Exam II: Valvular Disease Flashcards by Linsley Lloyd

Cardiac output definition

Amount of blood that is ejected from the LV during 1 minute

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Average CO

5 L/min

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Average CI

2.5 L/min/m2

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CO determined by ____ (__-__ bpm), and ___ ___ - the amount of blood ejected from the ____ with each beat (__mL)

HR (70-80 bpm)
Stroke volume
LV
70 mL

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Preload - effective tension of the blood on the ____ or the wall tension at the end of ____

Ventricle
Diastole

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Preload (passive) - flow from ___ to ____ during ____

Atria to ventricle
Diastole

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Preload (active) - volume contributed by the ___ ____

Atrial kick

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Frank-Starling Law:

The greater the wall tension, the greater the myocardial contractility until over distention of the myocardium occurs

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Preload measurement: ____ or ____

PCWP or PADP

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afterload - the ____ ____ that the myocardium needs to overcome to eject the ___ (open the ___ or ____ valves)

wall tension
CO
aortic or pulmonic

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afterload is the pressure within the ____ during peak ____

LV
systole

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afterload is affected by _____ and _____ compliance - ____ and ____, if only ____ is taken into account, ventricular wall tension is not considered

chamber and vasculature
SVR and MAP
SVR

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_____ _____ - the inotropic state that is independent of preload and/or afterload

myocardial contractility

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myocardial contractility - rate of ____ changes over time (__/__)

pressure
(dP/dt)

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myocardial contractility - velocity of contraction developed by ____ ____

cardiac muscle

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myocardial contractility - ____-____ loops

pressure-volume

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myocardial contractility - clinically wide range so comparisons between pts is ____ _____, look at changes in _____ over time for a single patient

not reasonable
contractility

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Pressure-volume loops: denotes ______ pressure and volumes changes during the ____ ____

intraventricular
cardiac cycle

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Pressure-volume loops: simultaneously measure _____ _____ and the resultant _____

chamber pressures
volumes

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Cycle
Phase I –
Phase II –
Phase III –
Phase IV –

Cycle
Phase I – diastolic filling
Phase II – isovolumetric contraction
Phase III – systolic ejection
Phase IV – isovolumetric relaxation

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Pressure-volume loops - distance between vertical lines represents ____

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Pressure-Volume Loop - used to diagram key features of ____ during the ____ ____

LV
cardiac cycle

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SV = ____-____

EDV - ESV

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ejection fraction = % of ____ ejected with each _____

EDV
contraction

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EF = ___/___ x 100

EF = SV/EDV x 100 ex: 80/120 x 100 = 60-70%

minimal increase pressure with ventricular filling reflects ____ character of ____ ventricle

elastic compliant

cardiac work (pressure x volume) = total area of ____ ____ ____

pressure volume loop

pressure volume loop - greater O2 demand with ____ ____ vs ____ ____

pressure work (afterload) vs volume work (preload)

stroke work of the RV 1/7 that of the LV bc ____ much less than ____

PVR SVR

A: end of _____ EDV = 110-150 mL B: beginning of ____ ____ C: end of ____ ESV = 40-80 mL D: begins ___ ____ – diastolic pressure close to 0

diastole systolic ejection systole LV filling

A to B – all valves ____, no change in volume, but ____ pressure

closed increased

B to C – stroke volume = ___-___ mL

60-90

C to D – all valves ____, no change in volume, but _____ pressure

closed decreased

D to A – volume _____ with diastolic filling, pressure ____ only slightly - reflects elastic character of _____ ventricle

increases increases compliant

Changes in Preload - theory: If ___ is increased (preload), ejection of blood to same ____; increased SV, EF

EDV ESV

Changes in Preload - theory: If EDV is decreased (preload), SV _____ as ESV is _____.

decreases unchanged

To examine the independent effects of preload, assume that ____ ____ and ______ pressure (afterload), and _____ are held constant

aortic systolic diastolic inotropy

Increased preload (stretch) means increased ___, increased ___, aortic pressure, increased ____, increased ESV due to decreased velocity [Changes in Preload – Interdependent with Afterload]

SV CO afterload

Decreased preload means decreased ____, decreased ____ ____, decreased ____ [Changes in Preload – Interdependent with Afterload]

