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Part 2 exam > Periop cardiology > Flashcards

Periop cardiology Flashcards

1
Q

What is the aeitology of aortic stenosis?

A

Acquired: Calcification (degnerative), rheumatic
Congenital: bicuspid, unicuspid, quadricuspid

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2
Q

What is the presentation of aortic stenosis?

A
  • Angina
  • Syncope
  • Dyspnoea
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3
Q

What is the severity grading of Aortic stenosis?

A

Normal: Valve area > 2cm2, Vmax <2 m/s
Mild: Mean gradient <20mmHg, valve area 1.5-2cm2, Vmax 2-2.9
Mod: Mean gradient 20 - 40mmHg, valve area 1-1.5, Vmax 3 - 3.9
Severe: Mean gradient >40mmHg, valve area <1, Vmax >4

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4
Q

What is the management of aortic stenosis?

A
  • Antihypertensives
  • Balloon valvloplasty
  • TAVI
  • Open AV replacement
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5
Q

What are the anaesthetic goals for a patient with aortic stenosis?

A

“Slow, full and tight “

  • rate = low normal
  • rhythm = maintain sinus rhythm is critical (atrial kick may contribute up to 40%of preload)
  • preload = careful balance, keep filled but also prone to pulmonary oedema
  • afterload = critical to defend MAP for adequate coronary perfusion
  • contractility = maintain
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5
Q

What is the aetiology of aortic regurgitation?

A

Acute: Infective endocarditis, aortic dissection
Chronic: Rheumatic, connective tissue eg Marfan, elhers-danlos, arthritic disease eg Ank spond, RA, SLE

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5
Q

What is the presentation of Aortic regurg?

A

Acute: Sudden LV volume overload -> CCF
Chronic: Gradual LV dilation -> LV Dysfunction
- widened pulse pressure, collapsing pulse (waterhammer)

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5
Q

How is aortic regurg severity rated?

A

Jet width (%LVOT)
Normal and mild < 25
Moderate 25-65
Severe >65

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5
Q

What is the treatment for aortic regurg?

A

-Aortic valve replacement
- Antihypertensives for chronic AR

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6
Q

What are the anaesthetic goals for managing aortic regurgitation?

A
  • Rate: High/normal
  • Rhythm: Sinus rhythm (less critical)
  • Contractility: Maintain
  • Preload: Keep filled
  • Afterload: Reduced

-For hypertension use arteriolar vasodilator (phentolamine) > venodilator (GTN)

  • For hypotension ephedrine > metaraminol
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7
Q

What is the aetiology of mitral stenosis?

A

Use acquired via rheumatic heart disease

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8
Q

What is the presentation of mitral stenosis?

A
  • Angina
  • Dyspnoea
  • Syncope
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9
Q

How do you grade the severity of mitral stenosis?

A

Valve area in cm2 (although HR and filling are major determinents)

Normal 4 -6
Progressive 1.5 - 4
Asymptomatic severe < 1.5
Symptomatic severe <1

Progressively get worse pulmonary hypertension and LA dilation

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10
Q

What are the treatments for mitral stenosis?

A
  • Anticoagulation if in AF
  • Rate control
  • Percutaneous balloon valvuloplasty
  • Mitral valve surgery
  • Excision of LAA if recurrent embolic events
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11
Q

What are the anaesthetic goals for mitral stenosis?

A

Rate: Slow/normal (tachycardia bad)
Rhythm: Critical to maintain SR if in sinus (early Cardioversion)
Contractility: Normal (RV may be reduced due to pulm HTN)
Preload: Maintain normal
Afterload: Maintain

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12
Q

What is the aeitology of mitral regurg?

A

Acute: ruptured chordae tendinae, infective endocarditis
Chronic: LV dilation, connective tissue, rheumatic heart disease

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13
Q

What is the presentation of mitral regurg?

A

Acute: APO
Chronic: AF

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14
Q

What is the grading severity of mitral regurg?

A

Progressive <50% regurg, central jet 20-40%
Severe >50% regurg, central jet >40%

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15
Q

What is the treatment for mitral regurg?

A

Primary MR -> mitral valve repair rather than replacement

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16
Q

What are the anaesthetic goals for mitral regurg?

A

Heart rate: High/normal
Rhythm: Sinus
Contractility: Normal
Preload: Low/normal
Afterload: Low/normal (promote forward flow)

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17
Q

What is the aetiology of HOCM?

A

-asymmetrical hypertrophy of the septum (usually anterior) causing dynamic obstruction of the LVOT

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18
Q

What is the presentation of HOCM?

A
  • Exertional angina/dyspnoea
  • LVH on ECG and deep sharp Q waves inferiolateral
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19
Q

What is the management of HOCM?

A
  • Beta blockers, ca channel blockers
    -AICD and pacemaker
  • Myomectomy
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20
Q

What are the anaesthetic goals with HOCM?

A

Heart rate: low/normal
Rhythm: Sinus (critical)
Contractility: Normal (Avoid increases eg inotropes)
Preload: Keep full
Afterload: High/normal (splints LVOT)

