APEX Valvular Disease

Question 1

Where to listen to heart valves

Answer 1

Aortic- R sternal border 2IC
pulmonic- L sternal border 2 IC
tricuspid- L sternal border 4IC
mitral- L Midclavicular line 5 IC
Top two- most important- next to eachother (aortic first/pulmonic next)
Bottom two- from R to L just like in real heart

Question 2

Which valvular diseases are associated with eccentric hypertrophy?

Answer 2

Regurg of mitral and aortic

Question 3

Eccentric vs concentric hypertrophy

Answer 3

E-Dilated chamber + thin wall, regurg makes it wider
C- Smaller chamber + thick wall, stenosis makes it grow stronger to push thru

Question 4

Does stenosis or regurg cause concentric hypertophy?

Answer 4

Stenosis

Question 5

What produce sarcomeres in a parallel? in a series? what is it normally?

Answer 5

Concentric hypertophy (think, its thick so sarcomeres are parallel on top of eachother)
Eccentric hypertophy (think, it gets wider so sarcomeres are next to eachother)
Normal- just two sarcomeres

Question 6

Normal area of opening of aortic valve

Answer 6

Normal valve- 2-4cm^2
Stenotic valve- <1cm

Question 7

Causes of aortic stenosis

Answer 7

Most common- calcification of valve leaflets
Rheumatic fever
Infective endocarditis

Question 8

How will aortic stenosis effect PV loop

Answer 8

Increases afterload, makes graph skinny and tall

Question 9

Anesthetic considerations of tachycardia in AS

Answer 9

Cardioversion, BB
Dont speed up heart over 70-80

Question 10

Anesthetic considerations for bradycardia in AS

Answer 10

Atropine
Glycopyrrolate
Ephederine

Question 11

Why is spinal anesthesia avoided in severe aortic stenosis?

Answer 11

Spinal = sympathectomy reduces SVR, causing hypotension, reducing CPP, and causing cardiovascular collapse

Question 12

How does aortic stenosis effect a line tracing?

Answer 12

Pulsus parvus - slow upstroke
Pulses tradus - small pulse pressure, line doesnt go down as low
No dicrotic notch

Question 13

How does chronic aortic regurg look like on LV pressure loop?

Answer 13

Ejection is long af, though SV isnt long bc diastole is super short

Question 14

How does mitral stenosis look on PV loop?

Answer 14

Small square- shifted down and left

Question 15

Conditions that increase aortic regurgitation

Answer 15

Bradycardia (long filling time)
Increased SVR
Large valve orifice

Question 16

How to manage AR

Answer 16

Maintain preload,
Increase HR to decrease filling time
maintain good inotropy
Decrease SVR
Regional anesthesia! decreases afterload and thus regurg amount

Question 17

Aortic regurg effect on a line

Answer 17

(Bisferiens pulse) Biphasic- think the blood is going back to the heart, but has to go back to periphery again

Question 18

Regurg on PV loop vs stenosis on PV loop

Answer 18

r- wide af but not too tall
s- not wide, more skinny since the valves dont open

Question 19

MV size

Answer 19

normal- 4-6cm
Severe stenosis- 1cm

Question 20

Causes of aortic regurg

Answer 20

endocarditis
Aneurysm or trama- aortic root dissection

Question 21

MV stenosis causes

Answer 21

Rheumatic fever
endocarditis
atherosclerosis- calficiation

Question 22

MV stenosis anesthetic management

Answer 22

Slower side of HR
Maintain Preload, inotropy
Dont drop SVR, as it can cause reflec tachycardia
Tret hypotension with phenyl- wont cause increase in hr like ephederine

Question 23

ASSS ARDS MSDA MRSA

Answer 23

aortic stenosis systole murmur- sternal border
aortic regurg diastolic murmur - sternal border
Mitral stenosis diastole- apex
Mitral regurg systole - apex

Question 24

Sapian vs medtronic corevalve

Answer 24

S- requires cardiac standstill (via RVR pacing) to place valve, baloon valvuloplasty
MCV- vave is self expanding, no need for rapid ventricles/cardiac standstill

Question 25

Critical acute complications of improperly placed valve during TAVR?

Answer 25

Wide open aortic regurg

Question 26

How to access for TAVR

Answer 26

Transfemoral
Transaortic
Transapical

Question 27

s1 murmur s2

Answer 27

systolic

Question 28

s1 s2 murmur

Answer 28

diastolic

Question 29

Causes of mitral stenosis murmur

Answer 29

SLE ash
RA
Endocarditis

Question 30

Aortic regurg conditions

Answer 30

Ankylosing spondylitis
Marfan syndrom
Ehler danlos

Question 31

What should be heard with bell of stethoscope?

Answer 31

s3 s4 diastolic murmurs
lower pitch

Question 32

Aortic stenosis hemodynamics

Answer 32

Well tolerates increased SVR bc the valve is already hard to open,

Question 33

TAVR valve options

Answer 33

SAPIAN and medtronic