EXAM 2 - CHD Flashcards
Indications for cardiac surgery in adults with CHD include:
Primary Repair
Total correction after palliation
Revision of total correction
Conversion of suboptimal operation into more modern repair
**Wolff-Parkinson-White syndrome is associated with what CHD/lesion?
Ebstein’s anomaly
**A.Fib is associated with what CHD/lesion(s)?
Mitral Valve disease
Aortic Stenosis
Tetralogy of Fallot
Palliated single ventricle
**Ventricular Tachycardia is associated with what CHD/lesion(s)?
Tetralogy of Fallot
Aortic Stenosis
(others)
Spontaneous AV Block is associated with what CHD/lesion(s)?
AV Septal defects
Congenitally corrected transposition
Surgically induced AV Block is associated with what CHD/lesion(s)?
VSD Closure
Subaortic Stenosis Relief
AV Valve Replacement
Minute ventilation =
RR x TV
Any lesion that results in either increased pulmonary blood flow or pulmonary venous obstruction can cause what three things?
- ) increased pulmonary interstitial fluid with
- ) decreased pulmonary compliance and
- ) increased work of breathing.
**pts with cyanotic heart disease will have an increased ___ and maintain ____.
increased minute ventilation
maintain normocarbia (they have a normal ventilatory response to hypercapnia but a blunted response to hypoxemia.)
patients with cyanotic heart disease have a normal ventilatory response to hypercapnia but a blunted
response to hypoxemia.
**What non cardiac issue can occur in approx. 19% of pts with CHD (most commonly in cyanotic pts)?
scoliosis
Is Eisenmenger Syndrome acyanotic or cyanotic CHD?
cyanotic
Describe Eisenmenger Syndrome:
a large VSD with displacement of aorta to the RIGHT
- Occurs when intracardiac shunt reverse and becomes right to LEFT shunt
- frequent in children but can occur in late stage adults
Longstanding hypoxemia causes increased red blood cell mass. Some CHD patients develop:
- excessive HCT (Polycythemia)
- and are Iron deficient
*Increased viscosity
what direction does iron deficiency shift the oxy-hgb curve?
RIGHT
decreasing O2 affininty for lungs
Adults with persistent or potential intracardiac shunts remain at risk for…
why?
Parodoxic embolism
-venous embolism passes through a lateral opening in the heart into arterial circulation.
Brain abscesses are associated with what in CHD patients?
- they result from right to left shunts
- old brain abscess ==> seizures
End Stage Eisenmenger Syndrome is associated with what respiratory symptom?
hemoptysis
RLN injury is a potential noncardiac involvement in pts with CHD. Why?
prior thoracic surgery
rarely from encroachment of cardiac structures
Common hematologic involvement in CHD patients includes:
- *Abnormal Von Willebrand factor
- bleeding diathesis
- symptomatic hyperviscosity
Cardiac Complications/ Peripartum endocarditis presents when? up to?
presents usually in the last month of pregnancy and up to 5 mos postpartum
in pregnancy, Most major physiologic changes occur prior to
the 3rd trimester.
IF patient has maintained good FUNCTIONAL status to this point, risk is dramatically lowered
During pregnancy, with CHD, what requires close observation?
bearing down that is associated with stage 2
Oxytocin to SVR, HR, PVR
decreases SVR
Increases HR and PVR
Methylergonovine (Methergine) to SVR
increases SVR
are oxytocin and methergine tolerated well or poorly in parturients with CHD?
both can be poorly tolerated
Beta blockers impact on fetus:
- can interfere with fetal growth &
- response of fetus stress during labor
This medication can affect fetal thyroid function
Amiodarone
Maternal cardioversion can be safe during pregnancy with …
close fetal monitoring
Surgeries/treatments and palliative therapy performed as a child of CHD must be considered in:
the anesthetic management of the adult
Patients with the following CHD’s typically survive to adulthood without …..
