: 1.5 - 2.5 cm1.5 - 2.5 cm
22
Moderately stenotic: Moderately stenotic: 1.1 - 1.5 cm1.1 - 1.5 cm
22
Severely stenotic: Severely stenotic: < 1 cm< 1 cm
22
Usually have symptoms when area is Usually have symptoms when area is
decreased by 50%decreased by 50%

11. EtiologyEtiology

Delayed complication of rheumatic feverDelayed complication of rheumatic fever

66% of patients are female66% of patients are female

12. PathophysiologyPathophysiology

Valve leaflets thicken, calcify and become Valve leaflets thicken, calcify and become
funnel-shapedfunnel-shaped

Left atrium dilates (pressure)Left atrium dilates (pressure)

13. Signs and symptoms:Signs and symptoms:

90% of patients present with CHF and Atrial 90% of patients present with CHF and Atrial
fibrillationfibrillation

10-15% develop chest pain10-15% develop chest pain

Hoarseness caused by enlarged left atrium Hoarseness caused by enlarged left atrium
putting pressure on left recurrent laryngeal putting pressure on left recurrent laryngeal
nerve nerve

Pulmonary hypertension from chronic Pulmonary hypertension from chronic
increased pulmonary vascular resistanceincreased pulmonary vascular resistance
Hemoptysis often occursHemoptysis often occurs

14. Treatment:Treatment:

AnticoagulationAnticoagulation

Sodium restrictionSodium restriction

DiureticsDiuretics

Valve replacementValve replacement
Onset to incapacitation averages 5-10 years and Onset to incapacitation averages 5-10 years and
most patients die within 2-5 years of onsetmost patients die within 2-5 years of onset

15. Anesthesia concernsAnesthesia concerns

Maintain sinus rhythmMaintain sinus rhythm

Avoid tachycardia, large increases in COAvoid tachycardia, large increases in CO

Avoid both hypovolemia and fluid overloadAvoid both hypovolemia and fluid overload

Avoid increases in pulmonary vascular Avoid increases in pulmonary vascular
resistanceresistance

Phenylephrine is preferred over ephedrinePhenylephrine is preferred over ephedrine

Epidural is preferred over spinal due to Epidural is preferred over spinal due to
gradual onsetgradual onset of sympathetic block with of sympathetic block with
epiduralepidural

16. ManagementManagement
HRHR- keep slow to allow for diastolic filling; avoid sinus - keep slow to allow for diastolic filling; avoid sinus
tachycardiatachycardia
RhythmRhythm- sinus rhythm; if A-fib, control rate- sinus rhythm; if A-fib, control rate
PreloadPreload- Maintain or slightly increase to help with left - Maintain or slightly increase to help with left
ventricular filling; excess preload may cause pulmonary ventricular filling; excess preload may cause pulmonary
edemaedema
AfterloadAfterload- SVR should be maintained; avoid decreases in - SVR should be maintained; avoid decreases in
SVR; avoid increases in PVRSVR; avoid increases in PVR
ContractilityContractility- Maintain to provide adequate cardiac output- Maintain to provide adequate cardiac output
****epidural preferred over spinalepidural preferred over spinal

17. Pregnancy ConsiderationsPregnancy Considerations
Vaginal delivery: Early admission/invasive blood pressure Vaginal delivery: Early admission/invasive blood pressure
monitoring/ Small top-ups for epidural/avoid iv fluids.monitoring/ Small top-ups for epidural/avoid iv fluids.
Caesarean delivery :Caesarean delivery :
Spinal anaesthesia is best avoided. Spinal anaesthesia is best avoided.
Careful epidural anaesthesia in class 1 and 2 patientsCareful epidural anaesthesia in class 1 and 2 patients
General anaesthesia NYHA class 3 and 4 patients . Specific General anaesthesia NYHA class 3 and 4 patients . Specific
pharmacotherapy to obtund the intubation response. pharmacotherapy to obtund the intubation response.
Bolus oxytocin is contraindicated in view of the risk of precipitous Bolus oxytocin is contraindicated in view of the risk of precipitous
systemic hypotension and pulmonary hypertension. systemic hypotension and pulmonary hypertension.
A brief period of postoperative ventilation may be required in some A brief period of postoperative ventilation may be required in some
cases. cases.

