Acute Right Ventricular Failure Postintubation in a Mitral Stenosis Patient

Mitral stenosis (MS) is prevalent in 0.02-0.2% of the population in developed countries. The pathophysiology of MS results in elevated left atrial pressures and over-time results in pulmonary hypertension (HTN) which ultimately affects the right ventricle. In addition, MS restricts the diastolic filling of the left ventricle. Therefore, during induction patients with MS are limited by their ability to increase cardiac output by increasing stroke volume. Anesthesia goals in severe MS are to avoid sudden changes in heart rate, as well as systemic and pulmonary artery pressures. We report a patient who sustained severe hypotension upon induction and intubation which was resistant to conventional medications. Intraoperative transesophageal echocardiography displayed unique right atrial and right ventricular dilatation. In addition, the leftward inter-ventricular, inter-atrial septal shift and septal bounce were noted as the characteristic findings. Intravenous epinephrine bolus was administered to achieve normo-tension and normal chamber dimensions and interventricular septal position.