-Bicuspid aortic valve
-Coarctation of aorta
Pulmonic Valve stenosis
Ostium secundum atrial septal defect
Patent ductus arteriosus
Treatment
Survival with some congenital anomalies depends on the simultaneous presence of
another shunting lesion
for birthing mothers with CHD - what delivery method is preferable?
no favored method (c/s or vaginal)
Lesions causing OUTFLOW obstruction:
Left Ventricle:
- Aortic Stenosis
- Coarctation of the aorta
Right Ventricle:
-Pulmonic valve stenosis
Lesions causing LEFT to RIGHT shunting:
ASD PDA VSD Endocardial cushion defect Partial anomalous pulmonary venous return
Lesions causing Right to LEFT shunting – with DECREASED pulmonary blood flow:
Tetralogy of Fallot (TOF)
Pulmonary Atresia
Tricuspid Atresia
Lesions causing Right to LEFT shunting – with INCREASED pulmonary blood flow:
Transposition of great vessels Truncus arteriosus Single ventricle Double outlet Right Ventricle Total anomalous pulmonary venous return Hypoplastic Left heart
What CHD are cyanotic?
Tetralogy of Fallot (TOF)
Pulmonary Atresia
Tricuspid Atresia
Right to LEFT shunting – with DECREASED pulmonary blood flow
dental prophylaxis is important for CHD survivors due to
bacterial endocarditis
Tell me the difference b/w concentric and eccentric hypertrophy
Concentric = pressure overload hypertrophy
Eccentric = Volume overload hypertrophy
aortic stenosis is what kind of hypertrophy?
concentric
Aortic stenosis is the MCC of
obstruction to LV outflow
in Aortic stenosis, obstruction to ejection of blood into aorta d/t decreases in aortic valve area results in:
an increase in LV pressure to maintain forward flow
size of normal aortic valve =
severe stenosis =
2.55-3.5 cm2
less than or equal to 1.0cm2
pts with aortic stenosis may experience angina w/o CAD due to
increased O2 supply to the sub-endocardium by the reduced ventricular compliance
a decrease in atrial kick in NSR will decrease ventricular filling and may lead to what % reduction in CO?
40% reduction of CO
s/s of aortic stenosis
“SAD”
Syncope
Angina
Dsypnea on exertion
LV pressure Overload
what type of murmur is heard (where?) with aortic stenosis?
systolic murmur at 2nd ICS to the Right
Contraindications in severe aortic stenosis
spinals and epidurals
Aortic Stenosis Goals: -HR: Rhythm: Preload: Afterload: Contractility:
-HR: maintain 60-90bpm avoid brady/tachy; SV fixed
Rhythm: NSR!!
Preload: maintain and optimize
Afterload: maintain to CPP; avoid sudden in/decreases
Contractility: maintain
In Aortic Stenosis, Avoid :
- brady or tachy
- hypotension - tx with small doses of neo
- decreases in CO
how would you tx bradycardia in AS?
atropine! (faster)
how would you tx tachycardia in AS?
esmolol (cardiac specific; fast)
name the two types of aortic coarctation
- ) Preductal (infantile) - narrowing occurs proximal to the opening of the ductus
- ) postductal - s/s severity depends on severity of narrowing and extent of collateral circulation that develops to the lower body
coarctation of aorta the obstruction is usually located in the
descending aorta
in preductal coarctation, what part is cyanotic?
the lower half is cyanotic
-marked difference in perfusion b/w the upper and lower halves of the body - lower half is cyanotic - perfusion to the upper half is derived from aorta, while perfusion to lower half is derived primarily from pulmonary artery.
What % of patients with CHD do we see scoliosis in?
are these patients cyanotic or acyanotic?
approx. 19% of pts with CHD
most commonly in cyanotic pts
an attempt to increase pulmonary blood flow, large collateral vessels originating from the aorta may develop… this is the result of:
Eisenmenger Syndrome
3rd stage (delivery of the placenta) can be associated with 3 issues/complications:
- hypovolemia
- uterine atony
- hemorrhage
Tell me about atrial kick:
What is it normally (%)?
When do we most often lose it?
30%
lost in a.fib
ECG may show LV hypertrophy while an ECHO shows
severity
in AStenosis; how would you tx hypotension?
small doses of Neo
with COA, what happens with mortality risk if unrepaired in an adult?
Mortality increases with age:
25% by age 20 —90% by age 60
Common complications of COA in adults include persistent:
- persistent HTN
- aneurysm
- premature coronary atherosclerosis
- LVFailure
during pregnancy in COA, what is exacerbated?
