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CV: Valvular Heart Disease Flashcards

1
Q

S3 should make you think:

A

Heart failure

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2
Q

S4 should make you think:

A

Decreased ventricular compliance

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3
Q

What valves are closing when you hear S1?

A

MV TV

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4
Q

What valves are closing when you hear S2?

A

AV PV

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5
Q

Which heart sound corresponds to the start of systole?

A

S1

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6
Q

Which heart sound marks the onset of diastole?

A

S2

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7
Q

What event besides valve closures is represented by S2?

A

End of LV ejection and start of isovolumetric relaxation

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8
Q

Which heart sounds marks the onset of diastole?

A

S2

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9
Q

A flaccid heart is suggested by hearing what heart sound?

A

S3

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10
Q

Which heart sound marks the onset of diastole

A

S2

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11
Q

When is S3 heard? What portion of diastole

A

Middle 1/3 after S2

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12
Q

S4 is caused by:

A

Atrial systole

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13
Q

The diaphragm of your stethoscope is best for listening to which 4 heart sounds?

A

S1
S2
Heart murmurs: Aortic stenosis and mitral regurgitation
*All are high pitched sounds

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14
Q

The bell of your stethoscope is best for listening to which 4 heart sounds?

A

S3
S4
murmur of the mitral stenosis

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15
Q

What is the pneumonic for where to hear heart sounds?

A

All
Pigs
Eat
Too
Much

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16
Q

Where can aortic valve be auscultated?

A

Location: R of sternal border 2nd ICS
Sound: S2 “dub”

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17
Q

Where can pulmonic valve be auscultated?

A

Location: L of sternal border at 2nd ICS
Sound: S2 “dub”

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18
Q

Where can tricuspid valve be auscultated?

A

Location: Left of sternal border at 4th ICS (apex)
Sound: S1 “lub”

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19
Q

Where can mitral valve be auscultated?

A

Location: Midclavicular line on left at 5th ICS (apex)
Sound: S1 “lub”

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20
Q

THe atrioventricular valve leaflets are anchored to the interior of the ventricles by:

A

Chordae tendonae and papillary muscles

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21
Q

Semilunar valves have a _ appearance on TEE

A

Mercedes Benz

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22
Q

Briefly explain concentric hypertrophy

A

LV becomes THICKER. Usually due to a stenotic aortic valve forcing the ventricle to squeeze harder (generate more pressure) to over come the resistance of flow at the valve

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23
Q

Briefly explain eccentric hypertrophy

A

LV becomes stretched out, usually due to a regurgitant aortic valve. Volume overload occurs due to the blood that back flows and the blood that fills the LV from the atrium.

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24
Q

Heart compensates for eccentric hypertrophy by adding sarcomeres in series or parallel? What about for concentric?

