Key points for anesthetic and hemodynamic management for patients with aortic regurgitation or primary mitral regurgitation

Hemodynamic goals	Avoid	Monitor	Intervention
Normal to fast HR (80 to 100 bpm)	Avoid bradycardia	5-lead ECG Pulse oximetry with visible waveform	Management of bradycardia: Ephedrine Glycopyrrolate if necessary Low-dose infusion of epinephrine if necessary
Normal to low afterload	Avoid and/or immediately treat hypertension	Intra-arterial blood pressure (particularly MAP)	Prevent hypertension by continuing chronically administered antihypertensive medications, providing adequate anesthetic depth and effective analgesia If necessary, a vasodilator (eg, calcium channel blocker, nitroprusside) may be infused to decrease MAP and SVR If necessary, treat significant hypotension with careful titration of ephedrine Since patients with aortic regurgitation commonly have a wide pulse pressure, it is important to target control of the MAP rather than the systolic blood pressure
Normal to low preload	Avoid hypervolemia	Assess clinical response to small fluid boluses	Restrictive fluid management Intravenous nitroglycerin infusion for volume overload
Maintain contractility	Avoid doses of drugs that cause significant myocardial depression	Hemodynamics	If inotropic support is needed, milrinone, dobutamine, or low-dose epinephrine is preferred

HR: heart rate; bpm: beats per minute; ECG: electrocardiogram; MAP: mean arterial pressure; SVR: systemic vascular resistance.

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