ASK THE EXPERTS  h  ANESTHESIOLOGY  h  PEER REVIEWED

Anesthesia for Dogs

with Myxomatous
Mitral Valve Disease
Khursheed Mama, DVM, DACVAA
Marisa Ames, DVM, DACVIM (Cardiology)
Colorado State University

YOU HAVE ASKED ... tural abnormalities and resultant physi-

ologic consequences can influence the
What is the best approach for anesthesia protocol, periprocedural
anesthetizing animals with monitoring, and plans for emergency
interventions.
myxomatous mitral valve
disease? This discussion focuses on the anes-
thetic management of dogs with varying
stages of myxomatous mitral valve
THE EXPERTS SAY ... disease and commonly observed comor-
Proper anesthetic management of bidities.
patients with cardiac disease depends
on the nature and severity of the dis- Pathophysiology
ease. In a broad sense, the anesthetic Myxomatous mitral valve disease
approach to the cardiac patient is differ- (MMVD) is a degenerative valvular
ent for compensated vs decompensated disease in which a portion of the left ven-
heart disease. In addition, concurrent tricular stroke volume is regurgitated
disease and requisite supportive thera- backward into the left atrium with each
pies can cause decompensation of previ- contraction. As MMVD progresses, for-
ously compensated heart disease. ward stroke volume (ie, flow into the
aorta) decreases and the sympathetic ner- MMVD = myxomatous mitral
vous system is activated, which results in valve disease
Understanding the underlying struc-

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ASK THE EXPERTS  h  ANESTHESIOLOGY  h  PEER REVIEWED

increased heart rate and contractility. ure (CHF)—a common cause of death due
Decreased renal perfusion can also to MMVD.2 Pulmonary edema, a clinical
cause the release of renin and activation consequence of left-sided CHF, occurs
of the renin–angiotensin–aldosterone when the pressure in the left atrium and
system.1 This can contribute to sodium pulmonary venous system rises.1 MMVD
and water retention and vasoconstric- is typically a slowly progressive disease;
tion, which can cause increased preload at-home monitoring of resting respira-
and afterload. The neurohormonal acti- tory rates and exercise tolerance can aug-
vation is compensatory in the short- ment clinical monitoring via radiography
term, but it can become maladaptive in and echocardiography.
chronic heart disease.
Other sequelae relating to cardiac remod-
Additional compensation occurs via car- eling in MMVD include arrhythmia
diac remodeling (eccentric hypertrophy (most commonly atrial premature con-
in the case of MMVD), which can help tractions or atrial fibrillation), compres-
maintain forward stroke volume despite sion of the left mainstem bronchus, and
worsening mitral regurgitation. The cough. Acute CHF can occasionally occur
ventricle has a low-pressure reservoir with rupture of a chorda tendinea and an
into which it can eject blood (left abrupt increase in regurgitant fraction
atrium), so the wall stress and oxygen and left atrial pressure. Cardiogenic
demand on the myocardium are only shock can occur with left atrial rupture
modestly increased in the early and caused by hemopericardium and cardiac
intermediate stages of this disease.2 tamponade.
With chronicity and as the regurgitation
increases in severity, systolic function How Is MMVD Diagnosed?
often declines. MMVD is usually suspected following
auscultation of an adult-onset, left apical
Chronic volume overload, progressive systolic murmur of mitral insufficiency,
cardiac remodeling, and myocardial dys- often heard around the 5th intercostal
function can lead to congestive heart fail- space just below the costochondral junc-
tion; the palpable apex beat can also
serve as a landmark. Because MMVD is
characterized by a long preclinical
phase, many newly diagnosed dogs may

Because MMVD is characterized by a not have clinical signs of heart disease.

long preclinical phase, many newly Although the presence of a new, left api-

diagnosed dogs may not have clinical cal systolic murmur in a middle-aged-to-
older, small-breed dog can suggest
signs of heart disease. MMVD, confirmation and further stag-
ing requires a complete history, physical
examination, and additional imaging
studies. Clinicians should also evaluate
ACE = angiotensin-converting enzyme
for other diseases that are common in
CHF = congestive heart failure
this cohort that can exacerbate and/or
MMVD = myxomatous mitral valve disease
complicate MMVD (eg, systemic hyper-

100    cliniciansbrief.com    August 2016

tension due to renal or endocrine dis-
ease). This additional testing can
provide useful information to help
manage patients for both the anesthetic
period and the long-term.
A B1 B2 C1 C2 D1 D2
The ACVIM consensus statement offers
additional information regarding stag-
ing and medical therapy for MMVD
At risk Murmur & Failure or history Refractory:
(Figure 1).3 Historical and physical enlargement of failure: at home
examination findings such as exercise at home
intolerance, cough, tachypnea, dyspnea, Murmur & no Failure or Refractory:
collapse, end-inspiratory crackles, enlargement history of failure: hospitalized
hospitalized
tachycardia, and arrhythmia should
raise concern for decompensating d FIGURE 1 Schematic version of the ACVIM classification for MMVD in the dog. The

