Cardiac exam 2 Flashcards
Aortic Stenosis is what kind of murmur?
systolic
heard at R 2nd ICS
Nearly always occurs as a delayed complication of acute rheumatic fever
Mitral stenosis
Mitral stenosis can enlarge the L atrium and this can apply pressure to the RLN and cause what?
hoarseness
What do you want the HR to be with Mitral stenosis?
60-90 to allow diastolic filling, regular rhythm.
What heart rates do you want to avoid with mitral stenosis?
Tachycardia for sure, also bradycardia.
You want the heat rhythm normal
can pancuronium cause bradycardia or tachycardia?
tachycardia thus avoid use if someone has Mitral stenosis.
Patients with cyanotic heart disease, what type of minute ventilation and carbon dioxide levels do they have?
(what is their response to CO2 and low O2?)
increased minute ventilation and maintain normocarbia.
They have a normal ventilatory response to hypercapnia but a blunted response to hypoxemia.
What is Eisenmenger’s syndrome?
Congenital heart defect when a left to right shunt causes increased flow through the pulmonary vasculature causing pulmonary hypertension which in turn causes increased pressure in the right side of the heart and reverse the shunt into a right to left shunt.
cyanotic heart defect
*When do cardiac complications, spontaneous abortions, premature delivery, thrombolic complications, peripartum endocarditis typically occur if you you have a CHD?
presenting usually in the last month of pregnancy.
Can a pregnant lady have cardioversion performed?
could be safe with close fetal monitoring.
What type of hypertrophy is Aortic stenosis, concentric or eccentric?
Concentric (pressure)
What is the most common cause of obstruction to left ventricular outflow?
Aortic stenosis
What is the size of a normal aortic valve and what is the size of a severely stenosed valve?
Aortic valve is normally 2.5 - 3.5 cm2
sever stenosis is less than or equal to 1.0 cm2
What is the problem with losing your atrial kick if you have aortic stenosis?
decreases ventricular filling and would lead to a reduction of 40% in CO
Aortic Stenosis: HR?
maintain low HR (60-90 bpm) avoid bradycardia and tachycardia b/c SV is fixed
Aortic Stenosis: Rhythm?
NSR (very important) do not want a junctional rhythm or a fib bc that gets rid of the atrial kick they so desperately need to maintain.
AS: Preload?
maintain and optimize (very important)
What changes do you want to AVOID with aortic stenosis?
AVOID:
hypotension (treat with small doses of Phenylephrine (neo))
Decreases in CO
Tachycardia
What is the deal with spinals and epidurals with AS?
Spinals and epidurals are contraindicated in severe aortic stenosis. (risk for hypotension)
but
mild to moderate stenosis may tolerate spinal or epidural (epidural better)
With AS what will you treat bradycardia, tachycardia, SVT, and Ventricular dysrhythmias with?
Brady = atropine
Tachy = esmolol
SVT/V dys. = Amiodarone
What type of lesion is Aortic stenosis?
Obstructive
Coarctation of aorta is what type of lesion and located where typically?
obstructive and located in the descending aorta
In preductal (infantile) coarctation of aorta what is the perfusion difference between the upper and lower body?
Lower half is cyanotic… perfusion to upper half is derived from aorta, while perfusion to lower half is derived primarily from pulmonary artery.
The lower body below the point of coarctation.
What CHD is described: HTN in upper extremities with bounding pulses and hypotension of lower extremities with weak or absent pulses?
Coarctation of aorta
Pulmonic stenosis is what type of lesion?
obstructive
With pulmonic stenosis how do you want their HR, preload, and PVR?
HR = normal or slightly elevated
Preload = augment
PVR = avoid factors that increase (hypoxia, acidosis)
Symptoms of PS?
same as right ventricular HF
What type of hypertrophy does pulmonic stenosis cause?
concentric bc it is pressure related.
What type of shunt is ASD?
Left to right (simple) shunt between the two atria. Not cyanotic.
Duchenne muscular dystrophy is what cardiomyopathy?
Dilated cardiomyopathy
quiz question about obstructive cardiomyopathy and you had to choose 3 that were true?
a. Increase preload
b. Increase afterload
c. Decrease contractility
What age group is restrictive cardiomyopathies rare in?
rare in children
Five physical traits that are true about a person presenting with Marfan syndrome?
Tall and slender disproportionate arms and legs high arch palate and crowned teeth heart murmurs are common flat feet
Question on quiz about Tricuspid atresia, choose 3 that are true?
a. Cyanosis is usually present at birth
b. Early survival is depend on prostaglandin E1 infusion
c. Success of the fontan procedure is reliant upon low PVR and low atrial pressure
*What is the formula for SV?
