Mitral regurgitation in the critically ill: the devil is in the detail

Mitral regurgitation (MR) is common in the critically unwell and encompasses a heterogenous group of conditions with diverging therapeutic strategies. MR may present acutely with haemodynamic instability or more insidiously with failure to wean from mechanical ventilation. Critical illness is associated with marked physiological stress and haemodynamic changes that dynamically influence the severity and implication of MR. The expanding role of critical care echocardiography uniquely positions the intensivist to apply advanced bedside valvular assessment to recognise haemodynanically significant MR, manipulate and optimise cardiopulmonary physiology and identify patients requiring urgent cardiology and surgical referral. This review will consider common clinical scenarios, therapeutic strategies and the pearls and pitfalls of echocardiographic assessment and quantification in the critically unwell.

The Use of Vigileo® Monitor in a Parturient With Severe Mitral Valve Stenosis and Severe Pulmonary Hypertension Undergoing Cesarean Section Under General Anesthesia: A Case Report and Literature Review

We report a case of a 35-year-old pregnant female of Afghan origin who was admitted to the intensive care unit (ICU) because of pulmonary edema development when she was in the 30th week of gestation. During the bedside examination, the transthoracic echocardiogram (TTE) revealed severe mitral valve stenosis and pulmonary hypertension. The patient went into treatment with metoprolol for the control of tachycardia and furosemide for the prevention of fluid overload. During the 32nd week of gestation, the medical council decided on a cesarean section (CS) to be carried out under general anesthesia. The anesthesiologists decided to use the Vigileo monitor (Edwards Lifesciences, Irvine, CA, USA) as it is vitally important to approach fluid administration as fluid management is challenging concerning the obstetric patient. Vigileo monitoring is based on the invasive measurement of cardiac output (CO), cardiac index (CI), stroke volume (SV), and stroke volume variation (SVV). Fluid resuscitation based on hemodynamic parameters is a key component of patient care, especially in scenarios such as cardiovascular disease. This is the first case report where a Vigileo monitor was applied to a patient with severe mitral valve stenosis and severe pulmonary hypertension undergoing a cesarean section, which was accomplished without any complications. The patient was discharged from the hospital on the 12th postoperative day, hemodynamically stable. Each immigrant woman, regardless of her financial, social, cultural, or any other situation, has the fundamental right to receive complete perinatal healthcare. Nevertheless, the most recent statistical data show that those women's access to public healthcare is insufficient, leading to high rates of maternal mortality. The international medical community has to adapt to the new multicultural environment, and health services must be provided to this vulnerable population with the appropriate level of safety.

Anesthetic management of a parturient with Shone's syndrome -a case report with review of literature

BACKGROUND

Shone's syndrome is a rare complex congenital cardiac condition, characterized by a supra-valvular mitral ring, parachute deformity of the mitral valve, aortic stenosis, and coarctation of the aorta.

CASE

A 26-year-old parturient with partial Shone's syndrome presented to our delivery unit in pulmonary edema. She underwent a scheduled cesarean section performed under a combined spinal-epidural anesthetic at 33 weeks. She had multidisciplinary input from the cardiac, obstetric, and anesthetic teams, which led to a good outcome. A review of the five published case reports of Shone's syndrome in pregnancy is presented along with key findings.

CONCLUSIONS

Our case report and the review highlight the successful use of combined spinal-epidural anesthetic and provides guidance to the multidisciplinary team on the varied presentation and the optimum management of women with Shone's syndrome during the peripartum period.

An Unusual Cause of Stroke in a Young Adult

Stroke is an uncommon presentation in young adults, with different causes and risks factors implicated. Cardiogenic cerebral embolus is one of the most common causes in younger patients and must be considered in the investigation of young patients presenting with stroke. The authors describe a case of a young patient presenting with stroke as a result of distal embolization from a previously undiagnosed congenital mitral valve defect.