18. Mitral RegurgitationMitral Regurgitation
A portion of the LV volume is ejected back A portion of the LV volume is ejected back
into LA during systole because of an into LA during systole because of an
incompetent valve. This leads to:incompetent valve. This leads to:
Increased left atrial pressure, Increased left atrial pressure, **but the atrium**but the atrium
usually does not enlargeusually does not enlarge
Increased pulmonary artery pressureIncreased pulmonary artery pressure
Pulmonary edema/HTNPulmonary edema/HTN
Left ventricular hypertrophy occurs due to the Left ventricular hypertrophy occurs due to the
increased workload required to maintain volume increased workload required to maintain volume
outputoutput

20. EtiologyEtiology
ACUTEACUTE

Myocardial Myocardial
ischemia or ischemia or
infarctionsinfarctions

Infective Infective
endocarditisendocarditis

Chest traumaChest trauma
CHRONIC
Rheumatic fever
Incompetent valve
Destruction of mitral valve
annulus

21. PathophysiologyPathophysiology

Reduction in forward SV due to backward flow Reduction in forward SV due to backward flow
of blood into left atrium during of blood into left atrium during systolesystole (can be (can be
as much as 50% of SV)as much as 50% of SV)

Left ventricle compensates by dilating and Left ventricle compensates by dilating and
increasing end-diastolic volumeincreasing end-diastolic volume

Regurgitation reduces left ventricular Regurgitation reduces left ventricular
afterload, but may enhance contractilityafterload, but may enhance contractility

End-systolic volume remains normal, but End-systolic volume remains normal, but
eventually increases as disease progresseseventually increases as disease progresses

23. Signs and symptomsSigns and symptoms

Degree of atrial compliance will determine the Degree of atrial compliance will determine the
clinical manifestationsclinical manifestations
Normal or reduced atrial compliance (acute MR) Normal or reduced atrial compliance (acute MR)
will result in pulmonary vascular congestion and will result in pulmonary vascular congestion and
edemaedema
Increased atrial compliance (chronic MR) will Increased atrial compliance (chronic MR) will
demonstrate signs of decreased cardiac outputdemonstrate signs of decreased cardiac output

Chronic weakness and fatigueChronic weakness and fatigue

““Blowing pansystolic murmur” best heard at Blowing pansystolic murmur” best heard at
the cardiac apex and often radiating to left the cardiac apex and often radiating to left
axillaaxilla

24. TreatmentTreatment

Medical Tx: digoxin, diuretics and vasodilatorsMedical Tx: digoxin, diuretics and vasodilators

Surgical valvuloplastySurgical valvuloplasty
Usually reserved for those with moderate to severe Usually reserved for those with moderate to severe
symptoms (regurgitant volume 30-60% or >60%, symptoms (regurgitant volume 30-60% or >60%,
respectively, of SV)respectively, of SV)

25. ManagementManagement
HRHR- - maintain or increase; maintain or increase; avoid bradycardiaavoid bradycardia which worsens which worsens
regurgitant flowregurgitant flow
RhythmRhythm- - sinus rhythmsinus rhythm
PreloadPreload- - Maintain or slightly increaseMaintain or slightly increase; an; an elevated preload elevated preload
will cause an increase in regurgitant flow, and low preload will cause an increase in regurgitant flow, and low preload
causes inadequate cardiac outputcauses inadequate cardiac output
AfterloadAfterload- - DecreaseDecrease to improve forward cardiac output; to improve forward cardiac output;
avoid sudden increases in SVRavoid sudden increases in SVR
ContractilityContractility- - Maintain or increaseMaintain or increase to decrease left to decrease left
ventricular volumeventricular volume
**spinal & epidurals well tolerated, but bradycardia must be avoided****spinal & epidurals well tolerated, but bradycardia must be avoided**

26. Anesthesia concernsAnesthesia concerns

Avoid slow heart rate (ideally 80-100 bpm)Avoid slow heart rate (ideally 80-100 bpm)

Avoid increase in afterloadAvoid increase in afterload

WATCH IV FLUIDSWATCH IV FLUIDS
excess fluids will dilate the LV and worsen regurgitationexcess fluids will dilate the LV and worsen regurgitation
Need adequate volume to maintain forward SVNeed adequate volume to maintain forward SV

