Module 3: Anesthetic Management for Patients with Cardiovascular Disease

Question 1

Coronary Artery Disease

Preventing myocardial Ischemia
Avoid factors known to increase ______

Principle determinants of MVO2:

Answer 1

• MVO2

Wall tension
Contractility

Question 2

Myocardial O2 balance with CAD

1. Typically __________ at rest
2. Exercise/stress increases MVO2
   - Ischemic symptoms develop
   - O2 requirements greater than existing __________
   - Coronary vascular reserve is _______.

3. Ischemic symptoms develop:

Answer 2

1. asymptomatic
2. coronary blood flow; exceeded

• Angina
• Alterations in electrophysiology, metabolism, function

Question 3

Myocardial O2 balance with CAD

Obstructions
* ________ conductance vessels
* Normally, the resistance is almost ______

As the percent of stenosis increases, the ________ across the stenotic area increases
1. Resistance begins to increase when lumen is reduced by > ______%
1. Further _______, resistance increases dramatically
1. 80-90% stenosis, resistance across stenosis _________.
1. Small changes in vessel diameter can dramatically _______ resistance and ______ CBF.

Answer 3

Obstructions
* Large epicardial
* zero

resistance.
1. 50
2. restrictions
3. triples
4. increase; decrease

Question 4

Remember Laplace’s Law

• Wall tension is _______ proportional to intracavity pressure and radius
• Wall tension in _______ proportional to wall thickness

Can decrease MVO2 by:
* ______ intraventricular pressure
* Preventing or promptly treating _________.

Answer 4

• directly
• inversely

• Decreasing
• ventricular distention

Question 5

Preload and Afterload

Answer 5

Question 6

Myocardial Oxygen Supply

The only way to meet increasing myocardial O2 demands is by increasing ___________.

Answer 6

CBF

Question 7

Coronary Blood Flow

Critical factors/modifiers:

What area of the heart is most vulnerable to ischemia?

Answer 7

• Perfusion pressure
• Vascular tone of the coronary circulation
• Heart rate (time available for perfusion)
• Severity of intraluminal obstructions
• Presence of collateral circulation

Subendocardium of the LV

Question 8

Myocardial O2 balance with CAD: Compensatory Mechanisms

Collateral circulation
* Develops and matures over time
* Physiologic bypass of the obstructed vessels

Resting CBF maintained by progressive _______ at the microcirculation
* As proximal stenosis increases, _______ seeks to preserve flow
* Basal flow can increase ___-__ times with maximal vasodilation

Coronary vascular reserve progressively decreases and flow becomes ________.

Answer 8

vasodilation
- autoregulation
- 4-5

• pressure dependent

Question 9

Hemodynamic Goals for Coronary Artery Disease

Goals:
Define risk
Determine need for further testing
Form a safe anesthetic plan
Need for additional medications (beta blockers or anti-hypertensives)
Interventional therapies
Surgery

Recognize the S & S of:
uncontrolled HTN,
myocardial ischemia,
CHF,
valvular heart disease, and
cardiac dysrhythmias

What are the risks of a perioperative event?

Answer 9

Question 10

Goldman Cardiac Risk Index

Studied over 4,000 patients aged 50 years or older who were having elective, major noncardiac procedures

Found 6 independent predictors of complications

Complications increased with number of risk factors present

1
2
3
4
5
6

Answer 10

Question 11

Patients with Symptomatic CAD

• Preoperative Evaluation may show changes in frequency or pattern of angina symptoms
• Some patients may have more atypical or undiagnosed (silent) features: (3)
• _________ is associated with high perioperative risk of MI
• Perioperative period associated with __________ state an increase in endogenous catecholamines (increasing risk of MI)

Answer 11

Elderly
Women
Diabetics
/—-/
Unstable angina
/—-/
hypercoagulable

Question 12

Preoperative Evaluation: HISTORY of CAD

HTN: severity and duration, medications
Smoking
High cholesterol

Symptoms of any conditions
* Myocardial ischemia
* Ventricular failure
* PVD
* Diabetes (higher incidence of CAD, silent MI and ischemia)
* Chest pain, exercise tolerance, SOB
* Edema

