Remimazolam-Based Anesthesia in Patients with Heart Failure Due to Mitral Regurgitation and Low Left Ventricular Function: A Case Series

Abstract

Background and Objectives: Remimazolam is a new ultrashort-acting benzodiazepine anesthetic. Remimazolam appears to be useful in patients with severe valvular disease because of its minimal cardiovascular impact. In this retrospective case series study, we assessed the efficacy and safety of remimazolam for maintaining hemodynamic stability during anesthetic induction and maintenance. Cases: MitraClip was performed on 18 cases with severe mitral regurgitation with low left ventricular function who presented with heart failure, and remimazolam was administered for general anesthesia with induction (12 mg/kg/h) and maintenance (1 mg/kg/h). The impact of remimazolam on the hemodynamics at anesthetic induction and during anesthetic maintenance was investigated retrospectively using electronic medical records. Blood pressure decreased significantly during anesthetic induction with remimazolam (78.5 [72, 81.25] and 66.1 [62.2, 74.2], median [IQR], p = 0.0001), but only mildly, by about 10 mmHg. There was no significant change in the cardiac index (2.0 [1.8, 2.4] vs. 1.9 [1.8, 2.3], p = 0.57642) or pulse rate (73.5 ± 8.85 vs. 74.7 ± 11.7, mean ± SD, p = 0.0876) during anesthetic induction with remimazolam. All patients underwent MitraClip without major hemodynamic concerns, with no or small increases in inotropes. Conclusions: Remimazolam may be used safely in patients with severe mitral regurgitation and low left ventricular function presenting with heart failure.

Keywords: MitraClip; anesthesia; heart failure; mitral regurgitation; remimazolam.

Figure 1

The induction dose of remimazolam in this study. The mean induction dose was also 0.35 mg/kg, which was higher than the 0.1 mg/kg at which all the elderly in the phase I clinical trial fell asleep. There was also a large variation among cases. Whiskers indicate maximum and minimum values.

Figure 2

The changes in cardiovascular parameters before and after induction with remimazolam. MAP decreased significantly after induction, but the change was relatively small. CI and PR were maintained and did not differ significantly. MAP: mean arterial pressure, CI: cardiac index, PR: pulse rate. Whiskers indicate maximum and minimum values.