Preload reduction with vasodilators and diuretics Preload reduction with vasodilators and diuretics

Minimize drug-induced myocardial depressionMinimize drug-induced myocardial depression

Spinal and epidural are well tolerated (avoid Spinal and epidural are well tolerated (avoid
bradycardia)bradycardia)

Give prophylactic antibioticsGive prophylactic antibiotics

27. Anesthetic ConsiderationsAnesthetic Considerations
Prevent peripheral vasoconstrictionPrevent peripheral vasoconstriction
Avoid myocardial depressantsAvoid myocardial depressants
Treat acute atrial fibrillation immediatelyTreat acute atrial fibrillation immediately
Maintain a normal or slightly elevated heart Maintain a normal or slightly elevated heart
raterate
Monitor PCW pressure or intensity of Monitor PCW pressure or intensity of
murmurmurmur

28. Pregnancy ConsiderationsPregnancy Considerations
No specific recommendations for the No specific recommendations for the
management of mitral regurgitation during management of mitral regurgitation during
labour and delivery. labour and delivery.
Prior to labour symptoms may be Prior to labour symptoms may be
managed with diuretics and vasodilators.managed with diuretics and vasodilators.
During labour, regional anaesthesia is During labour, regional anaesthesia is
usually well tolerated. However, in usually well tolerated. However, in
complicated NYHA class 3-4 cases, complicated NYHA class 3-4 cases,
general anaesthesia may be required.general anaesthesia may be required.

29. Mitral Valve ProlapseMitral Valve Prolapse
Anesthetic ConsiderationsAnesthetic Considerations
Avoid decreases in preloadAvoid decreases in preload
Continue antiarrhythmic therapyContinue antiarrhythmic therapy
With MVP and moderate to severe mitral With MVP and moderate to severe mitral
insufficiency the same considerations as insufficiency the same considerations as
listed for mitral insufficiency alone applylisted for mitral insufficiency alone apply

30. Aortic StenosisAortic Stenosis
Aortic Valve AreaAortic Valve Area
Normal 2.6 - 3.5 cm2Normal 2.6 - 3.5 cm2
Mild 1.2 – 1.8 cm2Mild 1.2 – 1.8 cm2
Moderate 0.8 – 1.2 Moderate 0.8 – 1.2
cm2cm2
Significant 0.6 .0.8 Significant 0.6 .0.8
cm2cm2
Critical < 0.6 cm2Critical < 0.6 cm2
LV-Aortic GradientLV-Aortic Gradient
Mild 12 – 25 mmHgMild 12 – 25 mmHg
Moderate 25 – 40 Moderate 25 – 40
mmHgmmHg
Significant 40-50 Significant 40-50
mmHgmmHg
Critical > 50 mmHgCritical > 50 mmHg

31. EtiologyEtiology
congenital bicuspid aortic valve (2%).congenital bicuspid aortic valve (2%).
Rheumatic heart disease.Rheumatic heart disease.
Valve Calcification.Valve Calcification.

33. PathophysiologyPathophysiology
Obstruction of left ventricular ejection.Obstruction of left ventricular ejection.
Concentric hypertrophy of left ventricular Concentric hypertrophy of left ventricular
muscle.muscle.
Decreased compliance of left ventricle Decreased compliance of left ventricle
making it difficult to fill.making it difficult to fill.

34. Anesthesia concerns:Anesthesia concerns:

Maintain normal sinus rhythm, heart rate Maintain normal sinus rhythm, heart rate
and intravascular volumeand intravascular volume
Optimal heart rate 70-80 bpmOptimal heart rate 70-80 bpm

WATCH OUT FOR VASODILATIONWATCH OUT FOR VASODILATION

Treat hypotension with phenylephrineTreat hypotension with phenylephrine

Mild to moderate AS may tolerate spinal or Mild to moderate AS may tolerate spinal or
epidural (epidural preferred)epidural (epidural preferred)

Spinal and epidural contraindicated in Spinal and epidural contraindicated in
severe ASsevere AS

