34. Structural Cardiac Flashcards
preop testing for valvular anomalies
TEE
TTE
heart Cath
Echo
regurgitant valve
backflow
stenotic valve
restricting blood flow
valvular symptoms
low MET level
fatigability
pedal edema
dyspnea
orthopnea
paroxysmal nocturnal dyspnea
angina
TIA/CVA
Left sided valvular anomaly
pulmonary rales
S3 gallop
right sided valvular anomally
jugular vein distension
pedal edema
best physical exam indication for valvular anomaly
auscultation
advanced exams for valvular anomalies
TEE
TTE
Right heart cath
heart valve order
toilet paper my ass
Tricuspid
Pulmonic
Mitral
Aortic
vena contracta
diameter of stream is least
fluid velocity is max
when is vena contracta measured
regurgitant valves
EROA
effective regurgitatnt orifice area
EROA is measured by
TEE doppler
PISA method
Annulus
fibrous ring of tissue that accommodates the dynamic myocardium and valve leaflets
how is annular diameter measured
TEE
what HR is ideal for regurgitation?
Faster HR
– allows for more forward flow
– limits backflow
what HR is ideal for stenosis
Slower HR
– increases flow across small valve
RH valves
Tricuspid
pulmonic
tricuspid stenosis SE
Right atrial dilation
- arrythmias
- jugular venous distension
- ascites
- peripheral edema
- hepatomegaly
- anasarca (general swelling)
what is tricuspid stenosis associated with
RHD
valvular disorders
tricuspid stenosis anesthetic managment
high preload
adequate contractility
causes of tricuspid regurge
endocarditis
carcinoid syndrome
ebstein anomaly
secondary causes of tricuspid regurge
RV dilation
severe PHTN
tricuspid regurge symptoms
RHF
fatigue
edema
ascites
tricuspid regurge treatment
decr fluids
decr salt
diuretics
decr PHTN
what drugs decr PHTN
endothelin receptor antag
PDE inhibitors
tricuspid regurge anesthetic
manage PHTN
manage RHF
mx volume status
normal HR
how do you manage PHTN
avoid hypoxia
avoid fluid overload
avoid hypercarbia
how do you manage RHF
milrinone
dobutamine
when are neuraxial techniques CI for tricuspid regurge
with tricuspid regurge and RHF
pulmonic stenosis is most common in what pt population
peds
pulmonic stenosis symtoms
asymptomatic until severe
pulmonic stenosis managment
preserve RV preload
preserve contractility
avoid PVR increases
pulmonic regurg primary causes
endocarditis
carcinoid syndrom
iatrogenic
iatrogenic causes of pulmonic regurge
catheter
surgery issues
seconday cause of pulm regurge
pulmonary artery dilation
pulmonic regurge management
decr PHTN
mx RV function
LH valves
mitral
aortic
cause of mitral stenosis
rheumatic fever
mild-mod mitral stenosis
slight incr LA P/V
what makes symptoms worse in mild-mod mitral stenosis
incr in HR
severe mitral stenosis
incr LA P/V at rest
what increases mitral stenosis symptoms
sepsis
fever
emotional stress
pregnancy
mitral stenosis symptoms
PHTN
PHF
exertional dyspnea
Afib
Ortner syndrome
thromboemolism risk
ortner syndorm
LA compression on RLN
ortner syndrome SE
chest/back/epigastric pain
cough
wheeze
stridor
mitral stenosis physical exam
rales
peripheral edema
ascites
incr jugular venous pressure
mitral facies (patches on cheeks)
mitral stenosis heart impacts
LA hypertrophy
R heart changes
interstitial fibrosis
mitral stenosis management
optimize HR
prevent decr CO
prevent pulm edema
treat Afib or arrythmias
is epidural or spinal better for mitral stenosis
epidural
how do you prevent pulmonary edema
decr preload
== avoid fluid overload
what drug should you avoid in mitral stenosis
ketamine
– incr PVR
– decr SVR
–hypoxia
– hypercarbia
causes of acute mitral regurge
ischemia of papillary muscle
papillary muscle rupture
causes of chronic mitral regurge
annular dilation
endocardidits
chordae incopetence
myxoma
myxoma
pedunculated benign heart growth
most common in atria
mitral regurge CO
decreased
mitral regurge
LV hypertrophy
LHF
Pulmonary edema
RHF
mitral regurge symptoms
DOE
fatigue
mitral valve prolapse
valve leaflet tents up into left atrial cavity
cause of mitral valve prolapse
