Ch. 5 Valve Surgery & Procedures Flashcards
The Av valves are open during:
Closed during:
Semilunar valves are open during:
Closed during:
- Diastole
- Systole
- Systole
- Diastole
Chordae Tendinae & Papillary muscle
* Where are they located
- Attached only to AV valves
2 Causes of Murmurs
- Stenosis: forward flow of blood through narrow stenotic open valves
- Insufficiency: Backward flow through incompletely closed valves
Aortic Insufficiency (reguirgitation)
* Hemodynamic changes
* what type of HF is this
* symptoms - what type of murmur
* DeMusset sign
- Volume and pressure overload, sig increased LV volume, SVx3, Wide pulse pressure, hammer pulse w tall shortened peak,
- This is Diastolic HF
- Warm and flushed, pulsatile sensation, cardiogenic shock, dyspnea, angina, Diastolic murmur
- DeMusset sign is a type of rhythmic nodding or bobbing of the head in time with the heart beat
Aortic insufficiency (regurgitation)
* Causes
* when to do surgery
* Treatment
* contraindicated
- slow development of worsening HTN, rheumatic heart disease, bicuspid aortic valve, marfan’s syndrome, idiopathic
- Valve replacement is preferred over repair. Surgical intervention when EF<50%, or when the heart gets too big
- Inotropes, vasodilators, surgery
- IABP contraindicated
How many cusps does each valve have?
The semilunar valves both have 3 cusps. The AV valves have leaflets and the mitral valve is the only valve with 2 parts (2 leaflets)
As the heart grows in hypertrophy it becomes more stiff and dependent on:
Preload
Aortic Stenosis
* Hemodynamic changes
* Symptoms
* Treatment (3)
- High afterload/SVR, left ventricular hypertrophy, diastolic dysfunction which can progress to systolic dysfunction,
- Exertional dyspnea, Angina, Syncope, increased O2 demands, sudden cardiac death
- Replacement over repair Median sternotomy with CPB, minimally invasive, TAVR
Aortic Stenosis severity
* Mild AS gradient in mmHg
* Moderate AS gradient
* Severe AS gradient
- Mean gradient <25 mm Hg
- Mean gradient 25-40 mmHg
- Mean gradient >40 mm Hg
TAVR - Transcatheter Aortic Valve Replacement
* Definition
* What to monitor for post-surgery
* Key post-op management
- Low, moderate or high-risk patients, replace aortic valve while heart is still beating
- Monitor for bleeding @ insertion site (usually femoral), signs of stroke, bradycardia, signs of heart block
- manage BP and avoid hypertension, LVH and stiffness remains, avoid inotropes since their LV will likely be hyperdynamic with the fixed valve, control HR, may need pacing since AV is near bundle of HIS
Mitral Insufficiency (regurg)
* Definition
* Causes
* Symptoms, which murmur
* Treamtnet
- This is retrograde flow of blood during ventricular systole
- MI - esp anteroseptal wall mi, ruptured chordae tendinae, endocarditis, severe LHF, LVH, MV prolapse, rheumatic heart disease
- Systolic murmur, orthopnea/dyspnea, lung congestion, pulm HTN, fatigue, angina, increased LA pressure, RHF, high RV pressure, prone to atrial fib d/t LA enlargement/dilation, LVF over time
- Mitraclip w/ no long term anticoagulation, replacement
Mitral Stenosis
* Causes
* Symptoms
* Treatment
- Rheumatic heart disease, Luipus, Radiation therapy, Amyloid disease, Pulm HTN
- Pinkish cheeks, pulm edema, Prone to afib d/t atrial enlargement, may have R heart and pulm congestion issues like pulm htn
- Ace inhibitors, balloon valvuloplasty to widen placque, commissurotomy, surgical replacement
Mitral Stenosis
* Causes
* Symptoms - what type of murmur
* Treatment
* what is commissurotomy
- Rheumatic heart disease usually, lupus, radiation therapy, amyloid disease
- Occurs when valve is open during diastole (diastolic murmur), Pinkish cheeks, Pulm edema, prone to afib d/t LA enlargement, pulm HTN, increased LA dn PA pressures
