A 34-year-old woman with severe rheumatic mitral stenosis (valve area 0.9 cm2) undergoes laparotomy. After induction her heart rate rises from 82 to 138 beats per minute with atrial fibrillation and she develops pulmonary oedema. The immediate haemodynamic priority is:
- A Control the heart rate promptly with an esmolol infusion to restore diastolic filling time ✓
- B Reduce preload with glyceryl trinitrate infusion alone
- C Increase heart rate further with atropine to raise cardiac output
- D Administer a fluid bolus to improve left ventricular preload
Correct answer: A. Control the heart rate promptly with an esmolol infusion to restore diastolic filling time
Explanation
In mitral stenosis left ventricular filling depends entirely on the pressure gradient across the narrowed valve during diastole. Tachycardia shortens diastole disproportionately, drops transmitral flow, raises left atrial pressure, and precipitates pulmonary oedema. Rate control with a short acting beta-blocker such as esmolol is the immediate priority. Reducing preload alone does not restore filling time, a fluid bolus worsens atrial pressures, and raising the heart rate is actively harmful in this lesion.
Reference: Morgan and Mikhail's Clinical Anesthesiology, 7th ed.
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Written and medically reviewed by the StethoPrep medical team.