The role of premedication is to allay the anxiety of the impending surgical procedure, thereby controlling the sympathetic outflow that may accompany the stress response. Acute changes in heart rate, venous return, and systemic resistance can have profound effects on patients with valvular heart disease. Premedication is most safely administered in the operating room after placement of standard American Society of Anesthesiologists (ASA) monitors and supplemental nasal oxygen.

Patients with AS might benefit from premedication to minimize tachycardia. Concern must be taken to ensure adequate venous return and preservation of sinus rhythm (see next).

Patients with AI can similarly benefit from premedication because any increases in afterload, which accompany sympathetic stimulation, can increase regurgitant volume. Drug doses should be adjusted based on the severity of debilitation and degree of systemic hypoperfusion.

Patients with MS should be premedicated with caution. Elevations in carbon dioxide resulting from opioid-induced hypoventilation can dramatically elevate pulmonary pressures, further compromising right ventricle output. Also important, venodilation can excessively diminish filling pressures.

Patients with MR can respond similarly to those with MS, particularly when pulmonary hypertension is present. However, elevations in systemic pressure from acute preoperative stress can also compromise left ventricular output and even lead to acute pulmonary edema. Proper premedication can be delivered by careful dose selection and the provision of supplemental oxygen.

References

• Frogel J, Galusca D. Anesthetic considerations for patients with advanced valvular heart disease undergoing noncardiac surgery. Anesthesiol Clin. 2010;28:67-85.
• Ramakrishan H, Craner RC, Devaleria PA, Cook DJ, Housmans PR, Rehfeldt KH. Valvular heart disease: replacement and repair. In: Kaplan JA, Augustides J, Maneck GR, Maus T, eds. Kaplan's Cardiac Anesthesia. 7th ed. Elsevier; 2017:770-817.