SV = EDV-ESV
Mediastinoscopy question on quiz, choose the one that is false.
Patients with lung cancer may have Eaton-Lambert syndrome with sensitivity to NDMR and Depolarizers
b. The most severe complication of mediastinoscopy is major hemorrhage
c. A bronchial blocker can be used to provide lung isolation in the event of an emergency
d. Prior mediastinoscopy is not an absolute contraindication to the procedure.
D is false, prior mediastinoscopy is a MAJOR CONTRAINDICATION
What do you want to be sure and avoid in a patient with ASD?
air in IV tubing!
T/F : In VSD recurrent pulmonary infections are common?
True
Hypertrophic obstruction is worsened by?
Catecholamines (b/c it increases contractility)
All of the following are appropriate treatments for hyper cyanotic spells EXCEPT?
a. Esmolol
b. Propranolol
c. Fluids and phenylephrine
d. Ephedrine and epinephrine
e. Knees to chest
D. Ephedrine and epinephrine
T/F neo-synephrine is preferred over ephedrine for mitral stenosis?
True
Decreased afterload on a PV loop would be represented by what size loop?
smallest loop
T/F, Decreased PVR will increase right to left shunt in TOF?
False, it will not increase right to left shunt in TOF
SV is fixed in what Heart defect?
AS
Describes situations in which left-to-right intracardiac shunts are reversed d/t increased PVR levels equal to or greater than SVR?
Eisenmenger’s syndrome
increase in SVR will make a left to right shunt better or worse?
worsens left to right shunting.
if the pressure to leave the heart is increased then the blood will not leave and thus shunt more from left to right
What do volatile anesthetics do to SVR?
decrease SVR
What two things will decrease left to right shunt? (ASD or VSD)
Volatile anesthetics because they decrease SVR and increases in PRV.
Most common CHD? (25%-35% of CHD)
VSD (left to right shunt)
Most pts are asymptomatic, but have a loud pan-systolic murmur along left sternal border describes what CHD?
VSD
decreasing SVR and increasing PVR is what you want to occur with which CHD?
ASD and VSD (left to right shunts)
What types of shunts are considered cyanotic?
right to left
If PVR increases in a person with a left to right shunt what will happen?
you will have bi direction flow of blood (causing arterial hypoxemia to some degree).
If a left to right shunt changes to a right to left shunt then it is called Eisenmenger’s syndrome
When do you see clubbing and cyanosis?
reversal of left to right shunt into a right to left shunt… known as Eisenmenger’s syndrome
Common lesion in patients with Down syndrome?
Atrioventricular Septal Defects
left to right shunt that has increasing pulmonary HTN will do what?
become a right to left shunt = cyanosis
What medication may result in PDA closure?
Indomethacin
Which shunt type has an excellent clinical course and prognosis?
PAVR
partial anomalous venous return
Most common cyanotic defect is?
TOF
TOF is characterized by 4 lesions, what are they?
pulmonary stenosis (right ventricular outflow obstruction)
overriding aorta
VSD
right ventricular hypertrophy
What is IV prostaglandin E1 used for?
prevention of PDA closure
20-25% (about a quarter) of TOF pts. also have what issue?
pulmonic stenosis
When a child has a TET spell what is occurring?
hypercyanotic attack
typically associated with crying which increases Pulmonary vascular resistance and thus less de-oxygenated blood is going through the pulmonary artery and instead is going through the aorta which causes more mixed blood and more mixed with de-oxygenated blood to go out to the rest of the body.
What can increase the amount of de-oxygenated blood (right sided blood) going through the aorta in TOF?
Increased PVR due to airway obstruction, acidosis, crying.
Decreased SVR due to peripheral vasodilation.
Decreased blood volume, decreased CO due to dehydration.
Increased O2 requirements due to infection.
What is common in children with sever TOF?
CVA
Treatment for TET spells in TOF?
hyperventilate with 100% Fi02 bolus neo 5-20mcg/kg as needed (vasoconstriction) volume infusion 10-20ml/kg b-blockers morphine
If you have tricuspid atresia what does this mean?
tricuspid valve is not developed and blocked which means you do not have a R ventricle, instead just a useless R Ventricle sac. Thus you must have PDA or VSD to get blood flow from L ventricle into pulmonary artery for pulmonary circulation.
Early survival with tricuspid atresia is dependent on?
Prostaglandin E1
What is the preferred surgical management with tricuspid atresia?
Fontan procedure
In TOF how do you want your PVR?
AVOID increases in PVR because you want less resistance so that the blood flows into the pulmonary artery.
In TOF the goal of anesthetic management is to do what with the intravascular volume and SVR?
