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APEX-CV & Respiratory > CV valvular heart disease > Flashcards

CV valvular heart disease Flashcards

1
Q

What do the heart sounds coincide with

A

Heart valve closure

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2
Q

What are the 4 heart sounds (S)

What do they represent

A 
S1 = closure of mitral and tricuspid valve
S2 = closure of aortic and pulmonic valve
S3 = suggests CHF
S4 = suggests poor ventricular compliance
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3
Q 
Where is each valve best auscultated
Aortic valve
Pulmonic valve
Mitral valve
Tricuspid valve
A

Aortic valve = right sternal border at 2nd ICS
Pulmonic valve = left sternal border at 2nd ICS
Mitral valve = left midclavicular line at 5th ICS
Tricuspid valve = left sternal border at 4th ICS

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4
Q

When is S3 and S4 heard

A

During diastole when MV is open

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5
Q

When are S1 and S2 heard

A 
S1 = onset of systole
S2 = onset of diastole
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6
Q

What type of hypertrophy do regurgitant valves tend to produce.
Why

A

eccentric hypertrophy
(thin wall + dilated chamber)
Sarcomeres added in series
due to volume overload during diastole

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7
Q

What type of hypertrophy do stenotic valves tend to produce.

Why

A

concentric hypertrophy
(thick wall + small chamber)
sarcomeres added in parallel
due to pressure overload during systole

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8
Q

Definition of valvular stenosis

A

fixed obstruction to forward flow requiring higher pressure to overcome transvalvular pressure gradient

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9
Q

Definition of valvular regurgitation

A

incompetent valve allows blood to flow forward and backward during diastole. chamber radius increases to allow for greater volume

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10
Q

Normal size of aortic valve

What size is the AV valve to be considered severe

A

normal = 2.5 - 3.5 cm^2

Severe = <0.8 cm^2

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11
Q

3 common etiologies of aortic stenosis

A

Bicuspid aortic valve
Rheumatic fever
Infective endocarditis

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12
Q

What are 3 compensatory mechanisms of the LV in the presence of aortic stenosis

A

Increased LV wall thickness
Decreased compliance
Small chamber radius

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13
Q

50% survival rate for AS when pt presents with syncope, angina, or dyspnea, respectively

A 
syncope = 3 yrs
angina = 5 yrs
dyspnea = 2 yrs
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14
Q 
Anesthetic goals for aortic stenosis
HR
Rhythm
Preload
Afterload
Contractility
PVR
A 
HR = avoid tachycardia
Rhythm = NSR (atrial kick)
Preload = Increase (to overcome pressures)
Afterload = maintain or increase
Contractility = maintain
PVR = normal
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15
Q

What type of anesthesia should be avoided in pts with aortic stenosis? Why?

A

spinal anesthesia b/c increased risk for CV collapse d/t sympathectomy

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16
Q

What type of arterial waveform is noted with aortic stenosis

A

pulsus tardus (slow systolic upstroke and delayed peak) or pulsus parvus (narrow pulse pressure with small amplitude waveform)

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17
Q

What is the mean transvalvular pressure gradient that qualifies as severe AS

A

> 40 mmHg between LV and aorta

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18
Q

What is CO dependent on in the patient with AS

A

CO is HR dependent

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19
Q

What happens to SVR in pts with AS and how does this affect CPP

A

SVR is decreased

This reduces CPP

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20
Q

What type of hypertrophy occurs with AS?

What are the characteristics of this type of hypertrophy

A

concentric hypertrophy

Thick LV wall
Decreased compliance
Smaller chamber radius

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21
Q

How does the pressure-volume loop change in the patient with AS

A

Loop height increases
ESV shifts right
EDV shifts right

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22
Q

How is the subendocardium at risk in the patient with AS

A

Reduced O2 supply d/t compression

Increases risk for MI, LV failure, pulmonary edema

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23
Q

What benefits does aortic valve replacement produce in patients with AV stenosis

A
  1. decreases afterload
  2. decreases LV-Ao gradient
  3. Decreases LV-ESV
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24
Q

Why is NSR important in patients with AS

A

Atrial kick allows for adequate ventricular filling and stroke volume
Tachycardia decreases LV filling time and SV/CO

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25
Q

How can tachycardia be treated in patients with AS

A

Synchronized cardioversion
Beta-blockade

Avoid medications that produce tachycardia

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26
Q

How can bradycardia be risky in patients with AS

A

decreased HR allows for LV over-distension from volume. This causes compression of subendocardium and decreases O2 supply

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27
Q

Why is preload important in the patient with AS? What measures are used to increase preload?

