FU(10): CHD/Valvular disease

Question 1

Question: A 68-year-old patient with a history of severe aortic stenosis (AS) and compensated left ventricular hypertrophy is undergoing elective non-cardiac surgery. Intraoperatively, which hemodynamic parameter should be most meticulously managed to avoid exacerbating the patient’s condition?

A.) Heart Rate
B.) Preload
C.) Afterload
D.) Contractility

Answer 1

A.) Heart Rate

Question 2

A patient with severe mitral regurgitation (MR) due to rheumatic heart disease presents for surgery. During anesthesia, which of the following is a key management strategy?

A.) Rapid sequence induction to reduce the risk of aspiration
B.) Avoiding excessive fluid administration
C.) Maintenance of a high systemic vascular resistance (SVR)
D.) Using inotropic agents to increase myocardial contractility

Answer 2

B.) Avoiding excessive fluid administration

Question 3

In a patient with aortic regurgitation (AR) and left ventricular dilation, which anesthetic management strategy is the least appropriate?

A.) Inducing mild hypotension to reduce regurgitant volume
B.) Using vasodilators to reduce afterload
C.) Vasodilators are beneficial in AR to reduce afterload, thus decreasing the regurgitant fraction
D.) Maintaining a lower heart rate to enhance diastolic filling

Answer 3

A.) Inducing mild hypotension to reduce regurgitant volume

Question 4

A 72-year-old patient with chronic aortic stenosis (AS) and concentric left ventricular hypertrophy is scheduled for aortic valve replacement. During the perioperative period, which parameter should be most rigorously controlled?

A.) Rapid heart rate
B. Increased afterload
C.) Decreased preload
D.) Reduced contractility

Answer 4

B.) Increased afterload

Question 5

A patient with severe mitral stenosis (MS) and atrial fibrillation (AF) is undergoing elective surgery. What is the most critical aspect to manage intraoperatively?

A.) Rapid control of AF
B.) Aggressive fluid loading to maintain preload
C.) Maintenance of a controlled, moderate heart rate
D.) Administration of high-dose vasopressors

Answer 5

C.) Maintenance of a controlled, moderate heart rate

Question 6

In a patient with advanced tricuspid regurgitation (TR) and right ventricular (RV) dilation, what is the key anesthetic management strategy?

A.) Minimizing preload to reduce RV volume
B.) Avoiding hypotension to maintain coronary perfusion
C.) Using inotropes to enhance RV contractility
D.) Maximizing afterload to improve forward flow

Answer 6

B.) Avoiding hypotension to maintain coronary perfusion

Question 7

For a patient with compensated hypertrophic obstructive cardiomyopathy (HOCM) undergoing non-cardiac surgery, which anesthetic consideration is most critical?

A.) Aggressive fluid administration
B.) Use of high-dose inotropic agents
C.) Reduction of afterload
D.) Avoidance of tachycardia

Answer 7

D.) Avoidance of tachycardia

Question 8

During a complex spine surgery, a patient with mixed valvular heart disease (severe aortic stenosis and moderate mitral regurgitation) experiences sudden hypotension. What is the most appropriate initial management step?

A.) Immediate use of a vasopressor
B.) Rapid fluid bolus
C.) Administration of a beta-blocker
D.) Reducing anesthetic depth

Answer 8

A.) Immediate use of a vasopressor

Question 9

A 68-year-old patient with severe aortic regurgitation (AR) is scheduled for elective non-cardiac surgery. Which hemodynamic goal is most critical during surgery?

A.) Prolonging diastole to decrease regurgitant flow
B.) Decreasing heart rate to maintain coronary perfusion
C.) Decreasing heart rate in AR can extend diastolic time, increasing left ventricular volume overload
D.) Slightly increasing heart rate to reduce diastolic regurgitant

Answer 9

D.) Slightly increasing heart rate to reduce diastolic regurgitant

Question 10

In a patient with severe mitral stenosis (MS) and atrial fibrillation (AF), which management strategy is most critical during anesthesia?