Valvular Disease s/s:

Cardiac stents, implantable devices

Answer 12

Angina, dyspnea, syncope, CHF

Question 13

PHYSICAL EXAM

HEART SOUNDS
1. MURMURS
1. PMI LATERAL TO NORMAL (_______)
1. S4 GALLOP (______)
1. CAROTID BRUITS (_________)

LUNG SOUNDS
1. Pulmonary RALES AND S3 GALLOP (____)

BLOOD PRESSURE MEASUREMENT (SUPINE AND STANDING)

ORTHOSTATIC CHANGES
(VOLUME DEPLETION, HEMORRHAGE, EXCESSIVE VASODILATION)

One study showed: Admission BP and HR was the best predictor of response to laryngoscopy (anxiety?)

Answer 13

HEART SOUNDS
1. CARDIOMEGALY
2. LVH
3. VASCULAR DISEASE AFFECTING CORONARY CIRCULATION

LUNG SOUNDS
1. CHF

Question 14

Electrocardiogram

Provides info on state of the _____ and _________

Rate, Bundle branch blocks, lv

Old injuries/infarcts

Pacer spikes

Conduction abnormalities

Answer 14

myocardium and coronary circulation

Question 15

Abnormal “Q” waves

1. Highly suggestive of _____.
2. 30% of myocardial infarctions occur without symptoms (silent MI) with highest incidence in ____ and _____.
3. Presence of Q wave on preoperative EKG in a high risk patient = high indication of ______ and ______.

Answer 15

1. past MI
2. diabetics and hypertensives
3. increased perioperative risk and possible active ischemia

Question 16

Preoperative Evaluation might include:

CXR
________ results : (LVH, DIASTOLIC AND SYSTOLIC FUNCTION ESPECIALLY IN HEART FAILURE)
Cardiac tests
LABORATORY FINDINGS
RENAL: SERUM CREATININE AND BUN LEVELS
POTASSIUM (DIURETICS, DIGOXIN OR RENAL IMPAIRMENT, EKG CHANGES/ECTOPY)
Magnesium
Hemoglobin/Hematocrit

Answer 16

ECHO

Question 17

Surgical Procedure Risk

Major _______ procedures associated with highest incidence of complications

ACC/AHA risk stratification

Other high risk procedures:

Answer 17

• vascular
  /—–/
• Abdominal
• Thoracic
• Orthopedics

Question 18

2014 ACC/AHA guidelines

Answer 18

Question 19

Importance of Exercise Tolerance

Exercise tolerance is one of the most important determinants of perioperative risk and the need for further testing and invasive monitoring

Good exercise tolerance suggests that the myocardium can be stressed without failing (climbing two flights of stairs or walking 4 blocks)
Assessed with a questionnaire that assesses daily activity
(hip/knee issues?)
Treadmill testing

Answer 19

Question 20

Answer 20

Question 21

Choice of Anesthetic - Regional (CAD)

Regional anesthesia
Dense analgesia
Blockade of afferent and efferent nerve conduction (catecholamine release is _________)

Major disadvantages
1. __________ from sympathetic block
1. Increase in wall tension with ________ could precipitate subendocardial ischemia w/CAD
* Alpha-agonist may be better
* Large volume loads may be problematic after return of vascular tone

Answer 21

• suppressed

Major disadvantages
1. Hypotension
2. volume loading

Question 22

Choice of Anesthetic: General (CAD)

General anesthesia with ______
- Lack of myocardial depression (desirable in patients with markedly impaired ____________)
- Suppression of stress response
- Reduction of HR
- Hemodynamic stability

Can supplement with volatile anesthetics

Muscle relaxants

Emergence: relatively comfortable and _________ avoidance.

Answer 22

• Opioids
• ventricular function
• hypothermia

Question 23

Selection of Anesthetic (CAD)

There is _____ ideal anesthetic for patients with CAD

Opioids
Advantages: lack of myocardial depression, stable hemodynamic state and reduction of heart rate

High dose valuable only in the patient with severe __________.

Inhalational
Dose-dependent hemodynamic changes, reversible, titratable myocardial depression, suppression of sympathetic responses to surgical stress
Protect the myocardium from______and ________ and reduces _______ size
Disadvantages:
- ______.