SV aortic pressure ESV

An increase in preload (end-diastolic volume represented by red loop in figure) leads to an ____ ___ _____ ____ (width of loop) because of the Frank-Starling mechanism. [Changes in Preload – Interdependent with Afterload]

increase in stroke volume

If aortic pressure is increased, SV, EF are ____ and ESV is _____. [Changes in Afterload - theory]

smaller increased

If aortic pressure is decreased, SV, EF are ____ and ESV is _____. [Changes in Afterload - theory]

increased decreased

Increased SVR leads to decreased ___, increased ____ – this leads to increased ____ (preload), which increases contraction to offset change in SV (healthy) [Changes in Afterload – Interdependent with preload]

SV ESV EDV

Decreased aortic pressure, SV _____, ESV ______, EDV ______ only slightly [Changes in Afterload – Interdependent with preload]

increases decreases decreases

Two pressure-volume loops representing contractions with ____ ____ fractions and ____ _____, but markedly different mechanical work

identical ejection stroke volumes

Greater myocardial work due to higher afterload required to maintain ___ and ___

EF SV

Increased _____ of _____ _____ leads to increased SV, EF and decreased ESV. [Changes in Inotropy]

velocity of fiber shortening

Decreased pressure at a given LV volume (velocity) leads to decreased ___, ____ and increased ____. [Changes in Inotropy]

SV EF ESV

In PV loop diagrams, increased ______ increases the slope of the end-systolic pressure-volume relationship (ESPVR; red dash line in top panel), which permits the ventricle to generate ____ _____ at a given LV volume. Decreasing _____ has the opposite effects; namely, increased end-systolic volume and decreased stroke volume and ejection fraction (bottom panel of figure). [Changes in Inotropy]

inotropy more pressure inotropy

Increased inotropy leads to increased _____ at a given ___ _____; thus increased SV, EF, and decreased ESV. Then, decreased EDV. Increased CO and MAP. [Changes in Inotropy - Interdependent with preload]

pressure LV volume

Decreased ______ leads to increased ESV, decreased SV, EF. Then, increased ____. [Changes in Inotropy - Interdependent with preload]

inotropy EDV

Increased inotropy (red loop in figure) increases the ____ and shifts the end-systolic pressure-volume relationship (ESPVR) to the ____, which permits the ventricle to generate more pressure at a given LV volume. [Changes in Inotropy - Interdependent with preload]

slope left

Exercise leads to increased _____ _____ (increase in EDV); sympathetic stimulation increases ______ – decreased ESV. [Changes in Preload, Afterload, Inotropy during Exercise]

venous return inotropy

with exercise, Combined, small _____ in EDV, large _____ in ESV, _____ SV, EF. ______ BP [Changes in Preload, Afterload, Inotropy during Exercise]

increase decrease increased increased

Exercise is a good example of how simultaneous changes in preload, afterload and inotropy affect ______ ______ _____ ______ (red loop in figure). During whole body exercise (e.g., running, bicycling) increased venous return to the heart generally causes a small increase in end-diastolic volume. [Changes in Preload, Afterload, Inotropy during Exercise]

ventricular pressures and volumes

Valvular Disease - Most commonly affected (2)

mitral and aortic

primary valvular dysfunction - valve leaflets or ____ damage to ____ ____ to cause dysfunction

structural fibrous annulus

Secondary valvular dysfunction – no damage to valve or supporting structure, but dysfunction due to other pathology: ventricular dilation (___), retrograde aortic dissection (___), papillary muscle damage/infarction (___)

MR AR MR

left side of heart is ____ pressure side

higher

Stenosis – _____ of orifice (____ outflow)

narrowing fixed

Stenosis: pressure overload - _____ hypertrophy

concentric

Stenosis: compensation - adding _____ in parallel

sacromeres

Stenosis: _____ wall, decreased ____ of chamber

thicker radius

Insufficiency or regurgitation – flow _____, instead of ____/____ direction

retrograde forward/one

Insufficiency or regurgitation: Volume overload – _____ hypertrophy During ____, __ sources of blood entering

eccentric diastole 2

Insufficiency or regurgitation: Compensation – adding _____ in series

sacromeres

Insufficiency or regurgitation: _____ chamber, ____ radius

dilated increased

____ – both stenosis with insufficiency or insufficiency with stenosis (symptoms will be _____ for one over the other)

Mixed dominant

Sympathetic stimulation – may see _____, ______, ____ _____

anxiety, diaphoresis, resting tachycardia

pre-op eval: severity of disease (3)