A.) Rapid control of AF
B.) Maintenance of a controlled moderate heart rate
C.) Aggressive fluid loading to maintain preload
D.) Administration of high-dose vasopressors

Answer 10

B.) Maintenance of a controlled moderate heart rate

Question 11

A 25-year-old patient with a history of unrepaired atrial septal defect (ASD) is scheduled for noncardiac surgery. Which of the following anesthetic considerations is most important?

A.) Vigilant monitoring for paradoxical emboli
B.) Avoiding nitrous oxide to prevent increased pulmonary vascular resistance (PVR)
C.) Administration of high-dose opioids to suppress respiratory drive
D.) Use of inhaled anesthetics to maintain systemic vascular resistance (SVR)

Answer 11

A.) Vigilant monitoring for paradoxical emboli

Question 12

A patient with a history of ventricular septal defect (VSD) repaired in childhood now presents for elective surgery. Which of the following findings on preoperative evaluation would be most concerning?

A.) Mild tricuspid regurgitation
B.) Evidence of right ventricular hypertrophy
C.) A small residual VSD
D.) Systemic hypertension

Answer 12

B.) Evidence of right ventricular hypertrophy

Question 13

During the anesthesia for a patient with Tetralogy of Fallot (TOF), which of the following interventions is most likely to decrease the right-to-left shunt?

A.) Increasing systemic vascular resistance (SVR)
B.) Administering a beta-agonist to increase heart rate
C.) Decreasing preload by administering a diuretic
D.) Increasing pulmonary vascular resistance (PVR)

Answer 13

A.) Increasing systemic vascular resistance (SVR)

Question 14

A patient with Eisenmenger syndrome is undergoing a non-cardiac surgery. What is the most appropriate strategy for fluid management in this patient?

A.) Liberal fluid administration to increase preload
B.) Restrictive fluid strategy to avoid pulmonary edema
C.) Balanced fluid administration with close monitoring of hemodynamics
D.) Aggressive diuretics to decrease pulmonary vascular resistance

Answer 14

C.) Balanced fluid administration with close monitoring of hemodynamics

Question 15

In managing a patient with transposition of the great arteries (TGA) repaired with an atrial switch procedure, which of the following is a key anesthetic consideration?

A.) Maintaining low preload to reduce systemic venous return
B.) Administering high-dose beta-agonists to increase right ventricular contractility
C.) Vigilant monitoring for bradycardia due to sinoatrial (SA) node dysfunction
D.) Avoiding premedication to prevent hypotension from decreased left ventricular function

Answer 15

C.) Vigilant monitoring for bradycardia due to sinoatrial (SA) node dysfunction

Question 16

A 30-year-old patient with a history of L-TGA (Levo-Transposition of the Great Arteries) is undergoing a major abdominal surgery. Which of the following considerations is most critical in the anesthetic management of this patient?

A.) Avoidance of high-dose inotropes to prevent systemic ventricle failure
B.) Administration of large volumes of fluid to enhance preload
C.) Vigilant monitoring for systemic ventricular arrhythmias
D.) Ensuring increased pulmonary blood flow to improve oxygenation

Answer 16

C.) Vigilant monitoring for systemic ventricular arrhythmias

Question 17

In a patient with coarctation of the aorta, what is the primary anesthetic goal during non-cardiac surgery?

A.) Ensuring adequate cerebral perfusion pressure
B.) Aggressive lowering of blood pressure to reduce afterload
C.) Rapid induction to reduce stress response
D.) Minimizing fluid administration to prevent heart failure

Answer 17

A.) Ensuring adequate cerebral perfusion pressure

Question 18

A 20-year-old patient with a history of congenital aortic stenosis, who had a balloon valvuloplasty in childhood, presents for elective orthopedic surgery. Which of the following is the most critical anesthetic consideration for this patient?

A.) Administering high doses of vasodilators to reduce afterload
B.) Encouraging hyperventilation to induce respiratory alkalosis
C.) Increasing preload aggressively to optimize cardiac output
D.) Strict avoidance of tachycardia to reduce myocardial oxygen demand

Answer 18

D.) Strict avoidance of tachycardia to reduce myocardial oxygen demand

Question 19

A 35-year-old patient with a history of Marfan syndrome and aortic root replacement is undergoing a laparoscopic procedure. What is the most important anesthetic consideration in this case?

