Lesson 290: PreAnesthetic Assessment of the Pregnant Patient With Mitral Stenosis

Registration Fee: $15.00
2.0 AMA PRA Category 1 Credits^TM
available until February 28, 2012

Review Date: January, 2011

Participants who do not possess a copy of Anesthesiology News can download and print the course material in an easy to read convenient  format.  Participants must reflect on the information presented, and then register to complete the exam and course evaluation online before the availability date listed above.  (CME credit is not valid past this date).  

Click on the link below to download and print the course material and post-test exam.  Register for the exam to enter your responses to receive CME credit.  There are ten questions in the examination and you must achieve a score of 80% or better to earn CME credit.  Following successful completion, your certificate will be immediately available online.  In addition, a historical record of  completed CME courses is maintained online in an individualized profile.  This includes copies of course certificates which can be printed at any time.

The registration fee for this course is $15.00

Physicians are provided with two opportunities to successfully complete the exam presented here. 

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Mitral stenosis often is first diagnosed during pregnancy when normal physiologic changes exacerbate symptoms of the disease. To manage the obstetric patient with mitral stenosis, a multidisciplinary approach is crucial for ensuring an optimal outcome. A cardiologist, high-risk obstetrician, cardiothoracic surgeon, and anesthesiologist should be involved as early as possible in the patient’s care and delivery plan. Anesthesiologists also should be aware of the hemodynamic goals for mitral stenosis and how to manage the decompensating patient. This topic has been identified by committee as important information for anesthesiologists.

CASE HISTORY

A 32-year-old woman was diagnosed with moderate to severe mitral stenosis in week 29 of pregnancy. The presence of placenta previa was noted; there also was a concern for placenta accreta. Sixteen years previously, the patient had undergone a cesarean delivery (outside the United States) that was occasioned by fetal distress.

A healthy fetus was delivered and there were no complications of labor reported at that time. The woman reported having poor exercise tolerance (class 2, New York Heart Association [NYHA] functional classification of heart disease) prior to her current pregnancy, but had no other symptoms. She underwent trans-thoracic echocardiography at 29 weeks of gestation. The findings included a mitral valve pressure half-time of 169 milliseconds (corresponding to an estimated mitral valve area [MVA] of 1.3 cm2), a mean gradient of 17 mm Hg, and a Wilkins mitral valvuloplasty score of 7. Moderate-severe mitral valve regurgitation with an eccentric jet also was observed. Fractional area change in the left ventricle was estimated to be 60%. The patient had mild pulmonary hypertension with systolic pulmonary artery pressure estimated at 36 mm Hg. Moderate tricuspid regurgitation also was noted.

LEARNING OBJECTIVES

At the end of this activity, the participant should be able to:

1. Explain why mitral stenosis is commonly diagnosed for the first time during pregnancy.
2. Recognize the echocardiographic findings used to classify the severity of mitral stenosis.
3. Describe the normal physiologic changes in the cardiovascular system during pregnancy.
4. Assess the indications, risks, and scoring systems that predict the success of percutaneous balloon mitral valvuloplasty.
5. Summarize the risks and feasibility of cardiopulmonary bypass for the pregnant patient and the fetus.
6. List hemodynamic goals for a patient with mitral stenosis.
7. Compare the risks and benefits of regional analgesia and anesthesia versus general anesthesia in patients with severe mitral stenosis.
8. Select appropriate hemodynamic monitors for the anesthetic management of a patient with severe mitral stenosis.
9. Identify the particular risks that surgery and delivery of the fetus pose to the patient with severe mitral stenosis.
10. Describe the management of the decompensating patient with severe mitral stenosis.

 

TARGET AUDIENCE:  Anesthesiologists

Accreditation Statement

Mount Sinai School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation: The Mount Sinai School of Medicine designates each educational activity for a maximum of 2 AMA PRA Category 1 Credits^TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

It is the policy of Mount Sinai School of Medicine to ensure objectivity, balance, independence, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices.

Disclosures

The author, the reviewer, and the editor have no relation-ships with pharmaceutical companies or manufacturers of products to disclose. This educational activity may contain discussion of published and/or investigational uses of agents for the treatment of disease. Some uses of these agents have not been approved by the FDA. Please refer to the official prescribing information for each product for approved indications, contraindications, and warnings.

CONTACT INFORMATION

Questions regarding course content may be directed to Dr. Elizabeth Frost: ElzFrost@aol.com.

If you require technical assistance with completing this course, please contact Continuing Education Online Customer Service at 718-648-8080 or send e-mail to ceo.contact7@proceo.com.

CALL FOR WRITERS

If you would like to write a CME lesson in Anesthesiology News, please send an e-mail to Elizabeth A.M. Frost, MD, at ElzFrost@aol.com