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Advanced Principles III > Nagelhout Chp 25 - CV > Flashcards

Nagelhout Chp 25 - CV Flashcards

1
Q

What is normal aortic valve area

A

2.5 - 3.5 cm2

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2
Q

What is aortic stenosis and what are the causes :

A

Normal area is 2.5 - 3.5 cm2 . Reduction of 1/3 to 1/2 of the valve area means stenosis.
The narrowing results in obstruction of blood flow into the aorta .
Causes : 1) degeneration and calcification of the leaflets or
2) presence of bicuspid instead of tricuspid valve .

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3
Q

Patient with aortic regurgitation , how will you select muscle relaxant for the patient ?

A

Goal in aortic regurgitation is to 1) maintain normal to elevates HR . Pancuronium/ vagolytic good choice . But the potential for sux to cause bradycardia should be considered before administration.

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4
Q

What are the main anesthetic goal for patient with aortic regurgitation ?

A

HR : Normal to high with NSR
Preload : normal to high
Afterload : decreased
AVOID myocardial depression

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5
Q

Describe the difference between ACUTE and CHRONIC aortic regurgitation and

A

Acute : LV has no time to compensate for increase in LV volume = LV failure, Pulmonary edema , CV collapse may ensue .
Chronic : no s/s shown for a long time , during normal activity the symptoms are not incapacitating . As long as the mitral valve patience does not result from LVH , pulmonary circulation is preserved. End stage AR = myocardial failure, decreased CO , high elevation in LVEDV and pulmonary edema

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6
Q

What valve area and transvalular gradient is considered to be AS( Aortic Stenosis ) ?

A

N

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7
Q

Normal SVR

A

800 to 1500 dynes/sec/cm5

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8
Q

Normal Pulmonary vascular resistance is

A

50 to 150 dynes/sec/cm5

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9
Q

What is severe aortic stenosis ?

A

Valve area less than 0.8 cm2

And transvalvular gradient > 50 mmHg

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10
Q

What does increase DBP cause to AR?

A

Increases the backward pressure gradient which results in an increase in the proportion of SV that regurgitates back into the left ventricle

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11
Q

MC conditions affecting the aortic leaflets that result in AR ?

A

Rheumatic Fever
Bicuspid aortic valve
Infective endocarditis
Use of anorexigenic ( diet ) drugs

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12
Q

What is AR?

A

Failure of the aortic valve leaflet to velodrome properly due to disease of the aortic root or of the leaflets themselves

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13
Q

Why is Afib or a junction alone rhythm so detrimental to a patient with aortic stenosis?

A

There is DECREASED pressure gradient between the LA and the LV bc of the aortic stenosis , and the atrial kick is needed to achieve adequate LV filling. Afib and Junctional rhythms knock out that extra 20 30 % that is needed and results in CHF and hypotension

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14
Q

How is CO affected with aortic stenosis ?

A

At rest = CO is normal

Exertion = heart cannot increase CO = angina and dyspnea , even though there is no CAD

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15
Q

How is myocardial oxygen and demand affected by aortic stenosis ?

A

The demand is INCREASED bc of concentric ventricular hypertrophy and
The supppy is DECREASED bc of intramyicardial vessels during systole restricts arterial flow to the myocardium.

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16
Q

75% of patients with aortic stenosis die within

A

3 years if valve not replaced

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17
Q

S/S of severe aortic stenosis

A

Classic triad :

Angina , Syncope , CHF

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18
Q

Aortic regurgitation medical management ?

A

Reduce Afterload = reduce transvalvular gradient = easy forward flow out of LV => Hydralazine and nifedipine .

If acute exacerbation : Nitroprusside or Dobutamine can be used

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19
Q

Patient has mild mitral stenosis, what will the heart do to compensate in order to maintain a good SV ? What factors can cause this compensation not to occur ?

A

The left atrial pressure will increase in an attempt to increase blood flow through the narrow valve .

If tachycardia or Afib the increase in atrial pressure will not work and will not be able to maintain the SV

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20
Q

Mitral regurgitation vs Mitral stenosis .what are the goals for each ? How are they similar ?

A

MR = Increase HR and decrease afterload
MS= normal or decreased HR and normal afterload
In both: NSR, Maintain preload normal to increased levels , AVOID increase in PVR

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21
Q

What meds are good for Mitral Regurgitation?

A

Ace I, BB, biventricular pacemaker

22
Q

Mitral regurgitation , what do you see in the PAOP waveform

A

A large V wave , the changes in the V wave amplitude help estimate changes int he degree of mitral regurgitation

23
Q

What Heart sound in Mitral regurgitation ?

A

Holosystolic Murmur radiating to the axilla

24
Q

Mitral regurgitation , when to do surgery ?

A

When EF is greater than 60 % or if patient is symptomatic

25
Q

How does SVR affect the pressure gradient in Mitral regurgitation?

A

Low SVR = decrease in regurgitant volume

High SVR = worse regurgitant volume

26
Q

What 3 factors determine the regurgitant volunteer in Mitral regurgitation ?