A.) Liberal fluid administration to ensure adequate cardiac output
B.) Avoidance of all volatile anesthetics to prevent myocardial depression
C.) High-dose beta-blockade to reduce heart rate
D.) Strict control of blood pressure to avoid stress on the aortic root

Answer 19

D.) Strict control of blood pressure to avoid stress on the aortic root

Question 20

A 30-year-old patient with a history of unrepaired ventricular septal defect (VSD) is scheduled for non-cardiac surgery. Which of the following anesthetic considerations is most critical in this patient?

A.) Using rapid sequence induction to avoid aspiration risk from left ventricular overload
B.) Maintenance of systemic vascular resistance to avoid exacerbation of left-to-right shunt
C.) Positioning the patient in Trendelenburg to improve venous return
D.) Administering muscle relaxants with vagolytic properties to prevent bradycardia

Answer 20

B.) Maintenance of systemic vascular resistance to avoid exacerbation of left-to-right shunt

Question 21

How does aortic stenosis (AS) primarily alter left ventricular (LV) hemodynamics?

A.) Decreased left ventricular preload
B.) Concentric hypertrophy
C.) Eccentric hypertrophy
D.) Reduced systemic vascular resistance (SVR)

Answer 21

B.) Concentric hypertrophy

Question 22

What is the expected pathophysiological response of the left ventricle (LV) to mixed valvular lesions?

A.) A complex pattern of both concentric and eccentric remodeling
B.) Dilation of the right ventricle to compensate for left ventricular workload
C.) Development of only concentric remodeling due to pressure overload
D.) Purely eccentric remodeling due to predominant volume overload

Answer 22

A.) A complex pattern of both concentric and eccentric remodeling

Question 23

In valvular regurgitation, how does the LV adapt pathophysiologically?

A.) By decreasing preload, causing concentric remodeling
B.) By elevating afterload, leading to a reduction in ejection fraction
C.) By increasing preload, causing eccentric remodeling
D.) By directly decreasing myocardial contractility

Answer 23

C.) By increasing preload, causing eccentric remodeling

Question 24

How does the Frank-Starling mechanism operate in the context of valvular heart disease to sustain LV function?

A.) By accelerating heart rate to augment cardiac output
B.) Through increased contractility in response to enhanced end-diastolic volume
C.) By reducing preload to decrease myocardial oxygen consumption
D.) By augmenting afterload for myocardial efficiency

Answer 24

B.) Through increased contractility in response to enhanced end-diastolic volume

Question 25

Why does a bicuspid aortic valve predispose patients to aortic stenosis?

A.) It causes abnormal leaflet shear stress, leading to thickening and calcification
B.) It reduces coronary artery blood flow, leading to ischemia
C.) It increases the risk of infective endocarditis, causing stenosis
D.) It leads to a decrease in aortic valve leaflet mobility, reducing cardiac output

Answer 25

A.) It causes abnormal leaflet shear stress, leading to thickening and calcification

Question 26

Which clinical manifestation in advanced aortic stenosis indicates severe disease and the need for intervention?

A.) Exertional dyspnea due to diastolic dysfunction
B.) Constant fatigue due to reduced myocardial contractility
C.) Orthopnea and paroxysmal nocturnal dyspnea due to pulmonary congestion
D.) Peripheral edema due to right-sided heart failure

Answer 26

A.) Exertional dyspnea due to diastolic dysfunction

Question 27

During noncardiac surgery, why is it essential to avoid tachycardia in patients with aortic stenosis?

A.) It leads to rapid depletion of myocardial energy reserves
B.) Tachycardia can cause a sudden increase in LV preload
C.) It can trigger atrial fibrillation and subsequent hemodynamic instability
D.) Tachycardia significantly increases myocardial oxygen consumption

Answer 27

D.) Tachycardia significantly increases myocardial oxygen consumption

Question 28

What is the primary compensatory mechanism of the left ventricle (LV) in response to chronic aortic regurgitation?

A.) Concentric hypertrophy
B.) Eccentric hypertrophy
C.) Increased heart rate
D.) Enhanced contractility

Answer 28

B.) Eccentric hypertrophy

Question 29

Why does acute aortic regurgitation lead to more rapid decompensation compared to chronic aortic regurgitation?