Adjuncts: propofol, midazolam, dexmedetomidine

Answer 23

• no

Opioids:
myocardial dysfunction

Inhalational:
- ischemia and reperfusion injury; infarct
- systemic hypotension

Question 24

**Treatment of Intraoperative Problems ** (CAD)

Sinus tachycardia
* Increase anesthesia
* Beta blockers

Increase PCWP
* _________.
* Restrict fluids
* Volatile anesthetic with good LV function

HTN
* Anesthesia,
* vasodilators,
* beta blocker if tachycardia

Hypotension
*___________, if transient and not hypovolemic
* Volume, if hypovolemic
Inotrope
* Associated with increase PCWP and decrease CO
* Increase MVO2 offset by increased CPP and decreased ventricular size

• _________: Maintains perfusion pressure and keeps heart small

Answer 24

Increase PCWP
- Ntg (add inotrope or alpha agonist if decrease in BP

Hypotension
* Alpha agonist
* Neo/NTG

Question 25

# Pathophysiology of Valvular Heart Disease 1. Causes chronic ______ and _______ overload 1. Ventricular Hypertrophy: increased __________. 1. _________ overload: **Concentric** (_______ ventricular wall thickness, ________ chamber size) 1. ________ Overload: **Eccentric** (_________ wall thickness and _________ cardiac chamber)

Answer 25

1. volume and pressure overload 1. increased left ventricular mass 1. Pressure overload: **Concentric** (**increase** in ventricular wall thickness, **normal** chamber size) 1. Volume Overload: **Eccentric** (normal wall thickness and dilated cardiac chamber)

Question 26

# Valvular Heart Disease 1. **Should have a high index of suspicion** if patient has a history of: 1. Exercise tolerance usually **decreased** 1. Exhibit signs/symptoms of **heart failure** to include: 1. Angina can occur in patients with: 1._______ often accompanies enlargement of the atria

Answer 26

1. rheumatic fever, IV drug abuse, genetic disorders (i.e., Marfans), heart surgery as a child, or heart murmurs 2. -- 3. dyspnea, orthopnea, fatigue, pulmonary rales, jugular venous congestion, hepatic congestion, or edema 4. hypertrophied left ventricle 5. A-Fib

Question 27

# Concetric vs. Eccentric HF

Answer 27

Question 28

# Tests to evaluate valvular heart disease: **Echocardiography** with doppler can: **EKG**: Evidence of ischemia, arrhythmias, atrial enlargement, ventricular hypertrophy **CXR**: **Cardiac Cath**:

Answer 28

**ECHO:** * Measures size and function of the chambers * Pressure gradients of the valves * Valve area measurements * Severity of disease determined **CXR** * enlargement of chambers, * pulmonary HTN, * pulmonary edema and effusions **Cardiac Cath**: * used before surgery to diagnosis CAD, * measurement of heart pressures in the chambers and pressure gradients across valves

Question 29

# Transesophageal Echocardiography (TEE) * Can be used in the OR during **valve surgery** * Evaluate severity of **valvular disease, structural and functional changes** * Evaluation of the **valve repair or function of artificial valves** * ______ and ______ function of the Left and right ventricles before and after bypass * Determines postsurgical management

Answer 29

* Systolic; diastolic

Question 30

# Pressure-Volume Loops * Plots LV pressure against volume through one complete cardiac cycle * Each valvular lesion has a unique profile that suggests compensatory physiologic changes by the left ventricle

Answer 30

Question 31

# P-V Loops: Valve disease

Answer 31

A = normal B = mitral stenosis C = aortic stenosis D = mitral regurgitation (chronic) E = aortic regurgitation (chronic)

Question 32

# Aortic Stenosis (AS) 1. **Most common valvular disease** in the U.S. 1. Normally, composed of _____ semilunar cusps 1. Classified as ______, _______, or ________ obstruction 1. _________ hypertrophy develops:

Answer 32

1. - 2. 3 3. valvular, subvalvular, or supravalvular 4. Concentric: thickened ventricular wall with normal chamber size