- murmur - acute v. chronic - compensatory mechanisms (sympathetic stimulation, ventricular hypertrophy - angina due to increased demand even in the absence of CAD)

pre-op eval: myocardial contractility - _______ and symptoms ____, _____, _____

CHF basilar chest rales, jugular venous distention, S3 sound

pre-op eval: major _____ disease

organ

Murmurs (4) and acronyms to remember them

Mitral Stenosis M.S.D.A. – Diastolic, Apex/Axilla Mitral Regurgitation M.R.S.A. – Systolic, Apex/Axilla Aortic Stenosis A.S.S.S. – Systolic, Sternal Rt Aortic Regurgitation A.R.D.S. – Diastolic, Sternal Rt

Diagnostic tests: EKG Notched p wave – Axis deviation – Dysrhythmias –

Notched p wave – LA enlargement Axis deviation – RV or LV hypertrophy Dysrhythmias – atrial fib

Diagnostic tests: X-ray looking for cardiomegaly - ____ of internal width of thoracic cage valvular _____ and _____ in lungs

>50% calcifications and markings

Diagnostic tests: ECHO looking for _____ measurements, valve ____, _____ _____ across a valve, degree of ______ flow

cavity area pressure gradients regurgitant

Mitral Stenosis (MS) - most common cause _____ _____

rheumatic fever

Mitral Stenosis (MS): ____ progression, may become symptomatic after more than __-__ ___ from incidence of rheumatic fever

slow 20-30 years

Mitral Stenosis (MS) occurs more in _____

females

Mitral Stenosis (MS) symptoms (3)

- dyspnea on exertion - orthopnea - paroxysmal nocturnal dyspnea r/t increased LA pressures

Mitral Stenosis (MS): ______ of valvular leaflets and subvalvular apparatus, commissural fusion, and ______ of annulus and leaflets

thickening calcification

Mitral Stenosis (MS): Symptoms develop when mitral area _______ to less than ____ cm2 (considered severe < ___cm2)

decreases 1.5 1

Mitral Stenosis (MS): obstruction to ____ _____ filling

LV diastolic

Mitral Stenosis (MS): increase in LA _____ and _____. Backs up to cause increase in ______ _____ pressure.

pressure and volume pulmonary venous

Mitral Stenosis (MS): ____, ____, ____ failure may develop. ____ function is preserved - usually normal.

CHF, PHTN, RV LV

Mitral Stenosis (MS): ________ pressure – severe MS >10 mm Hg (normal ____mm Hg)

transvalvular < 5

Mitral Stenosis (MS): Broad notched P waves due to ____ _____

LA enlargement

Mitral Stenosis (MS): stasis of blood in distended LA increases risk of _____ ______

systemic thromboembolism

atrial fib occurs in ____ of severe ____ ____ patients

1/3 mitral stenosis

Mitral Stenosis (MS): may hear opening ____ early in _____ - rumbling diastolic heart murmur

snap diastole

MS treatment: (4)

- diuretics - HR control of Afib with digoxin, beta blockers, CCBs or a combo - anticoagulation - surgical repair

MS - AVOID ______ - causes increased LAP due to decreased LV filling

tachycardia

MS - stasis of blood in ____, esp with _____

LA Afib

MS surgical repair is necessary when _____ _____ and ____ worsening and may include percutaneous ____ _____, surgical ______, valve reconstruction or valve _____

pulmonary HTN and symptoms balloon valvotomy commissurotomy replacement

MS - stasis of blood, risk of embolic stroke is ___-___ per year

7-15%

Anesthetic implications - MS: avoid depression of ____ or facilitation of ___ ____

CO pulm edema

Anesthetic implications - MS: avoid _____ (avoid _____ - reflex ____)

tachycardia hypotension tachy

Anesthetic implications - MS: avoid over _____, ______ position. Careful titration.

