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Health Assessment Sp 25' > Exam 2 Valvular Disease > Flashcards

Exam 2 Valvular Disease Flashcards

1
Q

Prevalence of valvular heart disease in the U.S. ________ %.

A
  • 2.5%
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2
Q

The most frequently encountered cardiac valve lesions produce ________overload or _______overload on the LA or LV.

A
  • Pressure overload (stenosis)
  • Volume overload (regurgitation)
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3
Q

Preoperative evaluation of patients with valvular heart disease includes assessments of what 3 factors?

A
  • Severity of cardiac disease
  • Degree of impaired myocardial contractility
  • Presence of associated major organ system disease (JVD, Kidneys, DM)
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4
Q

Compensatory mechanisms for valvular disease.

A
  • ↑ SNS activity
  • Myocardial Hypertrophy
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5
Q

How will you evaluate the History and Physical Examination of Valvular Disease Patients?

A
  • METs score (exercise tolerance)
  • Cardiac reserve
  • NYHA Functional Classification Class
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6
Q

What are the NYHA Functional Classification of Patients with Heart Disease classes and descriptions?

A
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7
Q

What causes murmurs?

A
  • Turbulent blood flow across abnormal valves (pathological)
  • Increased flow across normal valves (functional/pregnancy)
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8
Q

What valve issues will produce a systolic murmur?

A
  • Aortic Stenosis
  • Mitral Valve Regurgitation
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9
Q

What valve issues will produce a diastolic murmur?

A
  • Aortic Regurgitation
  • Mitral Valve Stenosis
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10
Q

Describe a mid-systolic murmur.

A
  • Occur between distinct S1 and S2 heart sounds
  • Crescendo (louder)–decrescendo (softer) pattern
  • Can be functional
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11
Q

Where is the best place to hear a mid-systolic murmur

A

Right upper sternal border

If murmur radiates towards right carotids, possible aortic stenosis.

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12
Q

What murmur merges with S1 and S2

A
  • Holosystolic Murmur
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13
Q

Where is the best place to hear a Holosystolic Murmur?

A
  • Apex of the heart
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14
Q

Holosystolic Murmur that radiates to the left axilla correlates to what valvular issue?

A
  • Mitral regurgitation
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15
Q

What murmur follows S2?

A
  • Diastolic Murmur

Lub, Dub, Murmur - easiest one to hear

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16
Q

Aortic Stenosis
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:

A
  • Right upper sternal border
  • Midsystolic crescendo-decrescendo mumur
  • Radiation to carotids
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17
Q

Aortic Regurgitation
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:

A
  • Left Sternal border
  • Early diastolic murmur
  • May have ↑ systolic murmur d/t ↑ SV
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18
Q

Mitral Stenosis
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:

A
  • Apex
  • Mid-diastolic murmur
  • Radiation to left axilla
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19
Q

Mitral Regurgitation
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:

A
  • Apex
  • Holosystolic murmur
  • Radiation to the left axilla
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20
Q

Name the auscultation locations.
Aortic:
Pulmonic:
Tricuspid:
Mitral:

A
  • Aortic: 2nd ICS RSB
  • Pulmonic: 2nd ICS LSB
  • Tricuspid: 5th ICS LSB
  • Mitral: 5th ICS Left Mid-Clavicular
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21
Q

Diagnostics EKG:

Broad notched P waves on the ECG suggest _________ enlargement.

A
  • atrial enlargement
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22
Q

Right ventricular hypertrophy will result in a _________ axis deviation?

A
  • Right
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23
Q

This is the most common dysrhythmia presented in valvular disease.

A
  • Atrial fibrillation
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24
Q

CXR diagnostics for valvular disease patients.