Question 33

# Pathophysiology of **Aortic Stenosis** 1. Decreasing LV _______ accompanies _______ LV end-diastolic pressure 1. ______ and _________ can be maintained until late disease process 1. Atrial contraction account for ______ of the ventricular filling (normally _____) 4. Clinical factors associated with AS: ## Footnote 5. Causes:

Answer 33

1. compliance; elevated 2. Contractility and ejection fraction 3. 40%, 20% 4. * Older, male, smoker, HTN, Hyperlipidemia ## Footnote * Rheumatic fever (more common in developing countries) * Calcification of tri-leaflet * Congenital bicuspid valve

Question 34

# Presentation of Aortic Stenosis **Angina** * Angina can occur in the absence of CAD * Thickened myocardium is susceptible to ______ and elevated ___________ that decrease coronary perfusion pressure **Syncope** **CHF** Tighter AS, __________ increases to a level where LV hypertrophy can not normalize the wall tension so the heart starts to _______ with symptoms of **systolic dysfunction** and decreasing **cardiac output** ## Footnote **Life expectancy with symptoms of:** Angina: ____ years Appearance of syncope: ___-__ years Appearance of CHF: ___-__ years

Answer 34

**Angina** - CAD - ischemia; LV end-diastolic pressure **CHF** - LV systolic pressure - dilate ## Footnote - 5 - 3 - 4 years - 1 - 2 years

Question 35

# Aortic Stenosis

Answer 35

Question 36

# **P-V loop for Aortic Stenosis** 1. Left ventricle is working at higher _________ to generate normal SV 1. Elevated wall tension stimulated parallel replications of _______ 1. So… ______ and ______. 1. Increased _________ to accomplish the pressure work

Answer 36

1. intraventricular pressure 2. sarcomeres 3. myocardial thickening and LV hypertrophy 4. contractility

Question 37

# Anesthetic/Hemodynamic goals: AS **Preload**: **Afterload**: **Contractility**:

Answer 37

**Preload**: full to fill the noncompliant ventricle **Afterload**: maintain coronary perfusion gradient, *reduction in BP with decrease CPP risk of subendocardial ischemia and sudden death* **Contractility**: maintained to overcome the high-pressure gradient through the valve

Question 38

# Anesthetic/Hemodynamic Goals: AS **Rate**: **Rhythm**: **MVO2**:

Answer 38

**Rate**: NORMAL: avoid **bradycardia** (decreases CO with fixed stroke volume) and **tachycardia** (ischemia with limited diastolic time for coronary perfusion) **Rhythm**: sinus (important in atrial contraction in LV filling); cardioversion if hemodynamic compromise and arrhythmia **MVO2**: avoid tachycardia and hypotension (ischemia is big risk)

Question 39

# Anesthetic Management: Aortic stenosis **Monitoring:** Standard, 5-Lead, A-Line, PA/TEE depends on type of surgery, defibrillator handy **Induction**: Regional: SAB is relatively ________ in severe AS (sympathectomy) General: **Maintenance**: Maintain HR, treat tachycardia immediately Treat arrhythmias with **cardioversion** Treat hypotension immediately

Answer 39

- contraindicated - heavy opioid/benzo technique, volatiles fine

Question 40

# “The Death Spiral in AS” In severe or critical AS, * Any drop in SBP for any reason can result in the viscous cycle * Chest compressions are ineffective (difficult to generate enough mechanical force to create adequate SV across the stenotic valve * Resulting in sudden death

Answer 40

Question 41

# Aortic valve

Answer 41

Question 42

# Pathophysiology of Aortic Insufficiancy (AI) 1. ________, ___________, ________, and _________ are among the most common causes of AI 1. Acute AI causes: 1. Chronic AI: 1. ___________ hypertrophy:

Answer 42

1. Rheumatic fever, aortic root dilation, congenital bicuspid aortic valve, and infective endocarditis 2. infective endocarditis, aortic dissection (Marfan syndrome), after balloon valvotomy or failed surgical valve repair 1. LV diastolic volume overload (Stroke volume regurgitates back across the valve in diastole.) 1. Eccentric : (dilated LV with normal or thickened wall)