hydration trendelenburg

Anesthetic implications - MS: avoid sudden decrease in ____

SVR

Anesthetic implications - MS: avoid _____ and ______ to avoid pulm HTN

hypoxemia and hypercarbia

Anesthetic implications - MS: avoid postop pain - _____ (avoid hypoventilation with subsequent ____ _____)

tachycardia resp acidosis

Anesthetic implications - MS: anxiolytics - be careful about preop _____ _____ - may be sensitive to vent ______ effects

sedative effects depressant

Anesthetic implications - MS: No ______

anticholinergics

Anesthetic implications - MS: be careful of ______ if planning neuraxial block

anticoagulation

Anesthetic implications - MS: _____ is better for slower onset

epidural

Anesthetic implications - MS: avoid ____ - causes increased HR

ketamine

Anesthetic implications - MS: avoid ____ _____ - decreased SVR

histamine release

Anesthetic implications - MS: OPTIMIZE _____ _____ FILLING

DIASTOLIC LV

Anesthetic implications - MS: if hypotensive, treat with _____ or ______ to increase BP without increasing HR

phenylephrine or vasopressin

Anesthetic implications - MS: Goal (5)

- decreased to normal HR - NSR - normal afterload - normal to increased preload (titrate carefully not to overhydrate) - avoid increases in PVR

MS - underfilled ____ with decerased ____

LV SV

Mitral Regurgitation (MR): usually r/t _____

Mitral Regurgitation (MR): may be due to ____, _____ muscle dysfunction, rupture of _____ _____

IHD papillary chordae tendinae

Mitral Regurgitation (MR):

Mitral Regurgitation (MR): can be seen with MVP, _____, ____, ____, cardiomyopathy, systemic ____ _____, ankylosing spondylitis, and _____ syndrome.

endocarditis, trauma, LVH lupus erythematous carcinoid

Mitral Regurgitation (MR): ____ _____ of LA compensated for by vasodilation to promote _____ flow

volume overload forward

Mitral Regurgitation (MR): MR occurs during ____ (unlike ____) from the LV back into the ____ which becomes dilated

systole AR LA

Mitral Regurgitation (MR): _____ is the leading cause of functional MR

IHD

Mitral Regurgitation (MR): is one of the ____ ____ ____ forms of valvular heart disease in the elderly

two most common

Mitral Regurgitation (MR) patho: a portion of the ____ ____ is allowed to flow backward into the _____

LV volume LA

Mitral Regurgitation (MR) patho: leads to ____ _____ ____ and potentially ____ ____ - enlargement, not increased pressure in LA

LA volume overload pulmonary congestion

Mitral Regurgitation (MR) patho: ___ ______ - possibly without symptoms. Increased ____.

LV hypertrophy EDV

Mitral Regurgitation (MR) patho: when the fraction of SV which is _____ is more than ____, this is considered severe MR

regurgitant 0.6

Mitral Regurgitation (MR): determinants of fraction that flows backwards are (3)

1. size of the mitral valve orifice 2. heart rate (duration of ejection) 3. pressure gradients across the mitral valve

Treatment - MR: (3)

1. valve replacement 2. ACEIs, non-selective beta blockers (carvedilol) to decrease SVR 3. biventricular pacing

MR valve replacement - symptomatic patients should undergo surgery even if ___ is ____

EF is normal

MR valve replacement - asymptomatic patients with chronic MR don't _____ from _____ ____ - _____ MR patients do

benefit medical management acute

MR valve replacement - ______ device, high-risk, percutaneous

mitraclip

______ - non-selective beta blocker with alpha 1 blocking effect

carvedilol

Anesthesia Implications - MR: prevent ______ (want normal, slightly increased ___)

bradycardia HR

Anesthesia Implications - MR: prevent increase in ____

SVR

Anesthesia Implications - MR: minimize ______ _______

myocardial depression

Anesthesia Implications - MR: monitor ______ flow. ____ ____ on PAC. TEE.

regurgitant V wave

Anesthesia Implications - MR: GOAL improve forward ____ ____ _____ and decrease portion moving backwards, ____, decrease afterload, normal to increased _____ (avoid rapid volume expansion)

