EXAM 2 Flashcards
Most common symptoms of valvular disorders:
CHF
Angina
Dysrhythmias
Syncope
Valvular “Insufficiency”
Incomplete closure (causing regurg.)
Valvular “Stenosis”
Narrowing (restricts flow)
• “Mixed” valvular Disorder
combination of stenosis & regurg
Most common symptoms of rheumatic Fever
– Chills, fever, fatigue, migratory arthralgias
- It is ___________ reactivity between ____and _____
- Common symptoms: Advancing edge with clearing center_________associated with ___________
- Symptoms manifest ______ years after ARF
- Autoimmune cross reactivity between bacterial and cardiac antigens.
- Erythema marginatum; Rheumatic Fever
- 10-30 years
Diagnosis is established via________
______(valve) is most often affected in ______
What do patients need until adulthood?
Jones Criteria
• Mitral valve; Rheumatic Fever
-PCN Prophylaxis
Mitral Stenosis (“MS”)
• Primarily affects_______-
• Almost always_______in origin
– 50% of “MS” pts. have pos. Hx. ARhF ~ 20-30 yrs. prior
• Elderly pt.s – can b caused by ____________
what type of MS is rare ?
-females
- rheumatic in origin
-calcification of valve
Congenital
Pathologic features of Mitral Stenosis
-** Fibrous thickening and calcification of valve leaflets
– ***Fusion of commissures
– Thickening and SHORTENING of CHORDAE tendineae
Normal valve orifice: (mitral ) siz
4-6 cm^2
Pathologic valve orifice size
<2 cm^2
Pathologic valve when do you get symptoms
< 1.5cm^2
If LA pressure is > 25mmHg – Mitral area is _____cm^2.. If this high pressure can lead to __________
< 1 cm2; PULMONARY HTN
Back pressure to lungs > 25mmHg fluid
leaks into interstitial space = Pulmonary Edema
***–> ↓ lung compliance and ↑ W.O.B. (lymphatic can partially compensate
***Mitral Stenosis – Anesthesia Goals (MHTN notach)
Maintain: HR?Afterload? rhythm?
Avoid 3 things (HTN)
And avoid drugs that _______such as ____
Maintain Normal – Low HR; Normal Afterload; NSR
- Hypervolemia
–Trendelenberg position
–NO2 =↑ Pulm. Vasc. Resist.
- NO Drugs that can cause Tachy. (Pancuronium, Ketamine)
For Mitral Stenosis: If pt. has Intra-op. Tachy. Control with:
3 interventions (except
OBD
- *1. Opioids (except Meperidine = Tachy.)
2. ↑ Depth of Anesthesia
3: Beta blockers
_______and ________okay to use if BP ↓↓ (these don’t ↑ HR) For Mitral Stenosis
Phenylephrine or Vasopressin
Epidural vs. Spinal which one is preferred and why?
Epidural preferred – has less dramatic ↓ in sympathetic
activity
Mitral Stenosis Treatment (AwBCDD)
*** Diuretics for pulmonary congestion
• **β blockers, **Ca++ channel blockers or **Digoxin to control HR
• Anticoagulation if A-fib present
– Warfarin (INR 2.5 – 3.0)
Mitral Stenosis :Surgery if symptoms persist with above treatments
Percutaneous Ballon VALVULOPLASTY
Mitral regurgitation (Mrs3-PMA)___ may be present
• _______murmur heard at apex that radiates to
the_________
S3
Pansystolic murmur; axilla
Mitral Regurgitation Treatment (DVABB)
• Acute MR
– IV diuretics** to relieve pulmonary edema
– **Vasodilators to reduce resistance to forward flow
• Sodium nitroprusside
– Ace-i, β blockers, Biventricular pacing
Chronic Mitral Regurgitation Treatment
When is surgery recommended?
– Surgery recommended before Ejection Fraction <60% to avoid further LV impairment/failure
Mitral Regurgitation Which Anesthesia preferred.
(remember 2 gs in regurg)
______Optional why not?
General
***Neuraxial optional, but dramatic sympathetic decreases
can result in ↓↓↓ BP
Aortic Stenosis 3 factors with developement (ACR)
- **Aging: fibrosis/degeneration and calcification
- **Congenital: bicuspid vs. tricuspid↑turbulence/damage – - **RHEUMATIC VALVE DISEASE
Aortic Stenosis Pathophysiology SECOMIASC
Stenotic valve = ↓ C.O.
Elevated LV pressures =Ventricular Hypertrophy
Compression of coronary arteries
↓O2 supply; ↑O2 demand
Myocardial ischemia /Angina, Syncope, HF
•Initial compensatory mechanism is ↑LV press.
