A 65-year-old man with severe chronic mitral regurgitation (LVEF 55%, left atrial dilation) is undergoing elective total hip replacement under general anaesthesia. Which of the following is the MOST appropriate haemodynamic goal during the perioperative period?

• A Maintain strict bradycardia (50-60 bpm) to reduce myocardial oxygen demand
• B Maintain a relative tachycardia (80-100 bpm) and avoid excessive afterload ✓
• C Maintain high systemic vascular resistance to ensure coronary perfusion
• D Restrict intravenous fluids to minimise left ventricular volume overload

Explanation

In chronic severe mitral regurgitation, a relative tachycardia shortens diastole and reduces the time for regurgitant flow, improving forward cardiac output. Avoiding excessive afterload also reduces the regurgitant fraction. Bradycardia (option A) is harmful as it lengthens regurgitant time. High SVR (option C) worsens regurgitation. Moderate volume loading is needed to maintain forward flow, so fluid restriction (option D) is incorrect. The key principle is to keep the patient rate-loaded and afterload-reduced.

Reference: Miller's Anaesthesia, 9th ed.

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Written and medically reviewed by the StethoPrep medical team.