connective tissue disorder
- ehler danos
- marfans
most common precursor to mitral regurge
mitral valve prolapse
treatment for mitral valve prolapse
valve repaire
valve replacement
mitraclip
mitral regurge management
fast HR
full CO
forward stroke volume
decr afterload
how can you reduce afterload
neuraxial technique (epidural)
how do you correct LV dysfunction
vasodilator
inotropic agent
what should you avoid in mitral regurge
sympathetics (incr SVR)
hypoxia
hypercarbia
(incr PVR)
what decr sympathetics
opioids
most problematic valve dysfunction
aortic stenosis
causes of aortic stenosis
rheumatic fever
atherosclerosis
HTN
hypercholesterol
diabetes
smoking
male
age
aortic stenosis symptoms
syncope
DOE
angina
when does survival start to be threatened with aortic stenosis
once symptoms onset
TAVR
transfemoral aortic valve replacement
what age is TAVR better for
> 65
when is TAVR more risky
aortic root complication
low coronoary ostia height
LVOT calcification
aortic stenosis managment
mx preload (normovolemia)
normal HR
maximize LV
avoid hypotension
avoid SVR decr
is regional good for aortic stenosis
no
causes of aortic regurge
leflet development anomaly
obstruction
annular dilation
types of obstructions
calcification
myoxma
endocarditis
type of annular dilation
aortic root
LVOT
connective tissue disorder
aortic regurge
incr LV EDV/EDP
chronic aortic regurge
LV hypertrophy
acute aortic regurge
ischemia
what should you mx in aortic regurge
forward LV stroke volume
what should you avoid in aortic regurge
bradycardia
abrupt SVR incr
volume overload
should you wakeup be fast or slow with aortic regurge
slow
- aovid SVR incr
should you use high or low VA with aortic regurge
low VA
- high induces myocardial contractility depression
infective endocarditis
presents most like a regurgitant valve
– sometimes stenotic
cause of IE
frequent exposure of bacteria daily
IE high risk pts
prosthetic heart valves
annuloplasty
history of IE
cyanotic HD w/shunts
cardiac transplant
IE high risk procedures
dental
respiratory tract
infected skin
musculoskeletal
total joints
cause of HOCM
autosoma dominant
HOCM symptoms
death
DOE
palpitations
chest pain
tachydysrhthmias
HF
HOCM can be induced with
rest
valsalva
exercise
HOCM mimics
mitral regurge
aortic stenosis
HOCM
enlarge IVS
LVOT
myocardial hypertrophy
diastolic dysfunction
prolonged relaxation
ischemia
dysrhthmias
diastolic function causes
decr CPP
is deep or awake extubation better with HOCM
deep
what should you avoid in HOCM
incread outflow obstruction:
- incr myocardial contractility
- decr preload
- decr afterload
what should you favor in HOCM
decreaed outflow obstruction:
- decr myocardial contractility
- incr preload
- incr afterload
what incr myocardial contractility
beta stimulation
digitalis (digoxin)
what decreases preload
hypovolemia
vasodilators
tachycardia
PPV
what decreases afterload
hypotension
vasodilators
what decr myocardial contractility
beta blockade
VA
CCB
what incr preload
hypervolemia
bradycardia
what incr afterload
HTN
alpha stimulation
what drugs are CI with HOCM
ephedrine
dopamine
dobutamine
can you use regional with HOCM
yes - plan ahead for impactys
what can induce LVOT post-op
pain
anxiety
shivering
hypoxia
hypercarbia
broken heart disease
AKA takotsubo
stress cardiomyopathy
how do you manage broken heart disease
like HOCM
when do you use intraortic balloon pump
if stress cardiomyopath is prolonged w/negative effects
what gas is used in IABP
He
what EF triggers need for cardiac transplant
<20%
p wave is transplanted heart
2
-1st is pt
- 2nd is new heart
is elevated or slow HR normal after transplant
slightly elevated
do transplanted hearts respond to alpha and beta stimulation
yes
- indirect mechanisms are delayed
does glyco/atropine work on transplanted heart
no
transplanted heart
no sympathetics
no parasympathetics
no sensory
silent MI
cyclosporine
anti rejection meds
HTN
nephrotoxicity
tacrolimus
nephrotoxic
transplanted heart is dependent on
preload