A
  • Cardiomegaly
  • Left mainstem bronchus elevation
  • Valvular calcifications
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25
What diagnostic tool can be used to assess: * Cardiac anatomy and function * Presence of hypertrophy * Cavity dimensions * Valve area * Transvalvular pressure gradients * Magnitude of valvular regurgitation * Significance of murmurs * Ventricular EF * Evaluate prosthetic valve function
Echocardiogram
26
What is the purpose of angiography?
* Assess for presence and severity of valvular stenosis and/or regurgitation * Diagnose CAD * Assess for Intracardiac shunting * Assess Transvalvular pressure gradients * Delineate clinical vs echocardiographic findings
27
Describe a mechanical valve
* Valve can be metal or carbon alloy * Very durable, can last 20-30 years * Cons: Highly thrombogenic * Younger patients
28
Describe a bioprosthetic valve.
* Valve can be Porcine or bovine * Short lasting. 10-15 years * Low thrombogenic potential * Elderly patients
29
Patients with valvular disease undergoing surgery will discontinue what medication 3 to 5 days before surgery?
* Warfarin *Oftentimes, patients are on some sort of bridge therapy (heparin).*
30
Warfarin is not recommended in the _______ trimester because it can lead to spontaneous termination of pregnancy.
* First *Pregnant moms are usually on LMHW or ASA.*
31
Name this valve disorder: * Rare in the US * Usually occurs d/t Rheumatic heart disease * Primarily affects women * Asymptomatic for 20-30 years
* Mitral Stenosis
32
Normal mitral valve orifice area: When will symptoms of mitral valve stenosis develop?
* 4-6 cm2 * Symptoms develop when the mitral valve orifice is **less than 2 cm2**
33
How will mitral valve stenosis affect the following LA volume and pressure: LV contractility: SV:
* LA volume ↑/ LA pressure ↑ * No change in LV contractility * SV ↓
34
Mitral Valve Stenosis Signs and Symptoms:
* DOE * Orthopnea * Paroxysmal nocturnal dyspnea * Pulmonary edema * Pulmonary HTN * Atrial fibrillation *Think fluid backing up into the lungs.*
35
What will you see on Mitral Valve Stenosis CXR?
* Mitral calcification * Pulmonary edema or vascular congestion * Elevated left main bronchus * Straightening of left heart border
36
What will you see on Mitral Valve Stenosis Echo?
* Calcification * Left atrial thrombus * Left atrial enlargement
37
Mitral Valve Stenosis will enlarge the left atria, which will show a _________ on the EKG.
* notched P-wave *A-fib can also be seen in mitral valve stenosis.*
38
Mitral Valve Stenosis Treatment
* Rate control w/ β-blockers, CCB, digoxin * ↓ Left atrial pressure w/ Diuretics * Anticoagulation therapy * Surgical correction- Valve replacement
39
Mitral Valve Stenosis Anesthetic Considerations
* Normal HR (80), Volume, and Afterload * Prevent/Treat ↓CO or pulmonary edema (No Trendelenburg, can ↑CHF) * Maintain SVR and BP (Neo, Vaso) * Avoid Pulmonary HTN * Treat diuretic-induced complications (low K+)
40
Neuraxial Anesthesia Considerations for Mitral Valve Stenosis Pts.
* Maintain BP * Maintain Normal HR * Make sure the patient has adequate preload
41
What induction agent do you want to avoid in patients with mitral valve stenosis?
* Ketamine (↑HR) * Atracurium (↑ Histamine release)
42
Name this valve disorder: * Occurs in 2% of the US population * Associated with IHD, Ruptured papillary muscle, Endocarditis, and Cardiomyopathy
* Mitral Regurgitation
43
What conditions will you see eccentric hypertrophy?
* Mitral Valve regurgitation * Aortic Valve regurgitation
44
What type of heart wall thickening happens with aortic stenosis?
* Concentric Hypertrophy
45
Mitral valve regurgitant volume is dependent on:
* Size of the mitral valve orifice * The pressure gradient across the mitral valve
46
Mitral Valve Regurgitation Symptoms
* Holosystolic murmur at apex that radiates to the axilla * Cardiomegaly * Atrial fibrillation
47
Causes of Mitral Valve Regurgitation
* History of IHD * Endocarditis * Papillary muscle dysfunction
48
Mitral Valve Regurgitation Findings EKG CXR ECHO
* EKG: A-fib * CXR: Cardiomegaly, LA/LV hypertrophy * ECHO: Left atrial thrombus
49
Mitral Valve Regurgitation repair is recommended for patients with EF between ____ to ____ % .
* 30 to 60% *For EF < 30%, sugurical intervention will not help.*
50
What device is used to repair mitral valve regurgitation?
* Mitraclip
51
What are the pharmacological/medical treatments for mitral valve regurgitation?
* Vasodilators * Biventricular Pacing * ACE-inhibitors * Carvedilol
52
Anesthetic Considerations for Mitral Valve Regurgitation: * Goal * What do you want to prevent? * HR: * What do you want to avoid?
