Congenital Heart Disease Flashcards
1
Q
atresia
A
opening in the body that has been narrowed or closed of valves
2
Q
coarctation
A
narrowing
3
Q
cor pulmonale
A
right ventricular hypertrophy (RVH)
4
Q
infundibulum
A
muscle below the pulmonic valve
5
Q
palliative surgery
A
operation intended to decrease severity of symptoms until pt can tolerate operation to fix condition
6
Q
when is palliative surgery particularly common?
A
pediatric heart operations
7
Q
BT shunt
A
blaylock-taussig shunt
artificial connection between aortic arch and pulmonary artery (artificial ductus arteriosus)
8
Q
infective endocarditis
A
infection of the heart chambers or valves
9
Q
why is the risk of infective endocarditis in patients with congenital heart disease important?
A
prophylactic antibiotics have been recommended for patients who need to undergo operations
(unrepaired, palliated or corrected they all need it)
10
Q
compensating polycythemia
A
abnormally high Hct
-pts with congenital heart disease suffer from hypoxia and they make more red blood cells to compensate
11
Q
what are pts with compensating polycythemia more at risk for?
A
thrombosis
12
Q
paradoxical embolism
A
embolism that travels to the left side of the heart via ASD or VSD and is in arterial circulation (stroke!!)
13
Q
where does a normal embolism travel
A
travel to the lungs and stay on the right side of the heart/pulm artery
14
Q
what do anesthetists need to be very vigilant about when there is a risk for paradoxical embolism?
A
air bubbles in IV line
15
Q
cardiac shunt
A
abnormal blood flow pathways from one side of the heart to another
16
Q
what are the 4 possible cardiac shunts?
A
patent foramen ovale (PFO)
patent ductus arteriosus (PDA)
Atrial septal defect (ASD)
ventricular septal defect (VSD)
17
Q
affect of increase SVR on cardiac shunt
A
more left to right shunt
increase pulmonary blood flow
18
Q
affect of decrease in SVR on cardiac shunt
A
more right to left shunt
worsen hypoxemia
19
Q
affect of increase PVR on cardiac shunt
A
more right to left shunt
worsen hypoxemia
20
Q
affect of decrease PVR on cardiac shunt
A
more left to right shunt
increase pulmonary blood flow
21
Q
are patients with right to left or left to right shunts more prone to have compensating polycythemia?
A
pts with right to left shunt because they have more hypoxia
22
Q
what can the R-to-L shunt/hypoxemia be worsened by?
A
increases in PVR
decreases in SVR
23
Q
what increases PVR?
A
hypoventilation
24
Q
what can we do to decrease PVR?
A
higher FiO2
modest hyperventilation
25
what decreases SVR?
anesthetic agents (regional and general) titrate slowly
26
what induction agent can be used to maintain SVR?
ketamine
27
can you do single shot spinal anesthetic with right to left cardiac shunt?
no it is contraindicated
28
in a right to left cardiac shunt how will the inhalational induction speed change?
slower
blood from R will enter L without picking up agent
dilutes vapor in arterial blood
29
in a right to left cardiac shunt how will the intravenous induction speed change?
faster
| drugs get to the L side of the heart faster
30
in a patient with right to left cadiac shunt what is the alteration to epidural catheter placement?
MUST use saline for loss of resistance
| for risk of air in vein getting into systemic circulation
31
what does the left to right cardiac shunt do to pulmonary blood flow?
promotes excessive pulmonary blood flow
32
what can excessive pulmonary blood flow lead to?
increase PVR
right ventricular hypertrophy
right heart failure
33
what can the L-to-R shunt/pulm congestion be worsened by?
decreases in PVR
| increases in SVR
34
How is the anesthetic inhalation induction effected in the L-to-R shunt?
minimally (if any)
35
how is the anesthetic intravascular induction affected in the L-to-R shunt?
slightly prolonged
| it is slightly diluted
36
how should we change preload in a L-to-R shunt?
preload maintained to limit the amount of left to right shunting
37
eisenmengers syndrome
eventually the pressure in the right heart becomes large enough that the shunt converts to a right to left shunt.
38
is eisenmengers syndrome more likely with high or low PAP?
higher PAP
39
which do you need to be extremely vigilant in preventing intravenous air bubbles? R-to-L shunt or L-to-R shunt?