MMVD and/or overt heart failure. ACVIM consensus statement lists therapeutic recommendations based on stage of
disease.3 Figure courtesy of Clarke E. Atkins, DVM, DACVIM

What Are the Broad-Based

Considerations? In patients with clinical signs and sup-
Patients with early-stage (ACVIM classi- porting evidence of disease progression,
fication of B1) MMVD typically tolerate it is increasingly important to maintain
anesthesia well and do not require spe- heart rate in a normal-to-high-normal
cial management. Clinicians should range4,5 while using a conservative fluid
maintain the heart rate in the normal administration rate (eg, 2-5 mL/kg/hr)
range, avoid increases in afterload that to maintain adequate preload during the
may occur with some anesthesia medica- anesthesia period. Increases in systemic
tions, and avoid an increase in preload vascular resistance or afterload should
(as with rapid, high-volume IV fluid be avoided, as this may increase the
administration). fraction of regurgitant flow, which may
precipitate heart failure.
Clinically affected dogs (late stage B2
and stages C and D) are often prescribed How Can I Best Manage
chronic medications that include diuret- Anesthesia in a Dog with MMVD?
ics (eg, furosemide), vasodilators, or Premedication with an opioid (eg, hydro-
ACE inhibitors (eg, benazepril). With morphone 0.05-0.1 mg/kg IM or SC or
disease progression, these patients may 0.01-0.03 mg/kg IV) can provide
also receive drugs that stimulate con- mild-to-moderate sedation with minimal
tractility (eg, pimobendan). Although cardiovascular side effects. Benzodiaze-
these chronically administered medica- pines (eg, midazolam 0.1-0.2 mg/kg IV
tions help slow disease progression and or SC or IM) also have few to no cardio-
minimize consequences to the patient, vascular effects and can be useful
higher doses and the number of drug adjuncts in older or sicker dogs. They are,
classes needed to manage the disease in general, less effective as sole tranquil-
generally reflect increasing severity or izers in young or healthy active animals,
disease progression.3 and they may cause excitement.

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ASK THE EXPERTS  h  ANESTHESIOLOGY  h  PEER REVIEWED

Alpha-2 agonists are excellent sedatives ketamine (5-7 mg/kg IV) with midaz-
but are not recommended. They increase olam (0.2-0.3 mg/kg IV) can provide
systemic vascular resistance and intubation conditions in premedicated
decrease the heart rate, which can dogs. Alternatively, lower doses of ket-
increase regurgitant stroke volume amine (2-3 mg/kg IV) may be used in
while diminishing forward stroke vol- combination with similar doses of
ume. Conversely, acepromazine tends to propofol titrated to effect in dogs with
decrease afterload but can unduly mild-to-moderate disease.
decrease preload and contractility, so its
use should be carefully considered.5 Anesthesia induction for patients with
advanced disease can be more safely
Depending on premedication choice and accomplished using drugs with a low
subsequent planned anesthetic medica- likelihood of or manageable cardiovas-
tions, an anticholinergic (eg, atropine cular depression, such as a combination
0.02-0.03 mg/kg IM or SC, glycopyrrolate of an opioid (eg, fentanyl 10 µg/kg
0.01 mg/kg IM) may be added to prevent IV)11,12 or etomidate (1-2 mg/kg IV)13
or offset bradycardia that is commonly and a benzodiazepine (eg, midazolam
seen with use of opioids,6 especially fol- 0.1-0.2 mg/kg IV). Bradycardia is likely
lowing IV administration. It can also with IV opioids, and it can be mitigated
maintain the heart rate in a normal with use of anticholinergics. A small
range; tachycardia should be avoided, as dose (0.5-1.0 mg/kg IV) of a hypnotic
this can negatively affect ventricular fill- agent (eg, propofol) or alfaxalone may
ing. Treatment with an anticholinergic be necessary to facilitate intubation.
may be considered as an alternate strat- Data on alfaxalone’s cardiovascular
egy only in cases of observed bradycardia effects in this patient population are
or bradyarrhythmias. In the authors’ limited.
observation, this strategy commonly
results in an exacerbation of bradycardia Patients with severe heart failure sec-
and/or bradyarrhythmias with low-dose ondary to mitral insufficiency are at
anticholinergic administration and greater anesthetic risk; elective surgery
tachycardia with high-dose anticholiner- should be postponed for these patients
gic administration. until the condition is controlled or stabi-
lized with medical management. If this
For a patient with mild- (stage B1) to- is not possible, careful titration of a
moderate (early-to-intermediate stage benzodiazepine with a nonhistamine
B2) MMVD, the veterinarian may releasing µ-opioid agonist or etomidate
choose his or her preferred IV induction still provides the safest option for anes-
agent and titrate to the desired end thesia induction. Preplacement of heart
point. Propofol and alfaxalone are rate, rhythm, and blood pressure moni-
acceptable for dogs with mild disease toring equipment and availability of
and may be used judiciously in patients supportive medications are strongly rec-
with moderate disease.7-9 Ketamine sim- ommended in these animals.
ACE = angiotensin-converting
ilarly has indirect sympathomimetic
enzyme actions and can help maintain heart Maintenance with inhalation anesthetics
MMVD = myxomatous mitral rate and cardiac output in dogs with is appropriate for dogs with mild-to-
valve disease
mild-to-moderate disease.10 A dose of moderate disease. Supplemental analge-