High risk of myocardial ischaemiaHigh risk of myocardial ischaemia

35. Peri-operative Care.Peri-operative Care.
SymptomaticSymptomatic patients for elective non-cardiac patients for elective non-cardiac
surgery should have aortic valve replacement surgery should have aortic valve replacement
first as they are at great risk of sudden death first as they are at great risk of sudden death
perioperatively (untreated severe symptomatic perioperatively (untreated severe symptomatic
stenosis has a 50% one year survival).stenosis has a 50% one year survival).
Asymptomatic patients for major elective surgery Asymptomatic patients for major elective surgery
associated with marked fluid shifts (thoracic, associated with marked fluid shifts (thoracic,
abdominal, major orthopaedic) with gradients abdominal, major orthopaedic) with gradients
across the valve > 50 mmHg should have valve across the valve > 50 mmHg should have valve
replacement considered prior to surgery.replacement considered prior to surgery.
Asymptomatic patients for intermediate or minor Asymptomatic patients for intermediate or minor
surgery generally do well if managed carefully.surgery generally do well if managed carefully.

36. Haemodynamic goalsHaemodynamic goals
(Low) normal heart rate(Low) normal heart rate
Maintain sinus rhythmMaintain sinus rhythm
Adequate volume loadingAdequate volume loading
High normal systemic vascular High normal systemic vascular
resistanceresistance
(Phenylepherine / Metarminol)(Phenylepherine / Metarminol)
Effective analgesia.Effective analgesia.

37. Postoperative ManagementPostoperative Management
Have a low threshold for admission to ICU Have a low threshold for admission to ICU
/ HDU/ HDU
Meticulous attention must be paid to fluid Meticulous attention must be paid to fluid
balance and post operative pain balance and post operative pain
managementmanagement
Infusions of vasoconstrictors may be Infusions of vasoconstrictors may be
required to maintain haemodynamic required to maintain haemodynamic
stabilitystability

38. Pregnancy considerationsPregnancy considerations
Caesarean section: Caesarean section:
General anaesthesia with the aid of invasive General anaesthesia with the aid of invasive
haemodynamic monitoring. Aggressive maintenance haemodynamic monitoring. Aggressive maintenance
of systemic blood pressure with vasopressors (e.g. of systemic blood pressure with vasopressors (e.g.
phenylephrine).phenylephrine).
Spinal anaesthesia is generally contraindicated.Spinal anaesthesia is generally contraindicated.
There are reports of the successful management of There are reports of the successful management of
vaginal delivery under carefully introduced and limited vaginal delivery under carefully introduced and limited
epidural analgesia, but this should be restricted to very epidural analgesia, but this should be restricted to very
experienced hands. experienced hands.

39. Aortic regurgitation Aortic regurgitation
Etiology:Etiology:
Rheumatic heart disease.Rheumatic heart disease.
Endocarditis.Endocarditis.
Aortic dissection Aortic dissection
Connective tissue disorders Connective tissue disorders

40. ManagementManagement
HRHR- Avoid sudden decreases; an increase (10-15 beats) - Avoid sudden decreases; an increase (10-15 beats)
causes shortening of diastolic phase which decreases causes shortening of diastolic phase which decreases
the regurgitant fraction and increases cardiac outputthe regurgitant fraction and increases cardiac output
RhythmRhythm- sinus rhythm preferred- sinus rhythm preferred
PreloadPreload- increase to maximize forward cardiac output - increase to maximize forward cardiac output
and maintain blood pressureand maintain blood pressure
AfterloadAfterload- decrease afterload to favor forward cardiac - decrease afterload to favor forward cardiac
output (keep moving forward); avoid sudden increase output (keep moving forward); avoid sudden increase
in afterloadin afterload
ContractilityContractility- maintain- maintain
****most patients tolerate spinal or epidural provided intravascular volume is most patients tolerate spinal or epidural provided intravascular volume is
maintainedmaintained

41. TreatmentTreatment

Once symptomatic, death can occur within Once symptomatic, death can occur within
5 years unless lesion is surgically repaired5 years unless lesion is surgically repaired

Digitalis, diuretics and afterload reduction Digitalis, diuretics and afterload reduction
(ACE inhibitors) for chronic (eventual (ACE inhibitors) for chronic (eventual
surgical repair)surgical repair)