HTN
Pulmonic stenosis is what type of hypertrophy?
concentric
This heart defect obstructs RV outflow and causes concentric RVH and post-stenotic dilation of pulmonary artery:
pulmonic stenosis
Symptoms of Pulmonary stenosis:
same as RVHF:
- fatigue
- SOB
- -peripheral cyanosis w/exertion
Pulmonic Stenosis Goals: -HR: Rhythm: Preload: Afterload: Contractility:
-HR: maintain normal or slightly elevated HR
Rhythm: NSR!!
Preload: augment
Afterload: maintain to CPP; avoid sudden in/decreases
Contractility:
what do you want to avoid with pulmonic stenosis?
Increasing PVR
- hypoxia
- acidosis (pulm vasoconstriction)
- PE
Atrial septal defects (ASD) results from incomplete septal formation.
- What type of shunt is this b/w the atria?
- Name the three types of ASDs
- ASD is Left to right shunt
- Ostium Secundum
- Ostium Primum
- Sinus Venosus
the most common ASD is;
ostium secundum
this type of ASD is located high in the atrial septum
sinus venosus
this type of ASD is located low inthe atrial septum
ostium primum
this type of ASD is at the level of the foramen ovale
Ostium secundum
what type of murmur is associated with ASD?
Holosystolic murmur secondary to MR
- Ostium Primum type
in the absence of CHF, anesthetic responses to inhalation and IV agents with ASD are
generally not altered
** Volatiles decrease SVR and Increase PVR –> decreasing shunt
in ASD, what do we want to AVOID?
- Air in IV tubing
- Increases in SVR (worsen L-to-R shunting)
What conduction defects are common in ASD pts early post op?
SVT and AV conduction defects
This defect is most commonly in the inter-ventrcular septum and causes communication b/w R and LV’s:
VSD
L to R shunt
Name the 4 types of VSDs. Which is most common?
- Membranous VSD (MOST COMMON)
- Muscular VSD
- Supra-cristal VSD
- AV canal type VSD
VSD present with what s/s?
- most asymptomatic
- loud pan systolic murmur along left sternal border
what murmur is heard with VSD? location?
oud pan systolic murmur
along left sternal border
in the absence of CHF, anesthetic responses to inhalation and IV agents with VSD are
generally not altered
These complications are common in VSD pts
Recurrent Pulmonary Infections
CHF
Increases in SVR worsen these types of shunts:
Left to Right
-Goal is to decrease SVR; Volatiles
What post-op complication may present after VSD repair?
3rd HB TROUBLE!!
Goal in VSD patients is to
Increase PVR (induce PPV) avoid a decrease in PVR
Decrease SVR
Left to right shunt reversal syndrome is known as
Eisenmenger’s syndrome (right to left shunt)
situation in which left to right intra-cardiac shunts are reversed d/t INCREASED PVR levels = to or > than SVR
Eisenmenger’s syndrome
Eisenmenger’s syndrome occurs in approx what % of pt w/large VSDs?
50%
Eisenmenger Syndrome the shunt becomes:
RIGHT to Left (cyanotic)
-decreased pulm BF resulting in arterial hypoxemia
clubbing and cyanosis are associated s/s of
Eisenmenger’s syndrome
Common lesion in pts with Down syndrome is:
Atrioventricular septal defects
Atrioventricular septal defects result from inadequate fusion of the endocardial cushions during fetal life. This produces atrial and ventricular septal defects often w/very abnormal
AV Valves
-can produce large shunts in both atria and ventricles
Atrioventricular septal defects often result in mitral and tricuspid regurgitation. this regurgitation leads to what?
volume overload of ventricles
Atrioventricular septal defects shunt in which direction?
initially Left to Right
-with increasing PHTN, Eisenmenger syndrome develops with cyanosis (and RIGHT to left shunting)
persistence of communication b/w the main pulmonary artery and aorta is what defect?
Patent ductus arteriosus (PDA)
Anesthetic goals for PDA are:
like ASD and VSD
-generally unchanged
Treatment of PDA
Indomethacin - result in PDA closure
surgical ligation via left thoracotomy incision after pt is 2 yrs
PDA is associated with what post-op?
HTN
may require tx with vasodilator
PDA is a shunt that goes which direction?
Left to right
Partial anomalous venous return (PAVR) occurs when on or more pulmonary veins drain into the right side of the heart (veins are usually from the right lung).
