Exam 2 - Valvular Heart Disease Flashcards
What is the NYHA Functional Classification of Patients with Heart Disease?
I - Asymptomatic.
II - s/s with activity but relieved by rest.
III - s/s w/ minimal activity, relieved by rest.
IV - s/s at rest
What causes a murmur?
Turbulent flow across abnormal valves
Increased flow across normal valves
Describe functional vs physiologic murmurs?
Functional: innocent murmur
Physiologic: due to conditions outside the heart as opposed to structural defects
Systolic murmurs are caused by what valve pathologies?
- Aortic/Pulmonic Stenosis
- Mitral/Tricuspic Regurgitation
Diastolic murmurs are caused by what pathologies?
- Aortic/Pulmonic Regurgitation
- Mitral/Tricuspid Stenosis
Aortic stenosis
Timing:
Location:
Maneuvers:
Timing: midsystolic crescendo-decrescendo - may radiate to carotids
Location: 2nd ICS RSB
Maneuvers: Increases with squatting, decreases with valsalva and standing
Aortic Regurgitation
Timing:
Location:
Manuevers:
Timing: Early diastolic
Location: Left sternal border
Maneuvers: Increases with hand grip or blood pressure cuff
Mitral stenosis
Timing:
Location:
Maneuvers:
Timing: Mid-diastolic, radiates to left axilla
Location: Apex
Maneuvers: Increases with tachycardia
Mitral Regurgitation:
Timing:
Location:
Maneuvers:
Timing: Holosystolic - radiates to left axilla
Location: Apex
Maneuvers: Increases with hand grip of blood pressure cuff inflation
Tricuspid regurgitation
Timing:
Location:
Maneuvers:
Timing: Holosystolic
Location: Lower left sternal border
Maneuvers: Increases with inspiration
Will have signs of RH failure
Mitral valve prolapse
Timing:
Location:
Maneuvers:
Timing: Late systolic
Location: Apex
Maneuvers: Increaes with standing or valsalva
What 3 findings could you have in patients with valvular disorders?
- Heart failure
- A fib
- Angina pectoris from increased myocardial O2 demand d/t enlarged heart
What factors seen on a chest x-ray would indicate valvular disease?
- Cardiomegaly
- Left Bronchus Elevation
- Valvular Calcifications
What signs seen on an EKG could indicate valvular disease?
- LA enlargement (broad, notched p-wave)
- Axis deviations
- Dysrhythmias
- Ischemia/previous MI
What defines cardiomegaly?
If the heart size is >50 % of the internal width of the thoracic cage
Describe the characteristics of mechanical valves?
- Made of metal
- Very durable (20-30 years)
- Highly thrombogenic (requires anticoagulation)
- Preferred in young patients
Describe the characteristics of bioprosthetic valves?
- Porcine or bovine
- Shorter lasting (10-15 years)
- Low thrombogenic potential
- Better for elderly patients (less inflammatory response, doesnt require anticoagulation)
What should be done for a patient with a mechanical heart valve on warfarin who is having a major surgery?
- D/C warfarin 3-5 days pre op
- Use heparin or LMWH as a bridge until after surgery
Who is most commonly affected by mitral stenosis?
- Women
- Rheumatic patients
What is usually the first sign of rhuematism?
Acute vision changes
What is the normal mitral valve orifice surface area?
4 - 6 cm²
At what surface area do symptoms for mitral valve stenosis start to develop?
< 2 cm²
What are the s/s of mitral stenosis?
- Exertional dyspnea
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Pulmonary edema
- Pulmonary HTN
- A-Fib
How is mitral stenosis treated?
- Rate control (80bpm goal) - tachycardia ↓ LV filling and ↑ LAP
- ↓LAP (diuretics)
- Anticoagulation
- Surgical correction
What drug is preferred to treat hypotension in patients with mitral stenosis?
Why?
- Phenylephrine
- Increases SVR but does not increase HR
What 3 drugs are avoided in patients with mitral stenosis?
- Ketamine
- Pancuronium and Atracurium (causes histamine release)
What is the primary cause of mitral regurgitation?
Usually d/t CAD
Ishcemia causes papillary muscle dysfunction
Why is mitral repair preferred to mitral replacement in patients with regurg?
Repair restores the valves competence and functionality of the MV apparatus
Loss of the MV apparatus causes impaired LV ejection and geometry
What are other treatments for MR?
- MitraClip
- Vasodilators (ACE-I)
- Biventricular pacing
- Carvedilol
What heart rate would you want to maintain with mitral regurgitation?
Normal to slightly increase HR
Bradycardia will increase LV volume overload.
What do you want to avoid in MR patients?
- Increased SVR, causes decompensation of LV
- Give afterload reducer (nitroprusside)
What is the saying for anesthesia for patients with MR?
Full, fast, and forward
What is the most common congenital valvular abnormality?
Bicuspid aortic valve (1-2%)
What is the normal surface area of the aortic valve?
2.5 - 3.5 cm²
What is the surface area of a severely stenotic aortic valve?
< 1 cm²
What type of hypertrophy is seen in aortic stenosis?
Concentric hypertrophy
What symptoms are seen with aortic stenosis becomes critical?
- Angina
- Syncope
- Dyspnea on exertion
____% of aortic stenosis patients will die within three years without a valve replacement
75%
What EKG characteristics would be seen for a patient with aortic stenosis?
- ST depression
- T-wave inversion
CXR findings for aortic stenosis?
- Prominent ascending aorta
- Aortic valve calcification
What surgical treatments are available for aortic stenosis?
- Balloon valvotomy for younger patients
- TAVR
What patients cannot undergo a TAVR?
Patients with a bicuspid AV
What should be avoided in patients with aortic stenosis?
- Hypotension
- Decreased CO
- Bradycardia
- Tachycardia
What is not effective for patients with aortic stenosis?
CPR - impossible to create an adequate SV
Induction concerns for aortic stenosis?
- GETA preferred
- Avoid decreased SVR and hypotension (phenylephrine)
- Avoid tachycardia (esmolol)
Aortic regurgatation is primarily caused by:
- Endocarditis (drug use)
- Rheumantic fever
- Bicuspid aortic valves
CV symptoms of aortic regurgitation?
- Widened pulse pressure
- Decreased DBP
- Bounding pulses
Anesthetic considerations for aortic regurgitation?
- Avoid bradycardia (> 80 bpm) - lends to LV volume overload
- Avoid increased SVR
- GETA
What is the most sensitive indicator of left ventricular myocardial ischemia?
Wall motion abnormalities on Echo
What abnormal pulse is cardiac tamponade associated with?
pulsus paradoxus
What is the best TEE view intra op to monitor for myocardial ischemia?
Transgastric mid-papillary left ventricular short axis view
What medication class blocks angiotensin at the receptor?
ARB - losartan
Sildenafil and ____ are in the same drug class
Milrinone