Inotropes (dopamine, dobutamine) and Inotropes (dopamine, dobutamine) and
vasodilator for severe, chronic aortic vasodilator for severe, chronic aortic
regurgitation (requires surgery)regurgitation (requires surgery)

42. Anesthetic considerationsAnesthetic considerations

Maintain normal heart rate Maintain normal heart rate
Increased frequency of conduction abnormalities, Increased frequency of conduction abnormalities,
consider pacingconsider pacing

Keep SVR lowKeep SVR low

Avoid myocardial depressionAvoid myocardial depression
Maintain or slightly increase preloadMaintain or slightly increase preload

Give prophylactic antibioticsGive prophylactic antibiotics

Most patients will tolerate spinal or epidural, Most patients will tolerate spinal or epidural, provided provided
intravascular volume is maintainedintravascular volume is maintained

43. Peri-operative CarePeri-operative Care
Asymptomatic Patients- tolerate surgery well.Asymptomatic Patients- tolerate surgery well.
Patients with low functional capacity- Consider valve Patients with low functional capacity- Consider valve
replacement surgery first.replacement surgery first.
Haemodynamic goals Haemodynamic goals
High normal heart rate – around 90 bpmHigh normal heart rate – around 90 bpm
Adequate volume loadingAdequate volume loading
Low systemic vascular resistanceLow systemic vascular resistance
Maintain contractilityMaintain contractility
Spinal/Epidural well tolerated.Spinal/Epidural well tolerated.

44. Pregnancy considerationsPregnancy considerations
During labour, epidural analgesia During labour, epidural analgesia
improves forward flow, and is therefore the improves forward flow, and is therefore the
anaesthetic of choice in patient’s requiring anaesthetic of choice in patient’s requiring
an operative delivery. an operative delivery.

45. Pulmonary StenosisPulmonary Stenosis
•
Haemodynamic management: Maintain right Haemodynamic management: Maintain right
ventricular preload, left ventricular afterload ventricular preload, left ventricular afterload
and right ventricular contractility. and right ventricular contractility.
•
Avoid hypothermia, hypercarbia, acidosis,Avoid hypothermia, hypercarbia, acidosis,
hypoxia and high ventilatory pressures. hypoxia and high ventilatory pressures.
•
Spinal anaesthesia may be associated with an Spinal anaesthesia may be associated with an
uncontrolled reduction in right ventricular uncontrolled reduction in right ventricular
preload and should therefore be avoided in preload and should therefore be avoided in
severe cases.severe cases.

46. Pregnancy ConsiderationsPregnancy Considerations
Spinal anaesthesia may be associated Spinal anaesthesia may be associated
with an uncontrolled reduction in right with an uncontrolled reduction in right
ventricular preload and should therefore ventricular preload and should therefore
be avoided in severe cases.be avoided in severe cases.

47. Endocarditis prophylaxisEndocarditis prophylaxis
Consider prophylaxis for all patients with Consider prophylaxis for all patients with
valvular lesions.valvular lesions.
Three main questions:Three main questions:
Which patients have a high risk?Which patients have a high risk?
Which procedures cause "significant" Which procedures cause "significant"
bacteraemia?bacteraemia?
Which antibiotics are active against Which antibiotics are active against
these bacteria?these bacteria?

48. Prophylaxis for valvular heart Prophylaxis for valvular heart
disease.disease.
Prophylaxis against infective endocarditis is recommended for the following
patients:

Patients with prosthetic heart valves and patients with a history of infective
endocarditis. (Level of Evidence: C)

Patients with congenital cardiac valve malformations, particularly those with
bicuspid aortic valves, and patients with acquired valvular dysfunction (e.g.,
rheumatic heart disease). (Level of Evidence: C)
Patients who have undergone valve repair. (Level of Evidence: C)
Patients who have hypertrophic cardiomyopathy when there is latent or resting
obstruction. (Level of Evidence:C)
Patients with MV prolapse (MVP) and auscultatory evidence of valvular
regurgitation and/or thickened leaflets on echocardiography.* (Level of
Evidence: C)

49. No prophylaxis requiredNo prophylaxis required
Prophylaxis against infective endocarditis is not recommended for the
following patients:

Patients with MVP without MR or thickened leaflets on echocardiography.*
(Level of Evidence: C)