A.) Because of increased systemic vascular resistance (SVR)
B.) Due to reduced coronary artery perfusion
C.) Because of immediate LV hypertrophy and dilation
D.) Due to sudden volume overload without compensatory LV remodeling

Answer 29

D.) Due to sudden volume overload without compensatory LV remodeling

Question 30

During anesthesia in a patient with severe aortic regurgitation, why is it important to avoid bradycardia?

A.) It reduces myocardial oxygen supply
B.) It increases SVR, leading to increased afterload
C.) It prolongs diastolic time, increasing regurgitant volume
D.) It decreases LV contractility

Answer 30

C.) It prolongs diastolic time, increasing regurgitant volume

Question 31

During the induction of anesthesia for AR, why is slow titration of propofol beneficial?

A.) It minimizes the risk of myocardial depression
B.) It helps maintain a low normal systemic vascular resistance (SVR)
C.) It prevents a sudden increase in SVR
D.) It reduces the risk of reflex tachycardia

Answer 31

B.) It helps maintain a low normal systemic vascular resistance (SVR)

Question 32

What primary compensatory mechanism is seen in the left atrium in response to mitral stenosis?

A.) Eccentric hypertrophy
B.) Concentric hypertrophy
C.) Atrial dilation and geometric remodeling
D.) Increased contractility

Answer 32

C.) Atrial dilation and geometric remodeling

Question 33

Why does exertional dyspnea occur in patients with mitral stenosis (MS)?

A.) Because of increased pulmonary venous pressure
B.) Due to decreased left ventricular filling
C.) Resulting from direct lung involvement
D.) Due to reduced right ventricular function

Answer 33

A.) Because of increased pulmonary venous pressure

Question 34

During anesthesia, why is the avoidance of tachycardia crucial in patients with mitral stenosis?

A.) To prevent excessive myocardial oxygen demand
B.) To reduce the risk of atrial fibrillation
C.) To minimize pulmonary congestion
D.) To enhance diastolic filling time

Answer 34

D.) To enhance diastolic filling time

Question 35

How does the right atrium primarily respond to tricuspid regurgitation (TR)?

A.) By developing concentric hypertrophy
B.) By dilation to accommodate increased volume
C.) Through significant increase in right atrial pressure
D.) By reducing its compliance

Answer 35

B.) By dilation to accommodate increased volume

Question 36

Why are medications targeting pulmonary hypertension used in managing tricuspid regurgitation?

A.) To decrease pulmonary vascular resistance
B.) To reduce right atrial pressure
C.) To increase right ventricular contractility
D.) To enhance diastolic filling

Answer 36

A.) To decrease pulmonary vascular resistance

Question 37

What is a key hemodynamic consequence of chronic tricuspid regurgitation (TR)?

A.) Increased left ventricular preload
B.) Right ventricular systolic dysfunction and low forward output
C.) Decreased systemic vascular resistance
D.) Left atrial volume overload

Answer 37

B.) Right ventricular systolic dysfunction and low forward output

Question 38

A patient with a mechanical heart valve is undergoing a procedure that requires temporary cessation of anticoagulation. What is the best approach to manage the risk of thrombosis during this period?

A.) Discontinue all anticoagulants immediately before surgery
B.) Use aspirin alone as a bridge during the perioperative period
C.) Transition to low-molecular-weight heparin (LMWH) once INR falls below therapeutic range
D.) Continue vitamin K antagonists up to the day of surgery

Answer 38

C.) Transition to low-molecular-weight heparin (LMWH) once INR falls below therapeutic range

Question 39

A 35-year-old patient with a large ostium secundum ASD is scheduled for elective closure. Which hemodynamic change is most directly associated with this type of ASD?

A.) Increased pulmonary blood flow and right ventricular volume overload
B.) Decreased pulmonary blood flow
C.) Increased left atrial pressure
D.) Decreased right atrial pressure

Answer 39

A.) Increased pulmonary blood flow and right ventricular volume overload

Question 40

What is a likely long-term sequelae in a patient with an unrepaired large ASD?