A

Series
Parrallel

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25
What is the normal area of the aortic valve?
3-4 cm squared
26
What aortic valve area is considered severely stenotic?
< or equal to 1 cm squared
27
Mean transvalvular pressure gradient is another way to diagnose severe Aortic stenosis. What would it be if that were the case?
> 40 mmHg
28
Name 3 etiologies of aortic stenosis
Bicuspid valve/calcification of the valve leaflets (most common) Rheumatic fever) Infective endocarditis
29
With aortic stenosis, CO is dependent on what?
HR
30
Is SVR high or low in aortic stenosis?
low
31
Why is there a risk of subendocardial ischemia with aortic stenosis?
The high pressure the LV has to generate to pump against the aortic valve can compress the small vessels in the muscle that perfuse it
32
What 2 changes occur to the PV loop with aortic stenosis?
Increased height due to increased ventricular pressure EDV and ESV increase (shift to R)
33
What is the pneumonic for severe aortic valve disease presentation?
SAD Syncope Angina Dyspnea
34
Clinical pearl: why should you listen to every older patient for heart sounds especially if you are planning a spinal?
To assess for aortic stenosis because patients typically remain asymptomatic until LV dysfunction develops.
35
Which bleeding disorder is aquired in up to 90% of patients with severe aortic stenosis and why?
vWD because the molecule is damaged when it passes through the stenotic valve
36
How do you prefer HR to be with Aortic stenosis?
Slow side of normal
37
Ideally, preload is preferred to be increased or decreased in AS?
Increased
38
Ideally, contractility is preferred to be increased or decreased or maintained in AS?
Maintained and if LV dysfunction occurs, increased
39
Ideally, SVR is preferred to be increased or decreased in AS?
Maintain or increase
40
Ideally, PVR is preferred to be increased or decreased in AS?
Avoid increase
41
What kind of anesthesia is avoided with severe AS?
Spinal
42
What wold the a line tracing look like with AS?
Overall impression of a dampened waveform
43
Aortic insufficiency leads to eccentric or concentric hypertrophy?
eccentric
44
Is CO reduced or increased with AI?
Reduced
45
What does the PV loop look like for AS?
Refer to apex
46
What would bradycardia do to the PV loop in AS?
make it worse
47
What would Increased SVR do to the PV loop in AS?
Make it worse
48
What would a large valve orifice do to the PV loop in AS?
Make it worse
49
In the patient with aortic regurgitation, cardioplegia must be injected where?
retrograde through coronary sinus or directly into each coronary ostia
50
Etiologies of Aortic regurg?
Ankylosing spondylitis Ehler Danlos syndrome Marfan syndrome valvular calcification
51
What is the goal with preload in AI?
Maintain or increase. Avoid hypovolemia because some of he stroke volume is lost to the LV
52
What is the goal with heart rate in AI?
Increase
53
What is the goal with contractility in AI?
Maintain
54
What is the goal with SVR in AI?
Decrease
55
What is the goal with PVR in AI?
Maintain
56
What is the benefit of doing spinal anesthesia with AI?
Sympathectomy reduces afterload and will reduce the regurgitant fraction (this is a benefit!!)
57
What would arterial waveform look like in AI?
Bunny ears. Refer to apex
58
What is the normal area of the mitral valve?
4-6 cm squared
59
What is the area of a severely stenosed mitral valve?
< 1 cm squared
60
Severe MS can also be diagnosed by transvalvular pressure gradient of:
> 10 mmHg
61
Etiologies of MS:
Rheumatic fever is developing countries Endocarditis and calcification of valve in the US RA, Lupus, Carcinoid syndrome are others
62
How would mitral stenosis lead to Afib?
Stretch if conduction system
63
Does MS lead to concentric or eccentric hypertrophy?
Concentric
64
What would PV loop look like withe mitral stenosis?
Shorter height and shift to the L. Refer to apex
65
What is the goal with heart rate in Mitral stenosis?
Slower side of normal
66
What is the goal with preload in MS?
Maintain
67
What is the goal with contractility in MS?
Maintain
68
What is the goal with SVR in MS?
Maintain
69
What is the goal with PVR in AI?
Avoid increase
70
Would you do spinal anesthesia on a patient with mitral stenosis? Why or why not?
No. These pts should be anticoagulated to prevent clots due to blood statsis in LA
71
Mitral insufficiency leads to eccentric or concentric LV?
Eccentric
72
Etiologies of Mitral insufficiency
Rheumatic fever Ruptured chordae tendonae Endocarditis Rheumatoid arthritis Lupus Carcinoid syndrome
73
What would pressure volume loop look with mitral insufficiency?
Reference apex
74
What is the goal with HR in MInsuffiency?
Increased with NSR
75
What is the goal with preload in MInsuffiency?
Maintain or increase
76
What is the goal with contractility MInsuffiency?
Maintain
77
What is the goal of SVR with MInsuffiency?
Decrease
78
What is the goal of PVR with MInsuffiency?
Avoid increase
79
Should spinal anesthesia be done with Mitral insufficiency or not? Why?
Sympathectomy reduces SVR, promotes forward flow, and reduces the regurgitant fraction.
80
Where would aortic stenosis murmur be heard and during systole or diastole?
Aortic stenosis is a systolic murmur at the right sternal border
81
Where would aortic regurg murmur be heard and during systole or diastole?
Aortic regurg is a diastolic murmer heard at the right sternal border
82
Where would mitral stenosis murmur be heard and during systole or diastole?
Mitral stenosis is a diastolic murmer heard at the apex of the left axilla
83
Where would mitral regurg murmur be heard and during systole or diastole?
Mitral regur is a systolic murmur heard at the apex and the left axilla
84
Fluroscopy will be used with TAVR T or F
T!!!!
84
3 surgical approaches to TAVR (how to enter)
1. transfemoral 2. transaortic 3. transapical
85
What does TAVR stand for?
Transcatheter Aortic Valve Replacement
86
What are the 2 most common aortic valves used for replacement? They determine anesthetic considerations
Edwards SAPIAN Medtronic CoreValve
87
Between the 2 valves that can be used to replace the aortic valve, which one requires balloon valvuloplasty (to widen the aortic valve area) prior to deploying the replacement valve
Sapian
87
To minimize patient movement during deployment of sapian valve, _ is required
apnea
88
Why is rapid ventricular pacing used with Sapian valve depolyment?
to produce cardiac standstill during valvuloplasty and valve depolyment (reduing motion caused by ventricular ejection makes it easier to get the value into the correct position).
89
What should you anticipate with your vital signs during rapid ventricular paing during sapian valve placement?
Profound hypotension due to cardiac output being near zero during this time.
90
Of the 2 valves used for aortic valve replacement, which one does not require valvuloplasty or rapid ventricular pacing?
Corevalve
90
What happens if an aortic valve is malpositioned? How can it be fixed?
Aortic insufficiency. If it was a Sapian valve: valve in valve procedure is needed- valve must be placed through malpositioned valve If it was a corevalve: it can be removed and redepolyed
91
How will the pt present if TAVR results in occlusion of coronaries?
Myocardial ischemia (ST changes)
92
Hemmorhage can occur during TAVR. What kind of IV access do you want?
Multiple large bore

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