A

Adequate LVEDP is required to fill the non-compliant LV

Give IVF to ensure adequate intravascular volume

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28
Q

Why is it important to maintain or increase SVR in patients with AS

A

Stroke volume is fixed d/t the stenotic aortic valve
This means CO is dependent on HR
If pt becomes hypotensive, Ao root pressure drops and decreases CPP leading to MI

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29
Q

What medications are best for HoTN in patients with AS? Why

A

Alpha-1 agonist

This increases SVR and CPP but not HR

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30
Q

What effect does CPR have in patients with AS

A

Chest compressions won’t generate sufficient intracardiac pressure to overcome stenotic valve

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31
Q

When is increased PVR concerning in patients with AS and why

A

Late in the disease process

Diastolic failure leads to increased LAP, pulmonary congestion and dyspnea

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32
Q

Define:
Pulsus tardus
Pulses parvus

A

Pulsus tardus = arterial waveform with slow systolic upstroke and delayed peak

Pulsus parvus = narrow pulse pressure with small amplitude waveform

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33
Q

When a patient with aortic regurgitation is receiving cardioplegia, how is this given

A

Retrograde, via the coronary sinus

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34
Q 
Describe the anesthetic goals for each in the patient with aortic insufficiency
HR
Rhythm
Preload
Afterload
Contractility
PVR
A 
HR = increased
Rhythm = NSR
Preload = maintain or increase
Afterload = decrease (improves forward flow)
Contractility = maintain
PVR = maintain
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35
Q

How does the arterial waveform appear in patients with aortic insufficiency

A

Increased pulse pressure with bisferiens pulse

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36
Q

What are 2 etiologies of aortic regurgitation

A

Incompetent valve

dilation of the aortic root

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37
Q

What happens to stroke volume in patients with aortic regurgitation

A

it is decreased because a portion returns to the LV instead of forward into the aorta

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38
Q

How is ESV affect in patients with aortic insufficiency

A

It increases during isovolumetric relaxation

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39
Q

How does the pressure-volume loop change in patients with aortic regurgitation

A

The loop becomes wider

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40
Q

How does the pressure-volume loop compare for acute vs chronic aortic regurgitation

A

the acute loop is smaller and shifted right

the chronic loop is larger and wider

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41
Q

What conditions increase regurgitant volume and how

A 
Bradycardia (longer diastolic filling time)
Increased SVR (Ao-LV pressure gradient)
Large valve orifice (larger area for blood to return)
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42
Q

How does each factor increase regurgitant volume in aortic insufficiency

Bradycardia
Increased SVR
Large valve orifice

A

Bradycardia = longer diastolic filling time for more volume

Increased SVR = increased aorta-LV pressure gradient

Large valve orifice = larger area for blood to return through

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43
Q

How does the LV compensate in patients with aortic insufficiency

A

Through eccentric hypertrophy aka LV dilation.

The chamber radius increases to preserve stroke volume and contractility

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44
Q

How is CPP altered in patients with aortic insufficiency

A

Decreased

d/t decreased aortic DBP and increased LVEDP

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45
Q

What conditions are associated with chronic aortic regurgitation

A

Valvular calcification
Marfan syndrome
Ehler-Danlos syndrome
Ankylosing spondylitis

46
Q

Why should preload be maintained or increased in patients with aortic insufficiency

A

Because some of the stroke volume is lost to the LV

Avoid hypovolemia, fluid resusitate

47
Q

Why is a faster HR preferred in patients with aortic regurgitation

A

Increased HR = less time for regurgitant volume backflow, increased AoDBP and CPP

48
Q

Why should low HR be avoided in patients with aortic regurgitation

A

Low HR allows more time for volume backflow into LV
Reduces cardiac output
Decreases CPP d/t decreased Ao root pressure

49
Q

How should SVR be maintained in patients with aortic regurgitation and why

A

Decrease SVR

Allows for forward flow d/t decreased afterload pressure

50
Q

Which medications are used to reduce SVR in patients with aortic insufficiency

A

Phenylephrine or vasopressin (???)

51
Q

Can regional anesthesia be used in patients with aortic regurgitation. Why or why not

A

Yes

Sympathectomy reduces afterload and will reduce regurgitation fraction

52
Q

Define bisferiens pulse seen on arterial waveform

Which valvular conditions is this seen with

A

Sharp upstroke
Low diastolic pressure
Wide pulse pressure
Possible biphasic systolic peak

Seen with aortic regurgitation

53
Q

What is the normal size of the mitral valve?

What size valve is considered severe for mitral stenosis?