Entry sites include:
- RA
- SVC
- IVC
- Coronary Sinus
clinical course and prognosis for pts with PAVR is:
excellent
PAVR shunts in what direction?
left to right
“mixing lesions” are also called:
right to left complex shunts
atresia of any one of the cardiac valves represents an extreme form of obstruction. Shunting occurs proximal to the atretic valve and is completely
fixed
in Right to left shunts, survival depends on
another distal shunt; where BF is in opposite direction
- PDA
- PFO
- ASD
- VSD
Tetralogy of Fallot (TOF) is the most common:
cyanotic defect
Name the 4 characteristics of TOF:
- pulmonary stenosis (RV outflow obstruction)
- Overriding aorta
- VSD
- RV hypertrophy
TOF shunts in what direction? a/cyanotic?
Right to left
cyanotic
in TOF; the combination of RV obstruction and VSD results in…
Mixed blood:
-ejection of unoxygenated blood from RV
and
-oxygenated blood from LV into the Aorta
**arterial hypoxemia
Right to left shunting has both FIXED and VARIABLE shunting.
What do each depend on?
Fixed shunt depends on obstruction
Variable shunt depends on SVR and PVR
What is IV Prostaglandin E1 used for?
to keep PDA open in neonatees with severe RV obstruction
-When/if the PDA is allowed to close, these neonates decrease their pulmonary BF and deteriorate rapidly
TET spells occur in what % of children with TOF?
35%
What is the etiology of TET spell?
Hypoxemic cyanotic events exaggerated with changes in magnitude of Right to left shunt
Causes of TET spell include:
- Increased PVR (Crying , acidosis, airway obstruction)
- Increased O2 requirement (infection)
- Decreased Pulm BF d/t spasm (infundibular cardiac muscle)
- Decreased SVR (vasodilation)
- Decreased Blood Vol/ CO (dehydration)
how do you treat a TET spell?
- Hyperventilate - 100% FIO2
- Fluids for volume (10-20ml/kg)
- Neo (5-20mcg/kg)
- Beta blockers (propranolol/ esmolol)
- Morphine
What complication is common in children with severe TOF?
CVA
Anesthetic management of TOF
- Maintain Intravascular Volume and SVR (don’t overload)
- Avoid increase in PVR (acidosis, histamine release, etc)
What is common induction agent in TOF pts?
ketamine
-maintains SVR
Decreasing SVR in TOF patients results in what?
-what considerations do we have for anesthesia regarding this?
-Decreasing SVR will INCREASE Right to left shunt making hypoxemia worse.
(inhalational agents, ganglionic blockers, alpha adrenergic blockers, and vasodilators all will decrease SVR)
Is inhalation induction recommended for TOF (right to left shunts)?
explain
- Not recommended
- R to L shunting slows the uptake of INH agents and
- accelerates IV anesthetics
- oxygenation often improves after induction
Treat hypercyanotic spells with:
IV Neo
Propranolol
Sodium Bicarb (to correct met. acidosis)
monitor for hypovolemia
In tricuspid atresia, blood can only flow out of the RA via ____
PFO (or an ASD)
- a PDA or VSD is necessary for BF from the LV into pulmonary ciruclation
cyanosis is tricuspid atresia is evident at
birth
early survival in pts with tricuspid atresia is dependent on
Prostaglandin E1 infusion
with or w/o other palliative procedures
Preferred surgical procedure for tricuspid atresia
modified Fontan Procedure
Fontan Procedure success depends on maintaining:
- HIGH SVR
2. LOW PVR and LA pressure
- the aorta arises from the LV
- Pulm Artery and Aorta are anatomically switched
Therefore deoxygenated blood returns back into systemic circulation while oxygenated blood returns back to the lungs.
This describes what CHD?
Transposition of the Great ARteries (TGA)
TGA survival is only possible through:
mixing of de/oxygenated blood across the FO and a PDA
-presence of VSD increases mixing and reduces hypoxemia
would you use a prostaglandin E1 infusion for a pt with TGA?
yes
***TGA may occur with a VSD and pulmonic stenosis. This mimics what CHD?
- but what affect does this obstruction have on the heart?
- mimics TOF
- but the obstruction affects the LEFT ventricle, not the right (b/c the pulm valve and aorta are switched)
in a total anomalous venous return defect; which direction is the shunt?
is blood mixing? if so, where?