A

1) size of valve
2) HR
3) pressure gradient across valve

27
Q

What is the main problem in Mitral regurgitation?

A

Decrease in forward flow of blood ( SV) bc the volume is moving backwards into the left atrium during systole . ( holosystolic murmur )

28
Q

MCC of acute Mitral regurgitation?(5)

A

1) MI
2) Papillary muscle dysfunction
3) Chordae Tendinae rupture
4) Trauma to chest
5) Infectious endocarditis

29
Q

Primary anesthetic management objectives for patient with mitral stenosis ?

A

AVOID : hypovolemia , excessive Tberg = pulmonary edema

N2O : be careful = it can increase PVR ( which we want to avoid )

Drugs causing tachycardia = Ketamine, Pancuronium is a no no, or be careful !
Meperidine can cause tachycardia only opioid that can do it :) otherwise give OPIODS to prevent intraop tachycardia , or increase depth of anesthesia or give a Beta Blocker

Give phenylephrine or vasopressin if hypotension since they do not increase the HR

Epidural is preferred over spinal bc … less decrease in sympathetic activity with epidural !

30
Q

What is normal mitral valve area and when does symptoms occur ?

A

Normal is 4-6 cm2

Symptoms when less than 1.5cm2

31
Q

How can mitral valve stenosis result in pulmonary edema ?

A

LA pressure increase&raquo_space; transmitted into the pulmonary vasculature&raquo_space; Pulmonary venous pressure > 25mmHg= leak into pulmonary interstitial space&raquo_space; decreased pulmonary compliance&raquo_space; increased Work of Breathing ( WOB )

32
Q

Heart sound in Mitral valve prolapse (MVP)?

A

Midsystolic click and a late systolic murmur

33
Q

How are LA, Pulmonary vasculature and RV affected by Mitral stenosis ?

A

Mitral valve small» LA pressure increase > pulmonary blood volume and pressure increase&raquo_space; right ventricular afterload increase» RV hypertrophied and fails

34
Q

How is LV volume affected by mitral stenosis ?

A

Valve opening decreases» pressure gradient across valve increases» flow of blood through he opening decreases&raquo_space;LV volume decreases .

35
Q

What cardiac conditions develop from Mitral stenosis ?

A

CHF
Pulmonary HTN
RV hypertrophy

36
Q

Mitral Stenosis is higher in ____. Over a period of 20 to 30 years ____cause the mitral valve leaflets to thicken , the commisure may fuse, the leaflets and annulus may become calcified.

A

Higher in female

Over 20 to 30 years , Rheumatic Fever

37
Q

MCC of Mitral Stenosis

A

Rheumatic Fever

38
Q

MC symptoms of valvular disorders in general ?

A

1) CHF
2) Dysrhythmia
3) Syncope
4) Angina

39
Q

What is mixed valvular disorder ?

A

It is a combination of stenosis , and insufficiency. One usually more dominant than the other

40
Q

Heart sound in Mitral Stenosis ?

A

Opening Snap in early diastole and

Rumbling diastolic murmur heard best at the axilla or apex

41
Q

What are the risk factors for developing aortic stenosis ?

A

Simalar to those factors for Ischemic Heart Disease :

HTN , HLD, DM, Smoking, and male gender

42
Q

What is a the anesthetic choice in Mitral regurgitation .

A

1) Neuraxial is NOT contraindicated BUT : dramatic decrease in sympathetic activity = consider that super low bp may happen
General anesthesia is the anesthetic of choice .

43
Q

MVP is

A

When 1 or both mitral leaflets dip into the the left atrium during systole . It can occur with or without Mitral regurgitation.

44
Q

What factors decrease the degree of prolapse in MVP ?

A

Any factor that maintain a LARGER ventricular volume = decrease degree of prolapse .
HTN , Vasoconstriction, drug induced myocardial depression, increased preload = decrease degree of prolapse

Never thought HTN could be good for something in the heart *

45
Q

What factors will increase the prolapse ?

A

The more the ventricle empties the more the prolapse :

Increase LV contractility or decrease SVR = worse prolapse !

46
Q

S/S of MVP

A

Although many are asymptotic:

1) chest pain
2) MR
3) Infectious endocarditis
4) embolism
5) even sudden cardiac death

47
Q

What disorders exhibit high indidence of MVP?

A 
Marfan 
Lupus 
Rheumatic carditis 
Thyrotoxicosis 
Myocarditis
48
Q

MVP is more common in

A

Young females

49
Q

S1 happens then

A

Ventricular pressures are greater than Atrial pressures , closing the tricuspid and mitral valves

50
Q

SVR is the

A

Load that the cardiac muscles of the ventricle encounter after contracting starts

51
Q

What is Eisenmeger’s syndrome ?

A

Is a reversal of the left-to-right intracardiac shunt due to increase in the pulmonary vascular resistance.

Once the PVR = or > than SVR the shunts reverses to a right-to-left shunt.

52
Q

Medical treatment of PDAs

A

Indomethacin ( a nonselective cycloogenase Inhibitor) is the first line therapy

Advanced Principles III (11 decks)

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