A

Normal = 4 - 6 cm^2

Severe <1 cm^2

54
Q

What are the 3 most common causes of mitral stenosis

A

Endocarditis
Mitral calcification
Rheumatic fever

55
Q

How is BP maintained in patients with mitral stenosis

A

Increased SVR

56
Q

What pulmonary problem can result from mitral stenosis

A

Pulmonary HTN d/t increased left atrial pressures

57
Q 
What are anesthetic goals for patients with mitral stenosis
HR
Rhythm
Preload
Afterload
Contractility
PVR
A 
HR = LOW side of normal
Rhythm = NSR
Preload = maintain
Afterload = maintain
Contractility = maintain
PVR =avoid increase
58
Q

In patients that have pulmonary HTN as a result of mitral stenosis, what physiologic states should be avoided (4)

A

Hypoxia
Hypercarbia
Hypothermia
Acidosis

These all increase pulmonary vascular resistance

59
Q

Why are patients with mitral stenosis at increased risk for thrombus formation

A

Blood stasis in the left atrial appendage causes thrombus formation

60
Q

How does the possibility of thrombus formation in mitral stenosis impact an anesthetic

A

Pts may be on anticoagulants. Neuraxial blocks may need to be avoided

61
Q

Regional anesthesia effects on mitral stenosis

A

Epidural anesthesia is preferred over spinal

Rapid BP declines with spinals can cause significant CO reduction

62
Q

Which heart chambers are affected by severe mitral stenosis

A

left atrium has increased pressure

Left ventricle has decreased pressure and volume which affects CO

63
Q

What is a normal mitral valve transvalvular gradient?

When is it considered severe?

A 
Normal = 10 mmHg
Severe = 50 mmHg
64
Q

What are less common etiologies of mitral stenosis (5)

A 
SLE
Congenital defect
LA myxoma
Carcinoid syndrome
Problem following MV repair
65
Q

Which heart rhythm may result with mitral stenosis and why

A

Atrial fibrillation

Due to stretch of conduction system from increased LAP and volume altering anatomy

66
Q

Mitral stenosis cause what type of hypertrophy in which heart chamber

A

Concentric hypertrophy of left atrium

67
Q

What signs and symptoms are noted with severe mitral stenosis

A

S/S related to pulmonary HTN

  • Dyspnea
  • Increased RV workload
68
Q

How are stroke volume and LV-EDV affect in patients with severe mitral stenosis

A

LV is underfilled decreasing SV and LV-EDV

69
Q

How is the pressure-volume loop altered in patients with mitral stenosis

A

Left shift

Shorter height

70
Q

Describe the pulmonary effects of mitral stenosis

A 
Pulmonary HTN
Promotes fluid movement into pulmonary interstitium
Reduces pulmonary compliance
Increases WOB
Chronic fluid overload
71
Q

How is pulmonary compliances affected by mitral stenosis

A

Compliance is reduced

72
Q

What are the right heart effects of severe mitral stenosis

A 
Increased workload of RV 
RV failure (cor pulmonale)
73
Q

Goal for HR in mitral stenosis and why

A

Goal = slow side of NSR

Allows for increased filling time of LV
tachycardia decreases diastolic filling time and allows less time for blood to pass through stenotic valve

74
Q

What medications are used for tachyarrhythmias in mitral stenosis

A

Amiodarone
Beta-blockers
CCBs
Digoxin

75
Q

What types of drugs should be avoid in patients with mitral stenosis

A

Medications that increase HR

  • anticholinergics
  • Ketamine
  • Atracurium
  • ephedrine
76
Q

How should preload be maintained in patients with mitral stenosis

A

NORMAL

Low preload causes decreased SV/CO

High preload increases LAP and pulmonary congestion

77
Q

What medications can be used to adjust LAP in patients with mitral stenosis

A

Diuretics can decrease LAP by decreasing preload

78
Q

Is PAOP accurate in patients with mitral stenosis? Why or Why not?

A

It’s inaccurate

PAOP overestimates LVEDV d/t increased LAP from concentric hypertrophy

79
Q

How is the PAOP waveform altered in patients with mitral stenosis

A

a wave = prominent

y descent = decreased

80
Q

What medications should be used to treat hypotension in patients with mitral stenosis? Why?

A

Vasoconstrictors
-phenylephrine or vasopressin

they constrict without affecting HR

81
Q

What is the result of rapid drop in SVR in patients with mitral stenosis

A

SVR is increased to maintain BP

A rapid drop will elicit baroreceptor mediated increase in HR which should be avoided (keep HR slow)

82
Q

How should PVR be managed in patients with mitral stenosis? Why?

A

Avoid increase

Any increase in PVR increases the workload of the RV

83
Q

What physiologic conditions increase PVR

A 
Acidosis
Hypercarbia
Hypoxia
Hyperinflation
Nitrous oxide
T-burg
84
Q

What type of hypertrophy does mitral insufficiency cause and to which chamber

A

Eccentric hypertrophy to the left atrium

85
Q

What are common causes of mitral valve regurgitation?