Right to left
-mixing of de/oxygenated blood occurs at or before the RA level b/c the pulm vein drains into the SVC or IVC, Coronary sinus, or ductus venosus
abesence of a direct connection b/w the pulmonary veins and the LA results in what CHD?
total anomalous venous return
Obstruction in pulmonary venous return results in
severe pulmonary congestion
A single arterial trunk supplies the pulmonary and systemic circulation in this CHD:
truncus arteriosus
A truncus always overrides a VSD. This allows for
both ventricles to eject into it
As PVR decreases after birth, in pts with Truncus arteriosus, pulmonary BF increases greatly. This results in:
Heart Failure
what kind of shunt is truncus arteriosus?
right to left
mixed blood
A Group of defects characterized by Marked underdevelopment of the Left Ventricle is this CHD:
hypoplastic Left Heart Syndrome (HLHS)
Major Characteristics of Hypoplastic Left Heart Syndrome include:
- RV is Main Pumping chamber for both systemic and pulmonary circulations
- LV hypoplasia
- MV hypoplasia
- Aortic (ascending) hypoplasia
- AV atresia
In HLHS, systemic blood flow is dependent on
a PDA
Prostaglandin E1 infusion needed to maintain PDA
What kind of shunt is HLHS?
right to left
this is nearly always a delayed complication of acute rheumatic fever:
mitral stenosis
Mitral stenosis is more often fe/male?
2/3 pts are female
MS is less than 50% isolated as a sole complication.
What complications are often seen in conjunction with MS?
MR Aortic Valve (stenosis or regurg)
MS is a progressive mechanical obstruction to LV diastolic filling resulting in
increased LA volume and pressure
with MStenosis, the LA dilates. If Pulmonary pressure > 25mmHg what happens?
PVR increases –> Pulm HTN
an enlarged left Atrium may apply pressure to surrounding areas. In Mitral Stenosis, this atrial enlargement may present as:
Left RLN injury = Hoarseness
Mitral stenosis effect on a-wave
Prominent A-wave on PCWP
Mitral Stenosis Goals: -HR: Rhythm: Preload: Afterload: Contractility:
-HR: 60-90; avoid Tachy and large increase in CO
Rhythm: NSR; controlled a.fib if present
Preload: MAINTAIN. avoid hypovolemia AND Overload
Afterload: MAINTAIN SVR - move forward
Contractility: Maintain
Anesthesia considerations for Mitral Stenosis:
Anesthesia:
- Epidural over Spinal; vasodilation sensitivity
- AVOID Pancuronium (tachycardia)
- Tx Tachy with Opioid or Beta Blocker (Esmolol)
- Control A.fib with CCB, digoxin
- Neo pref. to tx BP d/t lack of beta agonist activity (avoid ↑HR)
Goal for HR in Mitral stenosis:
avoid tachycardia!
reduction of forward SV due to backward flow of blood into the LA during systole is known as:
mitral regurgitation
chronic MR is usually due to
rheumatic fever
What phase of cardiac cycle is the backward flow of blood in MR (diastole or systole)?
Systole
MV regurgitation is eccentric or concentric?
eccentric
MR reduces _______, but may enhance _____.
reduces LV Afterload
may enhance Contractility
With time, MR causes eccentric LV hypertrophy progressively impairing what?
contractility
- reflected by decreased EF <50%
- regurgitant volume exceeding the forward SV
Mitral Regurg Goals: -HR: Rhythm: Preload: Afterload: Contractility:
Mitral Regurg. Goals: -HR: Increase (brady can increase AL) 80-100bpm Rhythm: NSR Preload: maintain Afterload: reduce Contractility: Maintain / Increase
describe the type of murmur heard with MR:
blowing murmur
best heard at apex
radiates to axilla
**Symptomatic progression of MR
Regurgitant Factor % and symptoms =
Regurgitant Factors < 30% = mild symptoms
Regurgitant Factors 30-60% = moderate symptoms
Regurgitant Factors > 60% = severe symptoms
**When is surgical repair indicated for MR?
when EF is < 0.6 or before the LV ESD is 45 mm or greater
Anesthetic considerations for MR:
- reduce SVR with agents (pts generally do well)
- spinal/epidural well tolerated
- Avoid bradycardia
Can pt with MR receive spinal/epidural?
yes - well tolerated
AVOID bradycardia!!
