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CV Anesthesia > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

The body compensates for heart valve disease how? (3)

A

SNS activation

Increasing intravascular volume

Modified chamber dimension

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2
Q

Heart valve disease is associated with two things?

A

Abnormal ventricular volume loading

Decrease in forward flow

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3
Q

Aortic stenosis pressure volume loops characteristically have higher/lower intravascular pressure-volume relationships

A

HIGHER

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4
Q

Aortic regurgitation pressure volume loops characteristically have higher/lower ventricular volume/pressure and lack and isovolumic ________ component

A

HIGHER

VOLUME

RELAXATION

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5
Q

What is concentric hypertrophy? And What two valve disease does it occur in?

A

Concentric is when the muscle is LARGER, but can only hold small volume

AORTIC STENOSIS and MITRAL STENOSIS

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6
Q

What are pathologic features of aortic stenosis? (3)

A

Concentric ventricular hypertrophy

Pressure overload/high LV tension

Increased MVO2

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7
Q

What is severe/critical aortic stenosis associated with? (3)

A

Aortic valve area < 1 cm

Aorta/LV Gradient > 40 mmHg

Peak aortic jet velocity > 4 m/s

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8
Q

What two monitors should symptomatic aortic stenosis or NYHA III-IV should have for major surgery?

A

Arterial line

PAC or TEE

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9
Q

What are some hemodynamic goals in patients with aortic stenosis? (3)

A

Maintenance of slow or normal heart rate

Normal to high SVR

Preservation of LV contractility

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10
Q

Anesthetic considerations prior to cardiopulmonary bypass include?

A

Assessment of aorta for plaque

Heparinization (300-400 units/Kg)

ACT > 400 seconds

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11
Q

LV preload should be normal/high/low in Aortic stenosis?

A

Normal

Monitor fluid totals, LV usually underfilled

FIXED SV

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12
Q

Heart rate should be high/normal or low/normal in aortic stenosis?

A

Low/normal

Balance CO with MVO2; aggressively treat rhythm disturbances, especially ventricular

Give K, Mag, Esmolol or Metoprolol

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13
Q

Contractility should be low/normal or high/normal in aortic stenosis?

A

High/normal

Maintain as LV compensates for stenotic valves with increased contractility

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14
Q

If aortic valve stenosis is less than <0.6 cm, what kind of monitor would you need in the room?

A

DEFIBRILLATOR

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15
Q

What are some concerns for aortic stenosis?

A

Monitor for MI, especially post op

AVOID REGIONAL

CPR is ineffective

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16
Q

What is the best TEE window/view for assessing ventricular function and filling?

A

Transgastric view

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17
Q

Hemodynamic goals of POST-CPB in patients with aortic stenosis include? (3)

A

Maintenance of optimal LV filling

Sinus rhythm

Judicious use of inotropes

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18
Q

Mediastinal Bleeding in excess of _______ ml/hr usually necessitates __________ in the OR

A

300

Re-exploration

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19
Q

Cerebral protection during CIRC arrest include? (4)

A

Profound hypothermia (as low as 32 C)

Ice to head

Propofol infusion

Monitoring of cerebral oxygen saturation

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20
Q

What are there 3 clinical features of HCM (hypertrophic cardiomyopathy)?

A

Dyspnea

Angina

Syncope

Sometimes sudden death

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21
Q

What are some anesthesia consideration for HOCM (hypertrophic cardiomyopathy)? (4)

A

Maintenance of adequate intravascular volume

Increased SVR

Myocardial depression (Beta/Ca channel blockers)

Deep anesthesia

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22
Q

What two things are affected due to HOCM?

A

Interventricular septum

Left ventricular outflow tract (aortic valve is compressed) unable to get flow out

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23
Q

LV preload should be high or low of HOCM?

A

High

Maintain adequate preload to avoid MR (paradoxical due to septal anterior motion)

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24
Q

Heart rate should be high/normal or low/normal in HOCM?

A

Low/normal

Avoid increases in HR or contractility and SAM increase

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25
Q

Contractility should be what in HOCM?

A

Low to normal

Avoid increases in contractility (Increases SAM, increases MVO2)

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26
Q

SVR should be LOW or HIGH in HOCM?

A

HIGH

Modest increase (optimizes CPP, but also improves SAM)

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27
Q

What monitoring should be used in HOCM?

A

Arterial line if symptomatic

PAC/TEE if major sx

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28
Q

What two things are advantageous in HOCM?

A

Deep anesthesia

Myocardial depression (maintain with beta/ca blocker)

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29
Q

What are some pathological features of aortic regurgitation? (3)

A

Eccentric LV hypertrophy

Volume overload

Decreased net SV

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30
Q

Severe/moderate aortic regurgitation is associated with? (3)

A

Vena contracta > 6 mm

Pressure half-time < 200

Regurgitant jet > 65% of the width of left ventricular outflow tract (LVOT)

31
Q

LV preload should be high or low in aortic insufficiency/regurgitation?

A

HIGH

Normal to high to maintain forward flow

32
Q

Heart rate should be what in AI?

A

HIGH

Modest increase (hr 80-90) to maintain CO and decrease regurgitant volume

33
Q

Contractility should be HIGH or LOW in AI?

A

HIGH

Maintain or increase to avoid HF, especially with inhalation anesthesia

34
Q

SVR should be HIGH or LOW in AI

A

LOW

Decrease afterload/SVR to maintain CO and decrease regurgitant volume

35
Q

If a patient with AI comes in and is symptomatic, what kind of monitor is needed?

A

Arterial line

36
Q

If a patient with AI is having major sx and or has a low EF, what monitor is needed?

A

PAC/TEE

37
Q

If a patient with AI has low EF, what is this indicative of?