•AS develops over a chronic course.
•Concentric hypertrophy reduces wall compliance
resulting in a “stiff” LV
**Aortic Stenosis – Anesthesia Goals (MWAT)
Drugs to avoid VDN
Maintain NSR
• Watch for A-fib or Jct. Rhythm (CHF and Hypotension)
• Avoid hypotensive drugs.
– Vasodilators, diuretics, nitroglycerin
**Treat Hypotension aggressively!**
2 main Causes of Aortic Regurgitation
Abnormality of valve leaflets
Dilatation of Aortic Root
***AR: Abnormalities of valve leaflets (CRE)
Congenital (bicuspid)
Rheumatic
Endocarditis
AR: Dilatation of Aortic Root
Aortic Aneurysm
Aortic Dissection
Annuloaortic Ectasia
Syphillis
What is the hallmark of Aortic Regurgitation? What causes it? SV is \_\_\_\_\_\_ SBP \_\_\_\_\_\_\_ Aortic Diastolic P \_\_\_\_\_\_\_\_\_
Widened pulse pressure is HALLMARK
– From : (3) Increased SV Increased SBP Decreased Aortic Diastolic Pressure.
Decrescendo S2 murmur (S2 AM)
– Aortic diastolic press. falls (blue arrow)
– Murmur begins at S2 with regurg.
Aortic Regurgitation there is _________And _________ murmur
Widened pulse pressure
Descrescendo S2 murmur
SLE
Affect tissue in the body
CONNECTIVIE TISSUE
LUPUS Causes damage to connective
May cause Choardae tendiane to rupture
Aortic Regurgitation
Symptomatic pts. w/ (EF) ________
– Offered **surgical correction to prevent progression
– w/o surgery death usually occurs_______
ejection fraction <50%:
within 4 yrs.
Aortic Regurg. – Anesthesia Goals (MRA) M --> R--> A--> AVOID WHAT DRUG in AORTIC REGURG and WHY
Muscle Relaxants : Pancuronium (vagolytic, maintain increase HR)
**AVOID SUCCINYLCHOLINE (can cause Bradycardia)
Reduce Afterload
Nifedipine or Hydralazine•↓ ventricular reflux; ↑ forward flow
5. For Acute Exacerbations Nitroprusside and Positive inotropic (ex. Dobutamine)
Tricuspid valve : usually _______rather than ________, resulting from _____enlargement secondary to
Usually functional rather than structural, resulting
from RV enlargement 2o to pulmonary HTN,
rather than primary valve ds
Prosthetic Valves
↑risk of endocarditis for all type valve replacements
Endocarditis**Acute Bacterial Endocarditis (ABE) FSMH
•4
Fulminant infection
• Highly virulent & invasive
• Staph AUREUS usual causative organism
• May occur on previously healthy valves
Endocarditis **Subacute Bacterial Endocarditis (SBE) LSO
• Less virulent
• Strep VIRIDANS usual causative organism
• Often occurs in pts. w/ prior underlying valve
damage
***ENDOCARDITIS: Pathogenesis requires several conditions: (ETBA)
- 1 – endocardial surface injury
- 2 – thrombus formation @ injury
- 3 – bacteria enter circulation
- 4 – adherence to thrombus or injured surface
***Endocarditis Foreign material (2)
- *Indwelling venous catheter
* *** Prosthetic heart valve
2 Most common sources of endothelial injury:
- Turbulent flow from valvular disease
* Foreign material
In Endocarditis;
Platelets adhere to ________
Form____________ on _______
__________ stands for _________ endocarditis
Platelets adhere to injured endocardial tissue
• Form ** vegetations (Sterile thrombus) on endocardium
and/or valves
• **NBTE – nonbacterial thrombotic endocarditis
Complications of Bacteremia: (TEA)
Thrombotic or septic emboli
Antigen-Antibody complex deposition
Erosion into conduction system
***Complications of Bacteremia:
• Thrombotic or septic emboli
Infarct target organs (or vasa vasorum causing aortic
aneurysm)
***Complications of Bacteremia: Antigen-Antibody complex deposition
Glomerulonephritis, arthritis, vasculitis
***Complications of Bacteremia: Erosion into conduction system
Manifest as heart block or other new arrhythmias
Prenatal shunt is
Right to Left
***Explain prenatal circulation
Prenatal Right heart pressure is Higher than
Left, causing Right to-Left shunt
Fetal Circulation has 3 shunts (VeAR FO)
- Ductus venosus
- Foramen ovale
- Ductus arteriosus
Congenital heart lesions categorized:
- Cyanotic
* Acyanotic
– If postnatal shunt is Right-to-Left =
Cyanotic
If shunt present, Left-to-Right less harmful =
Acyanotic
Postnatal should be
closed
***Acyanotic Lesions (ASPAC)
- ASD
- VSD
- PDA
- (Aortic and Pulmonic Stenosis)
- Coarctation of the Aorta
ASD MOST COMMON
Shunt is : ________
most common @ Foramen Ovale (failed fusion)
If RA pressure increase secondary to Pulm. HTN or RHF = R-to-L shunt
***PDA
**Prenatal shunt is R-to-L
• Postnatal becomes L-to-R (2o to ↑ Left pressures)
If Left HF develops, right side pressures dominate
and shunt becomes ***right-to-left
PDA Causes volume overload in (3)
• Result:_________
PDA treatment
Pulmonary circuit, LA , LV
LV dilation & Left HF
Treatment:
• Indomethacin (block PGE1) or Surgery
Coarctation of AORTA associated with____valvve
Blood flow to_____________preserved is diminished.