* Goal: Improve forward SV and ↓ regurgitant fraction * Prevent ↓ CO * HR: Normal to slightly increased HR (90 bpm) * Avoid Bradycardia can lead to LV volume overload * Avoid increased SVR (use nitro)
53
How will neuraxial anesthesia affect the SVR of Mitral Valve Regurgitation Patients?
* ↓ SVR
54
What are the two factors that cause Aortic Stenosis?
* Calcifed aortic leaflets d/t aging * Bicuspid aortic valve (BAV)
55
_______is the most common congenital valvular abnormality, and it affects 1%–2% of the population.
* Bicuspid Aortic Valve
56
Area of the healthy aortic valve: _____cm2 Area of a severely stenotic aortic valve: less than _____ cm2
* 2.5 - 3.5 cm2 * < 1 cm2
57
Aortic Stenotic Symptoms
* Systolic or mid-systolic murmur at right upper sternal border * Crescendo–decrescendo pattern * Murmur radiates to the neck, mimics carotid bruit
58
Classic Symptoms of Critical Aortic Stenosis
* Angina pectoris (↑Risk of peri-op mortality and MI) * Syncope * DOE *The onset of these symptoms has been shown to correlate with an average time to death of 5, 3, and 2 years, respectively.*
59
______ % of symptomatic pts with aortic stenosis die within 3 years without valve replacement
* 75%
60
Aortic Stenosis Diagnostic Findings CXR: ECG:
**CXR** Prominent ascending aorta Aortic valve calcification **ECG** LV hypertrophy ST Depression T wave inversion
61
Aortic Stenosis Diagnostic Findings ECHO: Exercise Stress Test:
**Echocardiogram** Discern b/w 3 or 2-leaflet valve Thickened and calcified Valve area and transvalvular pressure gradients **Exercise stress testing** Poor exercise tolerance &/or abnormal BP with exercise
62
Aortic Stenosis Surgical Treatment
* Treatment is usually started when patients become symptomatic * Balloon valvotomy for adolescents/young adults * Transcatheter aortic valve replacement  (TAVR)
63
Anesthetic Considerations for Aortic Stenosis: What do you want to prevent or avoid? HR: What do you want to optimize?
* Prevent and avoid hypotension, ↓CO, bradycardia, tachycardia, ↓SVR * Maintain NSR (80 bpm) * Optimize intravascular fluid volume.
64
CPR is not effective for this valvular disorder.
* Aortic Stenosis
65
Why is General Anesthesia preferred over epidural or spinal for aortic stenotic patients?
General anesthesia is often preferred to epidural or spinal anesthesia because the sympathetic blockade produced by regional anesthesia can lead to significant hypotension.
66
What pressor would you want to use if an aortic stenosis patient experience hypotension?
* Phenylephrine (α-agonist) *α-agonist do not cause tachycardia and therefore maintain diastolic filling time.*
67
What drug would you want to use if an aortic stenosis patient experience tachycardia?
* Esmolol (short-acting β1 selective-blocker)
68
Name the valve disorder. * Failure of aortic leaflets caused by disease of the aortic leaflets or aortic root * Caused by Endocarditis, Rheumatic fever, Bicuspid aortic valve (BAV), Anorexigenic drugs (phen-phen) * Decrease CO d/t regurgitant SV * Usually a slow onset
* Aortic Regurgitation
69
The magnitude of aortic regurgitation is dependent on:
* Time available for regurgitant flow (HR) * Pressure gradient across the aortic valve (SVR)
70
↑ SVR in Aortic Valve regurgitation =
* more regurgitant *Lower SVR, more flow forward*
71
Aortic Valve Regurgitation's Effect on EF.
* Decrease EF over time
72
In what valvular condition will you hear a low-pitched diastolic rumble called an **Austin-Flint murmur**?
* Aortic Regurgitation
73
Aortic Regurgitation effect on Pulse Pressure DBP Pulse Characteristics
* Widened Pulse Pressure * Decrease DBP * Bounding Pulses
74
What are the manifestations of LV failure in aortic regurgitation patients?
* Dyspnea * Orthopnea * Fatigue * Coronary ischemia
75
Acute Aortic Regurgitation will result in severe ______ volume overload.
* LV
76
Symptoms of Acute Aortic Regurgitation.
* Coronary Ischemia * Rapid Deterioration of LV function * Immediate Heart Failure
77
Aortic Regurgitation Dx Findings EKG CXR ECHO
**EKG/CXR** LV enlargement and hypertrophy **ECHO** Leaflet prolapse or perforation
78
What are the medical treatments for aortic regurgitation?
* Decrease systolic HTN * Decrease LV wall stress * Improve LV function * Diuretics, ACE-I, CCB
79
What are the surgical treatments for aortic regurgitation?
* Aortic Valve Replacement * Aortic Root Replacement
80
Anesthetic considerations for aortic regurgitation. Goal: Avoid: HR: Minimize
* Goal is to maintain forward LV SV * Avoid ↓HR, avoid ↑SVR * HR: > 80 bpm * Minimize myocardial depression (use vasodilator to ↓ afterload and Inotrope to ↑ contractility)
81
What type of anesthesia is preferred for Aortic Regurgitation?
* General Anesthesia

Health Assessment Sp 25' (35 decks)

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