Question 43

# aortic regurgitation

Answer 43

Question 44

# P-V Loop in “**acute**” AI 1. EDV and ESV _______ 2. Contractility __________ (myocardium overstretched) 1. ______ may be increased, decreased or normal 1. LV volume _________ during isovolumetric relaxation (D-A segment) 1. EDP (A-B segment, B point) is _____

Answer 44

1. increase 2. decreased 2. SV 3. increasing 4. high

Question 45

# P-V Loop in “**chronic**” AI 1. _____, _______ and _____ enlarged 1. Cardiac output ______ 1. Contractility _______ 1. LV volume __________ during isovolumetric relaxation (D-A segment) 1. EDP (A-B segment, B point) _______ 1. Diastolic reserve ______

Answer 45

1. EDV, ESV, SV 2. normal 3. decreased 4. increasing 5. normal 6. intact

Question 46

# Anesthetic/Hemodynamic goals in AI **Preload**: **Afterload:** **Contractility**: **Rate**: **Rhythm**: **MVO2**:

Answer 46

**Preload**: Increase slightly, necessary for forward flow **Afterload:** Reduction augments forward flow; increase anesthetic depth or vasodilators (to decrease regurgitant fraction) **Contractility**: Usually adequate; maintain with beta-agonists; dobutamine is ideal (does not increase afterload) **Rate**: Increase→ improves forward flow by decreasing diastolic duration and decreasing regurgitant flow and increasing EF Also improves coronary perfusion **Rhythm**: Usually sinus **MVO2**: Usually not a problem

Question 47

# Anesthetic Management in AI Monitoring and preop management same as aortic stenosis **Induction**: * Regional: * General: **Maintenace**: Phenylephrine or Ephedrine to treat hypotension?

Answer 47

* Regional: may have an advantage of decreasing SVR and therefore afterload * General: Ketamine/Pancuronium may be useful to increase HR

Question 48

# Pathophysiology of **Mitral Stenosis** 1. causes: 2. Symptoms: 3. Worsened in conditions that need increased _______. 1. Blood stasis in left atrium (dilated LA) risk of: 1. _______ years before critical stenosis manifests (normal = ___-___ cm2; stenosis = ______cm2) 2. Develop:

Answer 48

1. causes: **Rheumatic disease **(80-90%), *infective endocarditis* (3.3%), *mitral annular calcification* (2.7%) 2. fatigue, dyspnea on exertion, hemoptysis, diastolic murmur 3. CO (pregnancy, anemia, exercise) 4. thrombus formation and SVT/A-Fib 5. **20+**/////**4-6**////**1.5** 6. hoarseness

Question 49

# Rheumatic fever/heart disease **Rheumatic fever:** _______ issue, usually in underdeveloped/developing countries where antibiotics are not routine **Rheumatic heart disease:** Cardiac *inflammation and scarring* triggered by an autoimmune reaction to infection with _______________. **Acute stage:** consist of ________. **Chronic stage**: ___________. Stenosis usually starts in **females** and up to _______ years after rheumatic heart disease diagnosis (progressive calcification and fusion of leaflets)

Answer 49

1. Childhood 2. group a streptococci 3. pancarditis (inflammation of the myocardium, endocardium, and epicardium) 4. valvular fibrosis (stenosis and/or insufficiency); 2

Question 50

# Mitral Stenosis

Answer 50

Question 51

# Anesthetic/Hemodynamic goals: MS **Preload**: **Afterload**: prevent _____; _______ RV afterload due to pulmonary vasoconstriction (hypoxia and _______); vasopressors for systemic hypotension **Contractility**: _______ for adequate filling of lv (atrial contraction contributes _____% of SV) **Rate**: Maintain at __________; avoid and treat __________. **Rhythm**: Control ventricular response in ___________. **Mvo2**:

Answer 51

**Preload**: good intravascular volume to maintain flow across stenotic valve, **avoid overhydration** **Afterload**: prevent increase; increase RV afterload due to pulmonary vasoconstriction (hypoxia and hypercarbia); vasopressors for systemic hypotension **Contractility**: sinus rhythm for adequate filling of lv (atrial contraction contributes 30% of SV) **Rate**: Maintain at low end of normal; avoid and treat tachycardia **Rhythm**: Control ventricular response in atrial fib **Mvo2**: Not a problem usually