Patients with physiological, functional, or innocent heart murmurs, including
patients with aortic valve sclerosis as defined by focal areas of increased
echogenicity and thickening of the leaflets without restriction of motion and a
peak velocity less than 2.0 m per second. (Level of Evidence: C)

Patients with echocardiographic evidence of physiologic MR in the absence of
a murmur and with structurally normal valves. (Level of Evidence: C)

Patients with echocardiographic evidence of physiological tricuspid
regurgitation (TR) and/or pulmonary regurgitation in the absence of a murmur
and with structurally normal valves. (Level of Evidence: C)

50. Prophylaxis recommended Prophylaxis not recommendedProphylaxis recommended Prophylaxis not recommended

Dental proceduresDental procedures
with mucosal bleeding without mucosal bleedingwith mucosal bleeding without mucosal bleeding

Respiratory tractRespiratory tract
tonsillectomy / adenoidectomy intubation of the tracheatonsillectomy / adenoidectomy intubation of the trachea
flexible bronchoscopyflexible bronchoscopy
Gastrointestinal tractGastrointestinal tract
procedures damaging the intestinal mucosa endoscopyprocedures damaging the intestinal mucosa endoscopy
surgery or endoscopy of the biliary tractsurgery or endoscopy of the biliary tract
sclerotherapy of oesophageal varicessclerotherapy of oesophageal varices
Urogenital tractUrogenital tract
surgery of the prostate hysterectomy*surgery of the prostate hysterectomy*
cystoscopy vaginal delivery*, Caesarean sectioncystoscopy vaginal delivery*, Caesarean section
dilatation of the urethra bladder catheterization (in the dilatation of the urethra bladder catheterization (in the
absence of infection)absence of infection)
* consider prophylaxis in high risk * consider prophylaxis in high risk
patientspatients

51. Antibiotic regimensAntibiotic regimens
1. Dental, Oral, Respiratory Tract, or Oesophageal Procedure1. Dental, Oral, Respiratory Tract, or Oesophageal Procedure
Standard: Amoxicillin 2.0 g (child: 50 mg/kg) per os 1 h preoperativelyStandard: Amoxicillin 2.0 g (child: 50 mg/kg) per os 1 h preoperatively
Ampicillin 2.0 g (child 50 mg/kg) iv 30 min preoperativelyAmpicillin 2.0 g (child 50 mg/kg) iv 30 min preoperatively
* Alternative: Clindamycin 600 mg (child 20 mg/kg) per os* Alternative: Clindamycin 600 mg (child 20 mg/kg) per os
or Cefalexin per os or Cefazolin iv or Erythromycin per osor Cefalexin per os or Cefazolin iv or Erythromycin per os
2. Gastrointestinal or Genitourinary Procedure2. Gastrointestinal or Genitourinary Procedure
High-risk patient:High-risk patient:
Standard: Ampicillin + Gentamicin (2.0 g + 1.5 mg/kg) iv,Standard: Ampicillin + Gentamicin (2.0 g + 1.5 mg/kg) iv,
after 6 h, Ampicillin 1.0 g iv or Amoxicillin 1.0 g per osafter 6 h, Ampicillin 1.0 g iv or Amoxicillin 1.0 g per os
* Alternative: Vancomycin + Gentamicin (1.0 g+ 1.5 mg/kg,* Alternative: Vancomycin + Gentamicin (1.0 g+ 1.5 mg/kg,
infuse over 1-2 h directly preoperatively, child: 20 mg/kg + 1.5 mg/kg)infuse over 1-2 h directly preoperatively, child: 20 mg/kg + 1.5 mg/kg)
Moderate-risk patient:Moderate-risk patient:
Standard: Amoxicillin per os or Ampicillin ivStandard: Amoxicillin per os or Ampicillin iv
* Alternative: Vancomycin (1.0 g) iv infuse over 1-2 h directly preoperatively* Alternative: Vancomycin (1.0 g) iv infuse over 1-2 h directly preoperatively

52. Anaesthesia for a patient with valvular Anaesthesia for a patient with valvular
heart disease can be challenging.heart disease can be challenging.
The aim of anaesthesia is to keep the The aim of anaesthesia is to keep the
diseased heart within its "optimal working diseased heart within its "optimal working
conditions"conditions"