Key points for anesthetic and hemodynamic management of patients with secondary mitral regurgitation

Hemodynamic goals	Avoid	Monitor	Intervention
Normal to slow HR (55 to 80 bpm)	Avoid tachycardia or 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 hypertension	Intra-arterial blood pressure	Prevent hypertension by providing adequate anesthetic depth and effective analgesia and treat hypertension with vasodilator therapy as needed. A reasonable approach is to maintain MAP at a level close to preoperative baseline level (which may be low-to-normal in this population). If necessary, treat significant hypotension with careful titration of ephedrine.
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.

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