Question 52

# Anesthetic/hemodynamic goals: MS **Objective** Maintain NSR, avoid ________ and large increases in ________ (both hypovolemia and fluid overload) **Monitoring** _________ to help guide perioperative management (fluids) Invasive monitoring dependent on type of surgery **Choice of agents** 1. Sensitive to vasodilating effects of: 1. Vasopressors to maintain vascular tone (neo? Ephedrine?) 1. Avoid intraoperative _________. 1. Adequate level of anesthesia to avoid:

Answer 52

**Objective** tachycardia; CO **Monitoring** TEE **Choice of agents** 1. SAB or epidural (pregnancy?) 2. ? 3. tachycardia (beta blockers, opioids) 4. sympathetic stimulation (SVR, PVR increases)

Question 53

# P-V Loop in Mitral Stenosis 1. _____ and _______ small (limited flow into the left ventricle) 1. LV generates _________. 1. Contractility is _________ (chronic _______ of the LV)

Answer 53

1. EDV, SV 2. low BP 3. decreased; decreased;

Question 54

# Etiology of **Mitral Regurgitation (MR)** 1. Results from any process that distorts the: **Organic MR** * _______. * _______. * _______. * _______. **Functional MR** * May have normal: * Often occurs from:

Answer 54

1. - mitral leaflets, - chordae tendineae, - papillary muscles, - valve annulus or - left ventricular geometry **Organic MR** * Mitral valve prolapse (most common), * rheumatic heart disease, * mitral annular calcification, * endocarditis **Functional MR** May have normal **mitral leaflets** and **chordal structures** Often occurs from **ischemic heart disease (IHD) or dilated cardiomyopathy**

Question 54

# Etiology of MR **Secondary to abnormalities of chordae tendineae** (3) ## Footnote **Papillary muscle dysfunction** (2)

Answer 54

* Rupture with acute myocardial ischemia or infarction * Bacterial endocarditis * Mitral prolapse ## Footnote * Ischemia of the posterior papillary muscle (blood supply from RCA) * Endocarditis

Question 55

# Etiology of MR **Acute MR** * Typically presents in _______. * Significant regurgitation into the LA with __________. * Precipitous increase in ____ and _______ * ______________ may develop rapidly. **Chronic MR** * __________ * Regurgitant volume over time causes atrial and ventricular ______ and __________.

Answer 55

**Acute MR** 1. Typically presents in pulmonary edema 1. Significant regurgitation into the LA with normal compliance 1. Precipitous increase in LAP and PCWP 1. Cardiogenic shock may develop rapidly **Chronic MR** * Progressive * enlargement and annular dilation

Question 56

# **Pathophysiology of Acute MR** * Sudden large volume overload into an uncompensated **LA and LV** causing severe pressure increase in _______ with_________. * Volume overload increases _______, modest increase in ___________. * Clinical presentation of_______ heart failure despite normal myocardial function

Answer 56

* both chambers with severe pulmonary edema * LV preload; LV stroke volume (Frank-Starling) * left-sided

Question 57

# **Pathophysiology of Chronic MR** **Volume overload:** * Ventricular and atrial volume overload * Compensatory LA and LV enlargement (eccentric hypertrophy) to permit extra volume **LV and RV issues:** * prolonged overload leads to________ which creates a viscous cycle * Leads to SV ______, filling pressure ______. * Pulmonary edema, pulmonary HTN and _____.