A 
MV prolapse
Myxomatous of MV
Ischemic heart disease
Ruptured cordae tendineae
Papillary muscle dysfunction 
LV hypertrophy
86
Q

What hemodynamic and valve conditions should be avoided in the patient with mitral valve regurgitation? Why?

A

Slow HR
Increased LV-LA pressure gradient
Increased SVR
Increased size of valve orifice

These conditions increase regurgitant volume

87
Q 
What are anesthetic goals for patients with mitral insufficiency
HR
Rhythm
Preload
Afterload
Contractility
PVR
A 
Full, fast, forward
HR = increased 
Rhythm = NSR
Preload = maintain or increase
Afterload = decrease
Contractility = maintain
PVR = avoid increase
88
Q

What are patients with MV repair at risk for following surgery?

A

At risk for systolic anterior motion of anterior leaflet which leads to outflow obstruction

89
Q

How is systolic anterior motion of the anterior leaflet treated after MV repair

A 
Increase intravascular volume
Increase afterload (phenylephrine)
90
Q

How is sympathectomy useful in patients with mitral insufficiency

A

It can facilitate forward flow by reducing SVR which reduces regurgitant fraction

91
Q

In the patient with mitral regurgitation, what happens to flow during isovolumetric contraction

A

Flow becomes bidirectional between LV-LA

92
Q

How does the pressure-volume loop change in patients with mitral insufficiency? Acute vs chronic

A

Chronic

  • Loop widens, ESV moves right and EDV moves right
  • The loop height is shorter (lower pressure)

Acute

  • Height is shorter
  • Width is smaller and moved right
  • ESV moves significantly right
  • EDV moves right
93
Q

How should HR be maintained in patients with mitral insufficiency? Why

A

INCREASED NSR

Regurg happens during systole
Faster HR decreases systolic time and decreases regurgitation fraction

94
Q

How should preload be maintained in patients with mitral insufficiency? Why

A

Maintain or INCREASE

Higher preload compensates for lost volume by increasing pressure forward

95
Q

How is PAOP affected by mitral regurgitation? How does this reflect LVEDP?

A

PAOP overestimates LVEDP

Unreliable measure of LV filling pressure

96
Q

How is the PAOP waveform altered in patients with mitral valve regurgitation

A

V wave = enlarged

representing regurgitant volume passing through incompetent valve

97
Q

How should SVR be maintained in patients with MV insufficiency

A

DECREASE

Vasodilation promotes forward flow because the pressure gradient is decreased

98
Q

What effect does vasoconstriction have on flow in patients with mitral valve regurgitation

A

It increases SVR and will increase regurgitant volume because the higher pressure

99
Q

How should PVR be maintained in patients with MV regurgitation? Why

A

Avoid increase

Pulmonary HTN increases workload of the RV

100
Q

Which valvular disorders are associated with systolic murmur

A

Mitral insufficiency

Aortic stenosis

101
Q

Where is a murmur heard associated with AS?

When in cardiac cycle

A

Right sternal border
(ASSS = AS systolic sternal border)

Systolic

102
Q

Where is a murmur heard associated with aortic regurgitation?
When in cardiac cycle

A

Right sternal border
(ARDS = AR diastolic sternal border)

Diastolic

103
Q

Where is a murmur heard associated with Mitral stenosis?

When in cardiac cycle

A

Apex and left axilla
(MSDA = MS diastolic apex/axilla)

diastolic

104
Q

Where is a murmur heard associated with mitral regurgitation?
When in cardiac cycle

A

Apex and left axilla
(MRSA = MR systolic apex/axilla)
systolic

105
Q

Where can a murmur associated with AS be transmitted?

Confused with what sound?

A

Transmitted to upper aorta and carotid arteries

confused with carotid bruit

106
Q

Anesthetic considerations when a valve is deployed during a TAVR

A

Rapid ventricular pacing to produce cardiac standstill

Anticipate profound HoTN due to no CO during this time

107
Q

When is apnea required during a TAVR

A

When the valve is being deployed

108
Q

Preoperative considerations for patients undergoing TAVR in preparation for possible complications

A

Have T&C with 4 units of blood in room

2 large bore IVs

109
Q

If valvuloplasty causes annular rupture during TAVR, what are the implications

A

Causes pericardial tamponade

Pt may require aortic root repair/replacement

110
Q

What are some risks of the TAVR procedure

A 
stroke
perivalvular lead
pericardial tamponade
AV block
Left BBB
CHB w/ presence of RBBB

APEX-CV & Respiratory (8 decks)

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