MAINTAIN intravascular volume and SVR! Do not decrease SVR because then the blood will flow more easily into the aorta from the R ventricle and it is not oxygenated, you need the blood to want to go into the pulmonary artery so it can pick up oxygen.
What is a common induction agent used for patients with TOF because it maintains SVR?
Ketamine
What drugs decrease SVR?
What does a decrease in SVR do to a TOF patient?
Inhalation agents
alpha adrenergic blockers
ganglionic blockers
peripheral dilation drugs
increases right to left shunt and accentuate arterial hypoxemia… however is beta blocker therapy is indicated… maintain therapy.
What does a right to left shunt do to inhalation agents compared to IV anesthetics?
right to left shunt usually slows the uptake of inhalation anesthetics but may ACCELERATE onset of IV anesthetics.
(inhalation agents work by blood-alveoli-brain, thus if you are skipping the alveoli due to the right to left shunt then brain concentration will not be reached as quickly and have a slower uptake)
What does histamine do to SVR?
Thus what drugs should be avoided with a right to left shunt due to histamine release?
Decreases SVR, thus muscle relaxants/drugs should be AVOIDED.
Are inhalation agents recommended with right to left shunts such as TOF??
NOT recommended
Why will you avoid IM drugs in a child with TOF?
IM drugs will make the child cry and crying will likely cause a TET spell and make the child cyanotic.
What drug is effective in treating infundibular spasm?
propranolol (beta blocker)
Success of the modified Fontan procedure for Tricuspid Atresia is dependent upon what?
high systemic venous pressure and maintaining both low PVR and low left atrial pressure.
Is a heart transplant ALWAYS necessary for a failed Fontan procedure?
NO, but it may be necessary.
early survival in TA is dependent on?
prostaglandin E1 infusion
What kind of blood is pumped to the body in tricuspid atresia?
MIXED blood (purple)
What kind of blood is pumped to the body in TOF?
MIXED blood (purple)
Survival in a patient who has TGA (transposition of the great arteries) is only possible if what is present?
Survival is only possible through mixing of oxygenated and deoxygenated blood across the foramen ovale and a PDA.
Transposition of the great arteries affects which ventricle compared to TOF?
TGA affects the Left ventricle where TOF affects the R ventricle.
What is Total anomalous pulmonary venous return?
When all four pulmonary veins connect to the superior vena cava
In truncus arteriosus after birth the PVR gradually decreases and pulmonary blood flow increases resulting in?
Heart Failure
In HLHS systemic blood flow is dependent on PDA thus how do you maintain the PDA and make sure it does not close?
infuse PGE-1 to maintain PDA open.
Pulmonary HTN is defined as?
pulmonary capillary pressure greater than 25 mm Hg
90% of patients with mitral stenosis also have what two issues?
CHF and A-fib (promotes clot formation in left atria)
With stenosis (mitral or aortic) you want to avoid?
tachycardia too much fluid or too little spinals and most of the time epidurals ketamine large increases in CO
(maintain Sinus rhythm (60-90), and neo is preferred over ephedrine as vasopressor due to its lack of beta agonist activity)
In MS if you have a-fib what medication will you control it with?
diltiazem or digoxin
Really, between aortic stenosis and mitral stenosis the only minor difference is in the preload … what is the difference?
AS = maintain and optimize preload MS = maintain bc excessive preload may cause pulmonary edema.
In mitral regurgitation what do you want to change about the SVR?
afterload reduction (reducing SVR) increases forward flow and reduces regurgitation volume
(if the SVR is reduced then the LV does not have to pump blood against as much resistance and thus less blood is likely to go back through the incompetent mitral valve)
Symptomatic progression of MR: what is the % for mild, moderate, and sever symptoms?
Regurgitant factors < 30%= mild symptoms
Regurgitant factors 30-60%= moderate symptoms
Regurgitant factors > 60%= severe symptoms
Ideal HR for MR?
80-100
Preload for MR?
vasodilators and diuretics can be helpful if not used in extremes, you want to maintain adequate volume to maintain forward stroke volume. Thus some preload reduction is ok
How do inotropes and vasodilators help with MR?
Inotropes increase contractility, vasodilators decrease afterload and these changes allow for improved forward flow
What HR MUST you avoid in MR?
BRADYCARDIA
can you use epidurals and spinals in a MR patient?
yes, well tolerated as long as you avoid bradycardia.
When can you use pancuronium + fentanyl for induction?
MR
Marfan syndrome has a high incidence of what valvular heart dz?
Mitral valve prolapse
factors that decrease ventricular size and thus would be worse for MVP that has MR? (what do you want to avoid)
HYPOVOLEMIA
increased sympathetic tone
decreased afterload
With valvular heart disease if a patient has a systolic murmur that puts them at greater risk for?
infective endocarditis