102    cliniciansbrief.com    August 2016

sia should be provided as needed. In dogs human patients. Information remains
showing clinical signs of heart failure, a limited in veterinary medicine, espe-
balanced technique including high doses cially for newer anticoagulants with
of an opioid (eg, fentanyl 20-40 µg/kg/ unique mechanisms of action.
hr) can allow for a reduction in the dose
of inhalation agents and, in turn, their How Do I Provide Proper
dose-dependent myocardial depressant Perianesthesia Management
effects. of Common Anesthetic
Complications & Comorbidities?
High-dose opioid infusions can cause Even when receiving an anesthetic proto-
respiratory depression. Alternative col that is selected to minimize adverse
approaches using anesthetic-sparing events, dogs may become hypotensive
infusions of ketamine (20 µg/kg/min) during an anesthetic event. This can be
and lidocaine (30-50 µg/kg/min) with challenging, even in dogs presented for
lower doses of nonhistamine-releasing elective procedures. The traditional
opioid infusions (eg, hydromorphone approach of IV crystalloid or synthetic
0.02-0.03 mg/kg/hr) may be considered colloid boluses for hypotension can cause
if mechanical ventilation is not possible. volume overload in the heart.
Consultation with or referral to a
board-certified anesthesiologist should Because of the potential for sustained
be considered in dogs with advanced expansion of vascular volume with col-
(stages C and D) disease. loids, the authors use crystalloids for
vascular volume expansion in these
Should Cardiac Medications Be patients. In case of an accidental crystal-
Withdrawn Before Anesthesia? loid overdose, administration of furose-
Some anesthesiologists recommend mide (1 mg/kg IV) can help alleviate
withdrawal of ACE inhibitors on the day negative consequences (eg, pulmonary
of anesthesia because of the potential edema).
for hypotension,14,15 but some reports in
human patients suggest no greater inci-
dence of hypotension when these medi-
cations are given the morning of The traditional approach of IV
surgery; some benefits have also been
noted.16,17 These differences may be crystalloid or synthetic colloid
explained by different degrees of left
ventricular function in patients as well
boluses for hypotension can cause
as different anesthesia protocols. This volume overload in the heart.
lack of consensus—even among physi-
cians18,19 —leaves the decision up to each
veterinarian. The authors’ preference is
to not withdraw these cardiac medica-
tions if the dog’s cardiac disease is well-
managed with them.

Clear guidelines exist for withdrawal of

warfarin and heparin therapy from

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ASK THE EXPERTS  h  ANESTHESIOLOGY  h  PEER REVIEWED

It is prudent to have available drugs that addressing common perianesthetic

support the cardiovascular system. In causes (eg, hypoxia, hypercapnia, light
general, targeting the cause of low blood plane of anesthesia), treatment may be
pressure (if known) is best. Therapy may necessary if there is a risk for progres-
involve simply increasing an abnormally sion of dysrhythmias (eg, ventricular
low heart rate with an anticholinergic to ectopy to tachycardia or fibrillation) or
improve cardiac output and forward if tissue perfusion is compromised.
stroke volume. Drugs that improve con-
tractility (eg, dobutamine CRI of 2-7 µg/ Lidocaine (1-2 mg/kg IV as bolus, fol-
kg/min IV) are ideal in dogs with myo- lowed [if needed] by a CRI of 75-100 µg/
cardial failure. Ephedrine (0.05-0.1 mg/ kg/min) is a good first-line choice for
kg IV) and dopamine (CRI of 2-5 µg/kg/ treatment of dogs with ventricular dys-
min IV) may also safely provide cardio- rhythmias. It also has the benefit of syn-
vascular support.4 ergistic effects with other anesthetic
agents. Signs of atrial tachydysrhythmias
Dopamine has the presumed added ben- (eg, poor ventricular filling because of
efit of enhancing renal perfusion in high heart rate and loss of the atrial kick
dogs when used at low doses and is a [ie, when the atrial contraction adds pre-
good choice if renal insufficiency is a load to the ventricle immediately before
comorbidity. High doses (>10 µg/kg/ ventricular systole, which increases the
min) of dopamine and other medica- volume ejected from the ventricle]) may
tions with a-adrenergic effects should be alleviated with b-blocking drugs (eg,
generally be avoided because of poten- esmolol) or calcium-channel blockers
tial to increase afterload. (eg, diltiazem), but both can cause hypo-
tension and must be used judiciously.
Dysrhythmias may be observed in the Electrical cardioversion may also be
perianesthetic period, and they are attempted for atrial fibrillation, but it is
more likely to be observed in dogs with likely not broadly available. n
CRI = constant rate infusion
myocardial failure. In addition to

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