BOTH
40
when managing a congenital heart disease patient what should you ask?
does this pt have too much pulm blood flow OR not enough pulm blood flow?
what can I do to correct that?
41
if the patient has too much pulm blood flow how can we decrease left to right shunting?
increase PVR
hypoventilate
lower fiO2
decrease SVR
42
if the patient doesnt have enough pulm blood flow how can we improve left to right shunting?
increase SVR
decrease PVR
hyperventilate
increase Fio2
43
patent ductus arteriosus
ductus arteriosus never closed after birth
| **some congenital heart disease having a PDA is necessary for survival
44
before birth how does the blood flow through the ductus arteriosus?
right to left shunt
45
after birth how does the blood flow through the ductus arteriosus?
left to right shunt
46
if no other defects are present how should blood flow through the PDA?
left to right
| increasing pulm blood flow
47
what is different about a patient with a PDAs blood pressure?
low diastolic blood pressure
48
anesthetic management of pt with PDA 3
1 measures to decrease left to right shunt and limit pulmonary congestion
2 up to 3 doses of indomethacin to close PDA
3 invasive monitoring is not essential in uncomplicated PDA
49
what should the fiO2 and PaCO2 be for a patient with a PDA?
low FiO2
| PaCO2 40-50mmHg
50
surgical repair of PDA
ligation via left VATS
51
preductal circulation
blood flow to areas of the body proximal to the ductus arteriosus
52
postductal circulation
blood flow to areas of the body distal to the ductus arteriosus
53
if the ductal connection is distal to the subclavian then the preductal circulation includes 3
```
head (left common carotid)
right arm (brachiocephalic)
left arm (left subclavian)
```
54
if the ductal connection is distal to the subclavian then the postductal circulation includes
lower extremities and abdomen
55
if the ductal connection is proximal to the subclavian then the preductal circulation includes 2
head
| right arm
56
if the ductal connection is proximal to the subclavian then the postductal circulation includes
left arm
| lower extremities and abdomen
57
where should you take a preductal blood sample from?
RIGHT radial artery
58
where should you take a postductal blood sample from?
artery in leg: femoral, dorsalis pedis, or posterior tibial artery
59
if preductal oxygen saturation is significantly different from postductal oxygen saturation what does that suggest?
a heart defect with right to left shunting across a PDA
60
Patient foramen ovale
foramen ovale never closed after birth
61
how is blood expected to shunt in a PFO?
left to right
62
anesthetic management for patient with PFO 2
1 decrease left to right shunting to limit pulmonary congestion
2 should not allow any air in IV
63
surgical repair of PFO
intravascular right atrial disc deployed
64
atrial septal defect
ASD is hole between right and left atria
| LARGER PFO
65
anesthetic management of pt with ASD
higher preload
elevated PVR
lower SVR
66
ventricular septal defect
hole between left and right ventricles
67
anesthetic management of pt with VSD
higher preload
elevated PVR
lower SVR
68
surgical repair of VSD
open surgery with a patch placed
69
Ebsteins Anomaly
malformation of tricuspid valve that results in tricuspid regurg= high right atrial pressure and right atrial enlargement
70
what other defect is more likely to occur when the pt has ebsteins anomaly
ASD (perforated foramen ovale)
| Right to left shunt
71
how does blood shunt with ebsteins anomaly and ASD?
right to left
72
anesthetic management of ebsteins anomaly
```
decrease PVR
increase SVR
hyperventilate
supplementary oxygen
avoid air bubbles in IV line at all costs
```
73
what will the patients SpO2 be for ebsteins anomaly with ASD?
lower b/c it is mixed venous/arterial blood
74
what would the hypoxemia in ebsteins anomaly cause?
compensating polycythemia
75
eisenmengers syndrome
left to right shunt reverses into a right to left shunt
76
clinical implication of eisenmengers syndrome
once it develops cyanosis ensures with varying degrees of heart failure
HIGH RISK for surgery
77
anesthetic management for left to right shunts that have possible eisenmengers physiology 3
1 maintain SVR and PVR
2 fine balance managing oxygenation
3 single shot spinal is contraindicated
78
coarctation of aorta
narrowing of the aorta distal to the left subclavian artery
79
postductal coartation of the aorta %
more common 95% of cases
80
what will a coarctation of the aorta do to cardiac output? what does this lead to?
severe decrease
| poor peripheral perfusion, metabolic acidosis, high afterload, CHF, aortic regurg
81
what will be the difference in blood pressures from the upper extremities and lower extremities in coarctation of the aorta
BP in upper extremities will be HIGHER than the lower extremities
82
if the patient has a preductal coarctation of the aorta then what other defect is vital to increase CO?