In cases of moderate to severe MR (30-60% or >60%) what anesthetic changes are required?
opioid based anesthesia
- pancuronium (tachy) + fentanyl
avoid bradycardia
**Inotropes increase contractility, vasodilators decrease afterload.
These changes allow for ….
improved forward flow
Mitral Valve Prolapse is characterized by:
mid systolic click
with or w/o late apical systolic murmur
What disorder is highly associated with MV Prolapse?
Marfan Syndrome (connective tissue d/o)
How do you dx MVP?
ECHO
MVP often has some element of what additional defect?
Mitral regurg.
When are women more susceptible to MVP?
pregnancy
-accommodation of increased volume
What worsens MVP?
DECREASED ventricular volume (PRELOAD)
stay hydrated!
most common dysrhythmias associated with MVP?
PSVT
Anesthetic considerations for MVP include:
*MOST ARE ASYMPTOMATIC AND DO NOT REQUIRE SPECIAL CARE**
- ABX prophylaxis (if systolic murmur greater risk of infective endocarditis)
- beta blocker for V. dysrhythmias
- MR caused by MVP is worsened by decreased Ventricular size:
- — avoid hypovolemia and decreased afterload
what vasopressor would you use in case of MVP?
alpha - adrenergic (NEO) is preferable to beta-adrenergic (ephedrine)
*abnormalities of aortic valve associated with Aortic Regurg are usually
congenital
Abnormalities affected the ascending aorta cause regurg. by dilating the aortic annulus. This can be caused by:
- syphilis
- systic medical necrosis (with or w/o marfan syndrome)
- ankylosing spondylitis
- RA
Acute AR follows:
trauma
infection (endocarditis)
aortic dissection
“TIA”
regurg. volume depends on:
HR!! (diastolic time)
-diastolic pressure gradient across the AV
a slow HR increases regurg d/t increased diastolic time
what type of hypertrophy is Aortic Regurgitation?
Eccentric (volume overload)
Patients with this HD have the largest EDV of any heart disease
Aortic Regurgitation
-the massively dilated heart is often referred to as “Cor bovinum” (massive hypertrophy of LV)
why is angina present in AR in the absence of CAD?
- increased myocardial O2 demand
- reduction in blood supply d/t low Diastolic pressure
*Coronaries are MOSTLY perfused during diastole!
what happens over time to heart with AR?
- Ventricular function deteriorates (late in dx)
- LV EDP and ESV INCREASE (may lead to pulm congestion)
Chronic AR usually presents as:
other symptoms would include?
-CHF! (DOE, Weakness, orthopnea)
- Diastolic murmur (Left sternal notch)
- Widened pulse pressure
- Decreased Diastolic pressure
- Bounding peripheral pulses
- Mitral regurg.
Aortic Regurg Goals: -HR: Rhythm: Preload: Afterload: Contractility:
-HR: Increase / normal 80-100bpm; avoid Brady (increases regurg. vol)
Rhythm: SR
Preload: Maintain; increase to max fwd CO and BP
Afterload: Decrease (keep moving fwd)
Contractility: Maintain
If a vasopressor is needed in AR, which would you use?
Ephedrine
prevent brady = neo can cause reflex brady
what side of the heart is Tricuspid Regurgitation?
right side
***clinically significant TR is most commonly due to dilation of RV from
Pulmonary HTN associated with chronic LVF
TR can also result from:
- infective endocarditis (injecting drug abusers)
- Rheumatic Fever
- Carcinoid syndrom
- Chest trauma
- Ebstein’s anomaly
Describe Ebstein’s Anomaly
downward displacement of the valve b/c of abnormal attachment of the valve leaflets
” a rare, congenital heart defect. In patients with Ebstein’s anomaly, the valve between the chambers on the right side of the heart (the tricuspid valve) does not close correctly.”
Ebstein’s anomaly is often linked to what condition?
Wolff-Parkinson-White syndrome
Tricuspid Regurg Goals: -HR: Rhythm: Preload: Afterload: Contractility:
- HR: Maintain
- Rhythm: NSR
- Preload: Maintain. avoid hypovolemia
- Afterload: Maintain. (avoid increasing)
- Contractility: Maintain
In what condition would PEEP and high mean airway pressures are UNdesirable?
Why?
Tricuspid Regurg.
- reduces venous return and increase RV afterload
What anesthetic gas should be administered with caution (if at all) in patients with Tricuspid regurgitation?
N2O