- Medical management with ace inhibitors, balloon valvuloplasty to widen placque, commissurotomy, surgical replacement
- procedure involves cutting through a band of muscle or nerve fibers, usually in the heart or brain to improve blood flow
MV stenosis medical management
* Monitor for
* Treatment
- RV failure, increasing CVP, RAP, RHF
- maintain adequate preload, may need diuretics, inotrope like milrinone, manage atrial fibrillation and tachycardia
Tricuspid valve Regurgitation/Insufficiency
* primary and secondary causes
* symptoms
* treatment
- Primary causes: congenital, rheumatic heard disease, infective endocarditis, blutn trauma, tumor
- Secondary causes: Pulm HTN, RV dilation/failure (RV systolic >55 mmHg), mitral/aortic valve dysfunction,
- Increased RAP/size, RHF, fatigue, peripheral edema from backup of fluid, hepatomegaly/ascites, weight loss, jaundice, atrial fibrillation
- Diuretics, meds to reduce Pulm HTN (sildenfail, flolan), Valve repair or replacement
Tricuspid stenosis
* How rare is this?
* Primary causes
* symptoms
* Treatment
* Treatment concerns
* tissue vs mechanical
- Very rare, <1% population
- Primary causes: RHD with MV disease, endocarditis, intracardiac tumors
- Right heart failure, Decreased CO, fatigue, edema, hepatomegaly/ascites, dyspnea
- Annuloplasty band, Tricuspid valve repair, Perc balloon commissurotomy, valve replacement
- concerns: injury to RCA or AV node,
- No difference in outcomes tissue vs mechanical
Endocarditis
* Definition
* Causes
* At risk patients
* Symptoms
- Infection of the endocardium or valve, damaged leaflets
- Caused by IV drug abuse, HIV, MV prolapse, trauma, bacteria from other sources, prosthetic valve endocarditis ~30% of cases
- At risk patients: cardiac surgery, rheumatic heart disease, dental procedures, IV lines, IVDA
- Fever, bacteremia (white count), stroke, petechiae, osler’s nodes, purpura - janeway lesions, hematuria, murmur, pulsus paradoxus, splinter hemorrhages on nailbeds
Osler Node
* definition
Painful, red, raised lesions that appear on the hands and feet. This is a cutaneous manifestation of endocarditis.
Janeway lesion
* definition
Rare, non-tender, small erythematous or haemorrhagic macular, papular or nodular lesions on the palms or soles only a few millimeters in diameter that are associated with infective endocarditis
Pericarditis
* Definition
* Constrictive vs. Restrictive
* Causes
* Dressler’s syndrome
- Acute or chronic inflammation of the pericardial sac
- Constrictive: Fibrous deposits on the pericardium
- Restrictive: effusions into the pericardial sac
- Caused by acute MI (10-15% of MI cases), post-CABG, connective tissue disease, infection
- Dressler’s syondrome: Pericarditis 2 - 12 weeks after MI, believed to occur as the result of the immune system responding to damage heart tissue or pericardium. The damage can result from a heart attack, surgery or traumatic injury.
Pericarditis
* Symptoms
* Treatment
- Chest pain - pain improved with sitting up or leaning forward, Pleuritic chest pain - worse with cough, positional changes and inspiration, Non-specific ST changes, pericardial effusion/tamponade, fever
- Time, Anti-inflammatory meds, corticosteroids, antibiotics if bacterial, **monitor for effusions which can lead to tamponade
Myocarditis
* Definition
* Clinical signs
* Treatment
- Focal or diffuse inflammation of the myocardium due to viral or bacterial infection
- Fever, chest pain, heart failure, dysrhythmiias, sudden cardiac death, may be accompanied by pericarditis/pericardial friction rub
- Antibiotics if bacterial, NSAIDs, diuretics, inotropes, ACE inhibitor