PDA to boost CO via right to left shunt
83
if the patient has a preductal coarctation of the aorta and PDA what is the affect on SpO2 for the upper and lower extremities?
```
upper= normal sp02
lower= low sp02
```
84
anesthetic management for coarctation of aorta
SVR maintained
preload maintained
bradycardia avoided
avoid abnormally high contractility or HR
85
what will increase the risk of aortic dissection in a pt with coarctation of the aorta?
abnormally high contractility or HR
86
2 options for surgical repair of coarctation of the aorta
balloon angioplasty
| resection with end to end anastamosis
87
interrupted aortic arch
aorta isnt fully developed and there is a gap between ascending and descending aorta
88
in order for a pt with interrupted aortic arch to survive what two other defects must they have?
PDA
| ASD or VSD
89
where does the oxygenated blood from the left ventricle perfuse? interrupted aortic arch pt
right upper extremity and part of the head
90
where does blood flow to the lower extremities come from in a pt with interrupted aortic arch?
right ventricle through PDA
| mixed venous/arterial blood
91
how do the blood pressure, pulse and spO2 differ from right arm to left arm
normally higher in the right because the interruption is usually proximal to the left subclavian
92
anesthetic management for interrupted aortic arch
```
keep ductus arteriosus patent
maintain preload
maintain SVR
maintain HR (avoid tachy and brady)
```
93
surgical repair for interrupted aortic arch
aorta 1 attached to aorta 2
| PDA and VSD closed
94
what are the 4 defects of tetralogy of fallot?
1 pulmonic stenosis (right ventricular outflow tract obstruction RVOT)
2 right ventricular hypertrophy
3 VSD
4 overriding aorta
95
in tetralogy of fallot how does the blood shunt?
right to left across the VSD
96
what type of blood is perfusing the body through the overriding aorta in TOF patient
mixed venous/arterial blood and has a lower than expected sp02
97
what are the 2 reasons that pulmonary blood flow is limited in a TOF pt?
1 pulm valve is stenotic
| 2 infundibulum is abnormal and causes stenosis below the valve as well
98
what are the two ways for blood to get to the lungs in patients with TOF?
stenotic pulm valve
| PDA (left to right shunt)
99
is a PDA necessary for life sustaining pulm blood flow in a patient with TOF?
YES
100
what are the two reasons that patients with TOF are hypoxic?
blood flow to lungs is limited
| blood flowing through aorta is mixed venous/arterial blood
101
what are the two primary ways to improve pulmonary blood flow and decrease hypoxia in patients with TOF?
1 keep PDA open
2 decrease amount of right to left shunt
(maintain/elevate SVR; keep PVR low)
102
tet spell
sudden onset life threatening hypoxic spell in pts with TOF
103
what are tet spells caused by
infundibular spasm
| subsequent increase in right to left shunt
104
pt that is experiencing a tet spell can do what at home to help?
squat or use valsalva maneuver
105
causes of infundibular spasm 3
1 tachycardia and increases in contractility
2 hyperventilation (with spontaneous ventilation)
3 hypovolemia
106
why does spontaneous hyperventilation cause an infundibular spasm?
decreases intrathoracic pressure with increases venous return and increases right to left shunt
107
how does hypovolemia cause a infundibular spasm?
underfilled heart decreases diameter of RVOT
108
treatment for tet spell 7
1- 100% O2
2- child in a knee chest position
3- fluid bolus to enhance preload
4- consider ketamine or phenylephrine increase SVR
5- consider moderate hyperventilation mechanically reduce PVR
6- consider beta blocker
7- avoid beta agonists when trying to raise blood pressure
109
anesthetic managment for tetralogy of fallot 7
1- PDA kept open
2- promote pulm blood flow and minimize right to left shunt
3- hypotension avoided on induction
4- phenylephrine or ketamine when cyanotic
5- sympathetic stimulation minimized
6- avoid air bubble in IV line
7- preload maintained/elevated with volume
110
surgical repair of TOF
initially BT shunt placed in palliative surgery
| eventually surgery to repair VSD and repair/replace pulmonic valve
111
TGA
transposition of the great arteries
RV pumps to aorta
LV pumps to pulm artery