Bicuspid aortic valve
most common assoc’d. abnormality.
head & upper extremities preserved
lower extremity flow
Untreated Coarctation of Aorta leads to
If uncorrected, causes:
– LV Hypertrophy
– Formation of compensatory collateral intercostal vessels
• Dilation of collaterals erodes undersurface of ribs
Coarctation of Aorta when less severe
Treatment of COA is
If less severe:
– Claudication in lower extremities following exercise
- SURGICAL CORRECTION
What are the 3 Cyanotic Lesions
- Tetralogy of Fallot
- Transposition of the Great Arteries TGA (EMERGENCY)
- Eisenmenger Syndrome
Four anomalies of TETRALOGY of FALLOT’ (4)
What is the SHUNT direction ?
- VSD
- Pulmonic Stenosis
- Aorta from both ventricles
- RV Hypertrophy
Right-to-Left shunt
Transposition of the Great Arteries (TGA)
• Each great vessel arises from the opposite ventricle
– Aorta from RV; Pulmonary artery from LV
Separates pulmonary & systemic circuits by placing
them in parallel rather than series
• **TGA is lethal after birth*
• Prenatal shunts allow communication btwn. 2 circuits
• MEDICAL EMERGENCY
***What is Eisenmenger Syndrome?
**• When chronic Left-to-Right shunt is reversed to
become a Right-to-Left shunt
***Treatment for Eisenmenger syndrome?
Tx: avoid factors that promote ***R-to-L shunt:
strenuous exercise, high altitude, vasodilators
VSD
Common?
Initially, _____
Overtime_______ –> (3 dysfunctions) CHS
Relatively common defect (~3 per 1000 live births)
- Initially, ↑ blood volume return through lungs to LA
& LV = ↑ SV
• Over time, ↑ volume causes: – Chamber dilation – Systolic dysfunction – HF
For what disease do we need prophylaxis? and what?
PCN prophylaxis until early adulthood
RHEUMATIC FEVER
MITRAL STENOSIS signs are signs of _________ HF signs (JAHDep HC)
Right sided HF
JVD Ascites Hepatomegaly Dependent (peripheral Edema) Hoarseness secondary to compression of RECURRENT laryngeal nerve by enlarged pulmonary artery or LA CXR : KERLEY B lines
Disorders with high chance of MVP (MSRTM)
Marfan syndrome SLE Rheumatic carditis Thyrotoxicosis Myocarditis.
Severe Aortic stenosis
Valve area is
Transvalvular pressure gradient is ______
CO is _______With exertion and ______At rest
Valve area<0.8cm^2
Transvalvular gradient pressure > 50 mmHg
low with exertion, normal at rest
MILD mitral stenosis is associated with
Loud S1
SEVERE MITRAL STENOSIS is associated with
Diminished S1
Mild mitral stenosis has a loud ____and an _______occurs in ________ (MLS1 OED)
S1; Opening snap occurs in early diastole
SEVERE MITRAL STENOSIS has a diminished ______with a __________ @ ____or ____ (SDS1 RMA)
Rumbling diastolic murmur at AXILLA or APEX
To differentiate aortic stenosis murmur from Mitral regurgitation what do you do?