A

very bad, it indicates DECOMPENSATION

38
Q

What are some concerns with AI? (3)

A

Watch for CHF with SB

HTN

Myocardial depression with inhalation agents

39
Q

What induction agents would you use with AI?

A

Dose with ketamine vs Etomidate vs. low dose propofol

40
Q

Anesthesia management patients with AI include? (3)

A

Faster heart rate

Lower SVR

Preservation of contractility

41
Q

Mitral stenosis is characterized by? (3)

A

Restricted diastolic flow

Decreased SV

Decreased Blood Pressure

42
Q

Mitral stenosis pressure volume loop characteristically have ___________ filling and _______ ventricular volumes?

A

DECREASED

LOWER

43
Q

Mitral stenosis patients typically have??

A

Pulmonary HTN

Tricuspid regurgitation

44
Q

Mitral stenosis patients typically have symptoms at rest when the valve area is less than _______ cm?

A

1.5 cm

45
Q

Pathological features of mitral stenosis include? (4)

A

Left atrial enlargement

Decreased LV filling

Heart rate dependent CO

Sinus-rhythm dependent blood pressure

46
Q

Moderate/severe mitral stenosis is associated with what? (3)

A

An orifice are of <1.5 cm

Pressure half time (PHT) > 150 ms

Pressure gradient across the valve of > 5 mm Hg

47
Q

LV preload should be low, normal, or high in Mitral Stenosis?

A

Normal

Maintain but avoid overfilling (Afib -> acute failure)

48
Q

Heart rate should be low, normal, or high in mitral stenosis’?

A

Normal

Too slow and no cardiac output (fixed SV)

Too high and not enough time for LV filling

49
Q

Contractility should be low/normal or high/normal in mitral stenosis?

A

High/normal

Maintain but watch for dysrhythmias, maintain RV function by optimizing PVR (pulmonary vascular resistance)

50
Q

SVR should be HIGH or LOW in Mitral Stenosis?

A

HIGH

Modest increase, understanding that SV is fixed and BP dependent on SVR

Norepi, vaso > Neo

51
Q

What kind of monitor is needed for a with symptoms of mitral stenosis?

A

A line

52
Q

If a patient with mitral stenosis is having major surgery, what kind of monitor is needed?

A

PAC/TEE

53
Q

If a patient with mitral stenosis has a PAC, what is one thing to consider?

A

PCWP overestimates LVEDP

54
Q

What are some concerns with a patient that has mitral stenosis?

A

NSR -> aggressively cardiovert. New onset AFib

Watch for RV Failure due to volume overload

55
Q

What two things due you want to avoid in patients with mitral stenosis during induction and post induction?

A

AVOID hypoxia and hypercapnia (increases PVR and causes RV failure)

Be gentle on induction agents and use minimal agent

56
Q

Mitral regurgitation pressure volume loops characteristically have higher/lower ventricular volumes and lack isovolumic ____________ component

A

HIGHER

Contraction

57
Q

Hemodynamic goals for mitral stenosis include? (2)

A

Slow to normal heart rate (NSR)

Increased SVR due to fixed SV

58
Q

With mitral stenosis, maintenance of normal ___________ vascular resistance is paramount as __________ ventricular failure is associated with moderate/severe mitral stenosis.

A

Pulmonary

RIGHT

59
Q

What are some drugs typically use to management right ventricular dysfunction?

A

Dobutamine
Milrinone
Eposprosterenol

60
Q

What are some pathological features of mitral regurgitation? (3)

A

Left atrial enlargement

Eccentric LV hypertrophy to accomodate increased LV volume

Decreased forward SV

61
Q

Moderate/severe mitral regurgitation is associated with? (2)

A

Regurgitant jet/vena contracta > 3-6 mm

Regurgitant jet that occupies at least 2/3 of the left atrium by TEE

62
Q

What are some hemodynamic goals with patients with mitral regurgitation?

A

Normal-fast heart rate

Low-normal SVR

Preservation of intravascular volume/contractility

63
Q

LV preload should be HIGH or LOW in mitral regurgitation?

A

HIGH

Maintain but avoid overfilling

64
Q

To keep the preload HIGH in mitral regurgitation, what kind of anesthesia should you avoid?

A

Spinal or epidural, decrease your preload

65
Q

Heart rate should be HIGH or LOW in Mitral regurg?

A

HIGH

Modest increase to maintain CO and decrease regurgitant volume

66
Q

Contractility should be HIGH or LOW in Mitral Regurg?

A

HIGH

Maintain left ventricle -> often puny

Right ventricle thin walled and does not tolerate afterload

67
Q

With mitral regurgitation needing HIGH contractility, what do you not want to do during induction?

A

OVERpressure your volatile agent and increase your MAC

68
Q

SVR should be high or low in Mitral regurgitation?

A

Low

Modest decrease to improve forward flow and decrease regurgitation

Keep SBP with 20%

69
Q

If a patient with mitral regurgitation is symptomatic, what kind of monitor should be utilized?

A

Arterial line

70
Q

What kind of monitor is useful to quantify and gauge interventions for MR?

A

PAC/TEE

71
Q

What are some major concerns when your patient has MR?

A

HYPOVENTILATION increases PAP (pulmonary artery pressures) which can lead to RV failure

72
Q

What medication is useful for patients with MR?

A

NTG is useful for titration get LV volume to decrease MR

73
Q

What are some post-bypass management of mitral valve surgery?

A

Inotropes

Lower BP

Faster heart rate

74
Q

What is now being used for inoperable patients (high risk, multiple comorbidities) and employs an Alfieri stitch and TEE?

A

Mitraclip surgery

CV Anesthesia (1 decks)

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