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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
Contractility should be what in HOCM?
Low to normal Avoid increases in contractility (Increases SAM, increases MVO2)
26
SVR should be LOW or HIGH in HOCM?
HIGH Modest increase (optimizes CPP, but also improves SAM)
27
What monitoring should be used in HOCM?
Arterial line if symptomatic PAC/TEE if major sx
28
What two things are advantageous in HOCM?
Deep anesthesia Myocardial depression (maintain with beta/ca blocker)
29
What are some pathological features of aortic regurgitation? (3)
Eccentric LV hypertrophy Volume overload Decreased net SV
30
Severe/moderate aortic regurgitation is associated with? (3)
Vena contracta > 6 mm Pressure half-time < 200 Regurgitant jet > 65% of the width of left ventricular outflow tract (LVOT)
31
LV preload should be high or low in aortic insufficiency/regurgitation?
HIGH Normal to high to maintain forward flow
32
Heart rate should be what in AI?
HIGH Modest increase (hr 80-90) to maintain CO and decrease regurgitant volume
33
Contractility should be HIGH or LOW in AI?
HIGH Maintain or increase to avoid HF, especially with inhalation anesthesia
34
SVR should be HIGH or LOW in AI
LOW Decrease afterload/SVR to maintain CO and decrease regurgitant volume
35
If a patient with AI comes in and is symptomatic, what kind of monitor is needed?
Arterial line
36
If a patient with AI is having major sx and or has a low EF, what monitor is needed?
PAC/TEE
37
If a patient with AI has low EF, what is this indicative of?
very bad, it indicates DECOMPENSATION
38
What are some concerns with AI? (3)
Watch for CHF with SB HTN Myocardial depression with inhalation agents
39
What induction agents would you use with AI?
Dose with ketamine vs Etomidate vs. low dose propofol
40
Anesthesia management patients with AI include? (3)
Faster heart rate Lower SVR Preservation of contractility
41
Mitral stenosis is characterized by? (3)
Restricted diastolic flow Decreased SV Decreased Blood Pressure
42
Mitral stenosis pressure volume loop characteristically have ___________ filling and _______ ventricular volumes?
DECREASED LOWER
43
Mitral stenosis patients typically have??
Pulmonary HTN Tricuspid regurgitation
44
Mitral stenosis patients typically have symptoms at rest when the valve area is less than _______ cm?
1.5 cm
45
Pathological features of mitral stenosis include? (4)
Left atrial enlargement Decreased LV filling Heart rate dependent CO Sinus-rhythm dependent blood pressure
46
Moderate/severe mitral stenosis is associated with what? (3)
An orifice are of <1.5 cm Pressure half time (PHT) > 150 ms Pressure gradient across the valve of > 5 mm Hg
47
LV preload should be low, normal, or high in Mitral Stenosis?
Normal Maintain but avoid overfilling (Afib -> acute failure)
48
Heart rate should be low, normal, or high in mitral stenosis’?
Normal Too slow and no cardiac output (fixed SV) Too high and not enough time for LV filling
49
Contractility should be low/normal or high/normal in mitral stenosis?
High/normal Maintain but watch for dysrhythmias, maintain RV function by optimizing PVR (pulmonary vascular resistance)
50
SVR should be HIGH or LOW in Mitral Stenosis?
HIGH Modest increase, understanding that SV is fixed and BP dependent on SVR Norepi, vaso > Neo
51
What kind of monitor is needed for a with symptoms of mitral stenosis?
A line
52
If a patient with mitral stenosis is having major surgery, what kind of monitor is needed?
PAC/TEE
53
If a patient with mitral stenosis has a PAC, what is one thing to consider?
PCWP overestimates LVEDP
54
What are some concerns with a patient that has mitral stenosis?
NSR -> aggressively cardiovert. New onset AFib Watch for RV Failure due to volume overload
55
What two things due you want to avoid in patients with mitral stenosis during induction and post induction?
AVOID hypoxia and hypercapnia (increases PVR and causes RV failure) Be gentle on induction agents and use minimal agent
56
Mitral regurgitation pressure volume loops characteristically have higher/lower ventricular volumes and lack isovolumic ____________ component
HIGHER Contraction
57
Hemodynamic goals for mitral stenosis include? (2)
Slow to normal heart rate (NSR) Increased SVR due to fixed SV
58
With mitral stenosis, maintenance of normal ___________ vascular resistance is paramount as __________ ventricular failure is associated with moderate/severe mitral stenosis.
Pulmonary RIGHT
59
What are some drugs typically use to management right ventricular dysfunction?
Dobutamine Milrinone Eposprosterenol
60
What are some pathological features of mitral regurgitation? (3)
Left atrial enlargement Eccentric LV hypertrophy to accomodate increased LV volume Decreased forward SV
61
Moderate/severe mitral regurgitation is associated with? (2)
Regurgitant jet/vena contracta > 3-6 mm Regurgitant jet that occupies at least 2/3 of the left atrium by TEE
62
What are some hemodynamic goals with patients with mitral regurgitation?
Normal-fast heart rate Low-normal SVR Preservation of intravascular volume/contractility
63
LV preload should be HIGH or LOW in mitral regurgitation?
HIGH Maintain but avoid overfilling
64
To keep the preload HIGH in mitral regurgitation, what kind of anesthesia should you avoid?
Spinal or epidural, decrease your preload
65
Heart rate should be HIGH or LOW in Mitral regurg?
HIGH Modest increase to maintain CO and decrease regurgitant volume
66
Contractility should be HIGH or LOW in Mitral Regurg?
HIGH Maintain left ventricle -> often puny Right ventricle thin walled and does not tolerate afterload
67
With mitral regurgitation needing HIGH contractility, what do you not want to do during induction?
OVERpressure your volatile agent and increase your MAC
68
SVR should be high or low in Mitral regurgitation?
Low Modest decrease to improve forward flow and decrease regurgitation Keep SBP with 20%
69
If a patient with mitral regurgitation is symptomatic, what kind of monitor should be utilized?
Arterial line
70
What kind of monitor is useful to quantify and gauge interventions for MR?
PAC/TEE
71
What are some major concerns when your patient has MR?
HYPOVENTILATION increases PAP (pulmonary artery pressures) which can lead to RV failure
72
What medication is useful for patients with MR?
NTG is useful for titration get LV volume to decrease MR
73
What are some post-bypass management of mitral valve surgery?
Inotropes Lower BP Faster heart rate
74
What is now being used for inoperable patients (high risk, multiple comorbidities) and employs an Alfieri stitch and TEE?
Mitraclip surgery

CV Anesthesia (1 decks)

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