MRI, ASnot
Ask patient to clench fist to INCREASE SVR
in MR murmur will intensify
in AS murmur will NOT
MVP occurs in _____-% of the population
2-3%
MVP is more common in
women
Symptoms in severe cases’CASIE of MVP
Chest pain Arrythmia Sudden cardiac death Infectious endocarditis EMBOLISM
MVP is associated with (murmur) ML
Midsystolic click
Late systolic murmur
What is a Midsystolic Click
sudden tensing of leaflet or choardae tendinae when forced back into LA
Late systolic Murmur is
if regurgitation is present with the prolapse
MVP is often
benign
Normal Aortic Valve area is
2-5.-3.5 cm2
S4 caused by
turbulent flow
EKG in AS show
LVH
For AS, ___%symptomatic patients w/surgery die within
75; 3 years
Aortic Regurgitation: asymptomatic patients with HTN with preserved LV function benefit (ACCB)
Medically from AFTERLOAD REDUCING DRUGS
CCB, Ace
NOT imp Pulmonic Regurgitation caused by
valve ring
Severe pulmonary HTN
Dilates valve
IVDA often involves
RIGHT SIDED HEART VALVES
Endocarditis best viewed with
TEE
Acute ABE symptoms (RH)
Rapidly progressing illness
High fever and chills
Subacute ABE symptoms
low grade fever
nonspecific sx , mistaken for INFLUENZA
SBE needs high level of SUSPICION
Skin findings of ENDOCARDITIS
VP JORS
VP JORS Vasculitis (peripheral stigmata of endocarditis) Petechiae JANEWAY LESIONS OSLER NODES ROTH SPOTS SPLINTER HEMORRHAGES
Prevention via prophylaxis ABX in certain conditions (READ)
Presense of prosthetic valve hx of endocarditis Hx of congenital HD Dental procedures URI GU GI procedures Infected ski
BP liver is
Ductus Venosus
BP lungs
Foramen Ovale
Foramen forced closed when
LA pressure become GREATER than RA pressure
After birth PGE1 levels
decline DA CONSTRICTS CLOSED
***A Patent Foramen Ovale with ________can result in _______
RIGHT TO LEFT SHUNT
PARADOXICAL EMBOLISM
VSD is a common defect with ______per ____LB
3 per 1000
In VSD, initially
Increase blood volume return through lungs to LA and LV = Increase SV
Overtime in VSD, increase volume cause (CSH)
Chamber dilation
Systolic dysfunction
HF
Symptoms of VSD (small)
Infants with small VSDs are symptom free
***In Mitral stenosis blood back up into______resulting in _________ as evidenced by ________
There is _________pulmonary vascular pressure which could rupture vessels causing ___________
Pulmonary veins resulting in pulmonary HTN
AEB- DYSPNEA and ORTHOPNEA
HEMOPTYSIS
***In mitral stenosis RV pumps against _________pulmonary vascular pressure leading to _________ which leads to 3 symptoms
Increase
Pulmonary HTN
RVH, CHF, RIGHT HF
***In mitral stenosis how does it lead to AFIB?
- LA Hypertrophy stretches conduction fibers
- Disrupts conduction system
- Leads to Afib, contributes to decrease CO and thrombus formation
**In mitral stenosis, what happens to LA
Atrial pressure increase
LA hypertrophy
**Mitral stenosis and SV and CO
There is impaired volume filling
Decreased SV and CO
Acute MR
Ventricle V shaped
***Acute MR : what happens to LA pressure > leads to what?
think ass non compliant
Left Atrium relatively NONCOMPLIANT
Acute rise in pressure leads to pulmonary edema
***Chronic MR” What hppens to LA
LA has time to BECOME COMPLIANT
less pulmonary pressure; pulmonary edema less common
***Chronic MR LV is
ENLARGED with ECCENTRIC Hypertrophy from chronic VOLUME overload.
***LA is dilated in
Chronic MR
***LV remodeling is ______in chronic MR
Eccentric Hypertrophy
***ACUTE Aortic Regurgitation (AAR - ANCH)
- Acute in increase in LV diastolic pressure
- NO TIME TO COMPENSATE
- CORONARY ISCHEMIA
- HF
***Surgical EMERGENCY requiring IMMEDIATE VALVE REPLACEMENT–> Pulmonary congestion /edema dyspnea
ACUTE Aortic REGURGITATION
***What happens to LA pressure in acute AORTIC REGURGITATION? what BAD symptoms does it lead to ? PED? Is this an emergency?
Increase
PULMONARY CONGESTION, EDEMA, DYSPNEA
***ChroniC Aortic Regurgitation (CAR - CRP)
- Causes ADAPTIVE ENLARGEMENT of LA and LV
- Regurgitation volume is ACCOMODATED with less - DIASTOLIC PRESSURE INCREASE
- PULMONARY CONGESTION less likely
What is meant by Functional tricuspid Regurgitation
Malfunctioning tricuspid valve allows backflow of blood into right atrium