LV stroke volume NSR preload

Anesthesia Implications - MR: ______, _____, _______

FASTER, FULLER, FORWARD

Anesthesia Implications - MR: Bradycardia leads to volume overload of LV – beware of ____ induced bradycardia – can use _____, but be careful to avoid bradycardia

opioid opioids

Anesthesia Implications - MR: Increased afterload leads to _______ of LV – avoid agents that increase ____

decompensation SVR

Anesthesia Implications - MR: Decreased SVR related to _____ is beneficial for these patients

regional

Anesthesia Implications - MR: ______ are good to decrease SVR, but be careful about myocardial depression

volatiles

Anesthesia Implications - MR: Monitoring Asymptomatic – _______ Severe MR – consider ____

Asymptomatic – noninvasive Severe MR – consider PA cath – MR produces v waves on PCWP waveform – changes in size of v wave might help with trending on fluids/management.

Anesthesia Implications - MR: ____ is good

pancuronium

Mitral Valve Prolapse: The movement of ___ or ____ leaflets of the mitral valve back into the LA during ____. May be with or without _____.

one or both systole regurgitation

Mitral Valve Prolapse: ____ ____ valvular disorder __-__, particularly in young _____

most common 2-3% women

Mitral Valve Prolapse: usually ____, but can lead to (5)

benign 1. emboli 2. infective endocarditis 3. MR 4. dysrhythmias 5. sudden death

Mitral Valve Prolapse: ECHO - prolapse of valve ___ mm above mitral annulus

> or equal to 2 mm

Mitral Valve Prolapse: mid systolic ____ and late systolic ____

click murmur

Mitral Valve Prolapse: Primary, anatomic form – redundant, thickened leaflets – typically occurs with ____ _____ disorders such as _____, systemic ______ ______ and in elderly men

connective tissue Marfan's lupus erythematosus

Mitral Valve Prolapse: Normal variant (functional) form – mild _____ and normal appearing _____ – risk similar to general population

bowing leaflets

MVP symptoms (6)

- anxiety - orthostatic hypotension - palpitations - dyspnea - fatigue - atypical chest pain

MVP may include arrhythmias ____ or _____ - both treatable with ____ _____

SVT or ventricular beta blockers

MVP - most have normal ___ ____

LV function

MVP - a larger ventricle will have less ____ than a smaller ventricle - factors that affect ventricular volume and contraction have an impact on the ____ of _____

prolapse quantity of prolapse

Anesthetic considerations - MVP: decrease LV emptying and increase ___ ____

LV volume

Anesthetic considerations - MVP: Avoid (3)

1. sympathetic activity 2. decreases in SVR 3. upright position

Anesthetic considerations - MVP: anticipate dysrhythmias, treat with _____ and ____ ____

lidocaine beta blockers

Anesthetic considerations - MVP: use _____ to maintain SVR

phenylephrine

Anesthetic considerations - MVP: want to avoid ____ ____ by more efficient emptying

decreased size

Anesthetic considerations - MVP: want to decrease emptying - decrease ____ and increase _____, _____ loading

contractility volume volume

Anesthetic considerations - MVP: want _____, pharmacologic decreased inotropic and volume

vasoconstriction

Anesthetic considerations - MVP: goals (5)

1. maintain or increase preload 2. maintain afterload 3. maintain contractility - but dont increase it 4. maintain HR 5. maintain NSR

Anesthetic considerations - MVP: _____ prophylaxis, potential _____

antibiotic endocarditis

Anesthetic considerations - MVP: if MR is present, anesthetic considerations follow those outlines for ____

Aortic Stenosis (AS): commonly seen and is seen with ____

Aortic Stenosis (AS): etiology - degeneration and ______ (elderly), _____ instead of ______ valve (__-__ yrs old)

calcification bicuspid tricuspic 30-50

Aortic Stenosis (AS) patho: Decrease ____ ____ _____ forces an increase in LV pressure to maintain stroke volume (transvalvular gradient of ___ mm Hg)

aortic valve opening 50

Aortic Stenosis (AS) patho: Valve area < ___ cm2 is severe (normal ___-___)

0.8 2.5-3.5

Aortic Stenosis (AS): Increasing incidence with population ____ ____.

growing older

Aortic Stenosis (AS): Other causes might be ____ _____ and _____ ____ ____. Risk factors are similar to _____ – HTN and hypercholesterolemia.