Answer 57

**Volume overload:** * Ventricular and atrial volume overload * Compensatory LA and LV enlargement (eccentric hypertrophy) to permit extra volume **LV and RV issues:** * LV dysfunction * decrease, rises. * RV failure

Question 58

# Anesthetic/hemodynamic Goals: MR **Preload**: **Afterload**: **Contractility**: **Rate**: **Rhythm**: **Mvo2**:

Answer 58

**Preload**: * Maintain *adequate preload* for good forward flow * *Do not overload* (dilate both LV and worsen MR/pulmonary congestion) **Afterload**: * **decrease *SVR***, * arterial vasodilators (*dobutamine*); * afterload reduction augments forward flow and decreases regurgitation **Contractility**: * *May be depressed*; titrate myocardial depressants carefully **Rate**: * **Increase slightly;** avoid bradycardia which can increase regurgitant flow decreasing the ejected flow in the aorta **Rhythm**: If atrial fib, control the ventricular response **Mvo2**: Compromised if MR coexists with **ischemic heart disease**

Question 59

# Anesthetic Considerations **MR ** **Preop** Versed for anxiety to prevent increase in ____ or _____ **Monitoring** Standard, 5-lead, ________,_______,________. **Induction** Regional (careful with abrupt decrease in ______) General (avoid ________) **Maintenance** Preload, normal EtCO2 Severe dysfunction may need ______.

Answer 59

**Preop** SVR or PVR **Monitoring** Standard, 5-lead, aline, CVP/PA, TEE **Induction** Regional: Preload General (avoid **bradycardia**) **Maintenance** - dobutamine

Question 60

# P-V loop in **Mitral Regurgitation** **Acute** * EDV _______ with _______ EDP * ESV _________, SV ________. * Ejected volume into the aorta is ______ depending on the regurgitant volume **Chronic** * EDV ________ with ______ EDP due to myocardial remodeling * ESV ________. * Markedly __________ SV

Answer 60

**Acute** * EDV **increases** with **high** EDP * ESV **normal or decreased**, SV **increased** * Ejected volume into the aorta is **small** depending on the regurgitant volume **Chronic** * EDV **increased** with **normal** EDP due to myocardial remodeling * ESV **normal or increased** * Markedly **increased** SV

Question 61

# Myocardial Remodeling Myocardial remodeling: **Ventricular remodeling (or cardiac remodeling) **refers to the changes in size, shape, structure, and function of the heart. This can happen as a result of ________ OR _____________

Answer 61

exercise (physiological remodeling) or after injury to the heart muscle (pathological remodeling).

Question 62

# Pathophysiology of **Tricuspid Stenosis (TS)** **Etiology**: ## Footnote * TS leads to ___________. * _________ dependence * ___________ system disease * Physiology resembles the restriction to ________ into the heart as seen in ___________.

Answer 62

**Etiology**: * Congenital, * rheumatic heart disease, or * mechanical due to thrombus ## Footnote * right atrial enlargement * PRELOAD dependence * **Conduction** system disease **(A-Fib/flutter, SVT)** * Physiology resembles the restriction to **venous return** into the heart as seen in **cardiac tamponade**

Question 63

# Anesthetic/hemodynamic Goals of **TS** **Monitors**: **Preload**: **Rate**: **Rhythm**

Answer 63

**Monitors**: A-line, CVP and TEE **Preload**: Maintain normal **Rate**: Normal range **Rhythm** Normal sinus

Question 64

# Pathophysiology of **Tricuspid Regurgitation (TR)** **Primary (TR with __________)** Causes: **Secondary (more common)** * RV _________ and annular ________. * Associated with longstanding ____________ * Most common in patients with _________ **Isolated TR:** ________ for many years S/S:

Answer 64

**Primary (TR with abnormal valve)** * Rheumatic heart disease, * infective endocarditis, * **carcinoid syndrome**, * **trauma** **Secondary (more common)** * RV **enlargement** and annular **dilation** * Associated with longstanding **pulmonary HTN** * Most common in patients with **MV disease** **Isolated TR:** **asymptomatic** for many years * Pulsatile neck veins, * Pansystolic murmur * generalized weakness, * early fatigue, * fullness in RUQ

Question 65

# Anesthetic Management for **TR** * Maintain intravascular volume and CVP in the ______ range * Avoid Increased _______ * Avoid hypoxia, hypercarbia, acidosis * Avoid ______ and _______, which can reduce venous return and increase RV afterload

Answer 65

* high normal * PVR * -. * PEEP and high airway pressures

Question 66

# Valvular Disease and Murmurs type of murmur and disease: - Aortic area - pulmonic area - left sternal border - tricuspid area - mitral area

Answer 66