A.) Decreased right ventricular size
B.) Left ventricular hypertrophy
C.) Pulmonary hypertension and right heart failure
D.) Systemic hypotension

Answer 40

C.) Pulmonary hypertension and right heart failure

Question 41

A 4-year-old child is diagnosed with a moderately restrictive VSD. Which hemodynamic effect is most likely associated with this type of VSD?

A.) Decreased pulmonary blood flow and right ventricular strain
B.) Equalization of left and right ventricular systolic pressures
C.) Decreased left ventricular preload and output
D.) Marked increase in systemic vascular resistance

Answer 41

B.) Equalization of left and right ventricular systolic pressures

Question 42

In patients with large, nonrestrictive VSDs, what is the most likely long-term complication if left untreated?

A.) Development of Eisenmenger Syndrome
B.) Spontaneous closure of the defect
C.) Significant decrease in pulmonary blood flow
D.) Spontaneous conversion to a restrictive defect

Answer 42

A.) Development of Eisenmenger Syndrome

Question 43

A neonate with a significant PDA undergoes surgical ligation. What immediate hemodynamic change is typically observed following successful ductal closure?

A.) Decreased systemic diastolic blood pressure
B.) Increased pulmonary arterial pressure
C.) Increased systemic diastolic blood pressure
D.) Decreased pulmonary venous return

Answer 43

C.) Increased systemic diastolic blood pressure

Question 44

What is a primary indication for the closure of a patent ductus arteriosus (PDA)?

A.) Presence of a PDA in any full-term neonate
B.) Any PDA detected via echocardiography.
C.) Development of significant left-to-right shunt with pulmonary overcirculation
D.) Mild left-to-right shunt without symptoms

Answer 44

C.) Development of significant left-to-right shunt with pulmonary overcirculation

Question 45

What is an important anesthetic goal when managing a neonate with PDA and severe pulmonary hypertension undergoing ductal closure?

A.) Aggressively reducing pulmonary vascular resistance
B.) Maintaining a balance between systemic and pulmonary vascular resistance
C.) Inducing a rapid increase in heart rate
D.) Ensuring profound systemic vasodilation

Answer 45

B.) Maintaining a balance between systemic and pulmonary vascular resistance

Question 46

During anesthesia for a patient with Ebstein Anomaly, what is a key consideration due to the atrialized right ventricle?

A.) Maintaining adequate right ventricular preload
B.) Avoiding drugs that increase pulmonary vascular resistance
C.) Prioritizing rapid sequence induction to reduce the risk of aspiration
D.) Using high doses of inotropes from the start of anesthesia

Answer 46

A.) Maintaining adequate right ventricular preload

Question 47

What is the most appropriate initial response to a hyper-cyanotic spell in a patient with Tetralogy of Fallot during the perioperative period?

A.) Immediate surgical intervention to repair the defect
B.) Rapid fluid depletion to decrease right-to-left shunting
C.) Administration of 100% oxygen and positioning
D.) Administration of high-dose diuretics

Answer 47

C.) Administration of 100% oxygen and positioning

Question 48

Which of the following anesthetic considerations is crucial for a patient with Tetralogy of Fallot?

A.) Prioritizing drugs that reduce right ventricular hypertrophy
B.) Maintaining a balance between pulmonary and systemic vascular resistance
C.) Using deep hypothermic circulatory arrest routinely
D.) Aggressive use of vasopressors to manage systemic hypertension

Answer 48

B.) Maintaining a balance between pulmonary and systemic vascular resistance

Question 49

Why should the use of spinal anesthesia be approached with caution in patients with Eisenmenger Syndrome?

A.) High risk of developing infectious complications postoperatively
B.) Increased likelihood of triggering a hypercyanotic spell
C.) Risk of sudden hypotension worsening right-to-left shunting
D.) Direct negative impact on pulmonary vascular resistance

Answer 49

C.) Risk of sudden hypotension worsening right-to-left shunting

Question 50

In a patient with Eisenmenger Syndrome under anesthesia, what does a sudden drop in oxygen saturation without changes in ventilation indicate?

A.) An acute increase in pulmonary vascular resistance
B.) An adverse reaction to the anesthetic agents used
C.) Development of a new intracardiac shunt
D.) A decrease in systemic vascular resistance

Answer 50

D.) A decrease in systemic vascular resistance