infective endocarditis rheumatic heart disease IHD

Aortic Stenosis (AS): May have angina without ____ due to ____ ____ ____and increase LV work

CAD concentric LV hypertrophy

Aortic Stenosis (AS): classic symptoms (3)

1. angina pectoris 2. syncope 3. dyspnea on exertion (CHF)

Aortic Stenosis (AS): onset of these symptoms correlate to mortality with __, __, and __ years respectively

5, 3 and 2

Aortic Stenosis (AS): murmur - ____- heard best at ____ area - may radiate to neck

systolic aortic

Aortic Stenosis (AS): ____ to determine severity of stenosis - area of valve, transvalvular gradient

ECHO

Anesthetic implications - AS: maintain ____ - ___ kick

NSR atrial

Anesthetic implications - AS: avoid ____ and _____

bradycardia and tachycardia

Anesthetic implications - AS: avoid hypo_____

hypotension

Anesthetic implications - AS: carefully titrate fluid volume to maintain ____ ____ and ____ filling - _____ dependent patients

venous return LV preload

Anesthetic implications - AS: goals - normal to slow ___, ____ (atrial kick), slight increase in ____, increased _____

HR NSR afterload preload

Anesthetic implications - AS: treat hypotension with ____ _____ - doesnt cause tachycardia and thus maintains diastolic filling time

alpha agonists

Aortic Regurgitation (AR): incompetent valves due to ____ ____, infective _____, _____ aortic valve

rheumatic fever, infective endocarditis, bicuspid aortic valve

Aortic Regurgitation (AR): damage due to (5) things

- Marfan's - Ehlers-Danlos - syphilitic aortitis - ankylosing spondylitis - psoriac arthritis

Aortic Regurgitation (AR): acute onset - ____ ____ or _____

aortic dissection or endocarditis

Aortic Regurgitation (AR): flow backwards from ____ into the ____ during diastole

aorta LV

Aortic Regurgitation (AR): both ____ and ____ ____ of LV

pressure and volume overload

Aortic Regurgitation (AR): degree of regurgitant flow determinants (2)

1. time to flow backwards (HR) 2. pressure gradient from aorta to LV (SVR)

Aortic Regurgitation (AR): decreased regurgitant flow related to (2)

1. tachycardia 2. peripheral vasodilation

Aortic Regurgitation (AR): widened ___ ____

pulse pressure

Aortic Regurgitation (AR): decreased _____ pressure

diastolic

Aortic Regurgitation (AR): bounding ____

pulses

Aortic Regurgitation (AR): acute AR - severe volume overload with LV unable to compensate leading to ____, rapid progression to ____ failure

ischemia LV failure

Aortic Regurgitation (AR): chronic AR - LV ____ _____ and LV ______

eccentric hypertrophy enlargement (concentric)

Aortic Regurgitation (AR): eccentric hypertrophy leads to increased _____ ____ _____

myocardial oxygen consumption

Aortic Regurgitation (AR) treatment: decrease systolic _____ and LV ____ ____, improve LV ____ ____, vasodilators and _____ agents such as ____, _____, _____.

HTN wall stress stroke volume inotropic dobutamine, nifedipine, or hydralazine

Anesthetic implications - AR

Anesthetic implications - AR: avoid ______, shorten diastolic time to minimize _____

bradycardia regurg

Anesthetic implications - AR: avoid increase in ____, sudden increases can cause LV failure

SVR

Anesthetic implications - AR: minimize _____ depression, consider using ____ to increase contractility

myocardial inotrope

Anesthetic implications - AR: Goals (4)

- moderate increase in HR - NSR - decrease afterload - normal preload

Prosthetic Heart Valves: _____ v ______

mechanical vs bioprosthetics

Prosthetic Heart Valves: mechanical - durable, for ____, ______

young anticoagulation

Prosthetic Heart Valves: bioprosthesis - porcine, _____, ______. Only lasts __-___ years and for elderly, no ______

bovine homografts 10-15 anticoagulation

Prosthetic Heart Valves: intravascular ______

hemolysis

Prosthetic Heart Valves: ______ prophylaxis

antibiotic

Prosthetic Heart Valves: anticoagulation continued for ____ surgery, coumadin dc'd __-___ days prior to surgery - replaced with ____

minor 3-5 LMWH