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21
What is the definition of heart failure?
failure of heart to meet oxygen demands of body resulting in tissue hypoxia and end-organ damage
22
What are the classifications of heart failure?
-HFrEF (HF with reduced EF <40%) (i.e Systolic dysfunction) -HFpEF (HT with preserved EF >50%) (ie. Diastolic dysfunction) - HFmrEF (HF with mid-range EF 40-49%) i.e also diastolic dysfunction
23
What is the diagnosis of HFpEF?
Hard to diagnose - TTE: evidence of impaired filling, non-dilated LV, LVH, increased LA vol. - PCWP: >15mmHg - LVEDP: >16mmHg
24
What is the treatment of HFpEF?
- Nil evidence for effective mx - Mainly aim to treat co-morbidities eg resp disease, obesity
25
What is the diagnosis of HFrEF?
- LV EF <40% on TTE
26
Which HF are high risk and what is their physiology?
severe HF (EF<30%) are very high risk, depend on preload for V filling and rely on increased SNS tone. Should only undergo absolutely necessary surgery
27
What are the pre-op considerations for a patient with heart failure?
Medication management: Continue anti-failure thearpies eg beta blockers, Ace inhibitors, statins, diuretics ?AICD: if insitu will need to be deactivated, and revert PPM to backup mode ECG and TTE preop to risk stratify
28
What are the intra-operative goals for a patient with heart failure?
- minimize negative inotropy, tachycardia, diastolic hypotension and systolic hypertension. - Defend renal perfusion. - Consider regional if possible
29
What are some post operative considerations for patients with heart failure?
- Disposition eg HDU/ICU - Adequate analgesia (reduce tachycardia due to pain) - Restart anti-failure meds as soon as possible
30
What is the guideline for patients undergoing surgery with recent MI?
Delay >60 days unless emergency surgery that cannot wait
31
How do you Quantify perioperative cardiac risk?
- use a validated risk-prediction tool (e.g. RCRI or ACS surgical risk calculator) - if low risk (Major Adverse Cardiac Event < 1%) then proceed - if high risk (MACE ≥ 1%) then estimate exercise tolerance - If METS > 4 then proceed, if METS < 4 then stress testing (if will change management)
32
When do you and don't you stress test patients?
- If negative stress test, CT-CA within the last year then don't repeat stress testing - If had intervention in the last year and no new sx then don't stress test eg PCI - If negative stress test then good NPV and can proceed confidently - If positive, poor PPV so will need cardiology opinion
33
What are the indications for revascularisation?
- symptomatic CAD - asymptomatic CAD with: - LM ≥ 50% - LAD ≥ 70% with positive stress test - ≥ 70% in 3 major vessels - ≥ 70% in 2 major vessels + positive stress test
34
How long should you wait for surgery after BMS, DES, CABG?
BMS: 30 days DES: ideally at least 6 months, not less than 3 months CABG: 4 - 6 weeks
35
What is the definition of pulmonary hypertension?
mPAP >20 mmHg at rest on right heart cath
36
What are the 5 types of pulmonary hypertension?
1: Pulmonary arterial hypertension 2: PH secondary to left heart disease 3: PH secondary to lung disease 4: PH secondary to chronic VTE 5: Unclear multifactorial
37
How do you assess severity of Pulmonary hypertension?
Hx: - medications - symptoms of RH failure - Symptoms of low cardiac output eg syncope/angina - Functional capacity Exam: - signs of RH failure eg peripheral oedema, raised JVP, pulsatile liver, parasternal heave - 6 minute walk test (600 m is ok, <300m is high risk) Ix: - Vitals eg hypoxia - TTE: RVSP, LVEF, RV function eg TAPSE - Right heart cath: Mild 20-40 Mod 40-55 Severe >55
38
What are the pre-operative considerations for a patient with pulmonary hypertension?
- Cardiac optimisation (in consultation with cardiologist) - Optomise pulmonary vascular resistance (pulmonary dilators) - Optomise preload (diuretics) - Optomise cardiac function (inotropes)
39
What are the intra-operative considerations for a patient with pulmonary hypertension?
- Regional vs GA - Adequate monitoring - Avoid factors that increase Pulm vasc resistance: - SNS surge (pain, laryngoscopy) - Acidosis - Hypercapnia - Hypoxaemia - Hypothermia - High PEEP - Drugs eg N20 and ketamine - Normal Tidal volumes and ventilator pressures to keep normal lung volumes - Avoid sudden drop in SVR (decreased coronary perfusion and increased myocardial ischaemia) - Have rescue drugs that can decrease pulmonary vasc resistance eg NO, Prostacyclin
40
What are the post operative considerations for patients with pulmonary hypertension?
- Disposition - Appropriate monitoring
41
What is pulmonary hypertensive crisis?
- acute on chronic increase in pulm vasc resistance - due to acute increase in vascular tone of pulm vasculature
42
What is the pathophysiology of pulmonary hypertensive crisis?
- Rapid increase in Pulm vasc resistance - Increase in RV afterload - Increase in RV pressure which reduces LV preload and coronary perfusion - Leads to myocardial ischaemia and subsequent hypoxia and acidosis which then worsens the pulm vasc resistance
43
What are clinical signs of pulmonary hypertensive crisis?
- Hypoxia - Hypotension - Decreased etCO2 - Sinus tachycardia - Elevated CVP
44
What is the treatment of pulmonary hypertensive crisis?
- 100% O2 (vasodilator) - Hyperventilate (decrease CO2) - Decrease airway pressures - Correct acidosis - Administer pulmonary vasodilators - Support cardiac output i.e inotropes such as adrenaline - Analgesia (if pain causing crisis) - ECMO
45
What are some of the physiological differences between a normal heart and a heart transplant?
- Transplant has no sensory, parasympathetic or sympathetic innervation - Resting HR is ~90-110 in heart transplant - CO in transplant is very preload dependent
46
What are some of the differences in pharmacological responses in heart transplants?
- Nil response to atropine/glyco - Increased response to adrenaline and noradrenaline
47
What are some pre op considerations for a patient with heart transplant?
- What was indication for tranplant, ?systemic disease - Any signs of recent rejection - Current cardiac function (coronary artery disease is common and doesn't present with angina) eg functional status, recent TTE, angiogram - Transplant meds -> continue during periop period, any side effects eg renal impairment
48
What are some intra op considerations for a patient with heart transplant?
- Strict asepsis, with all lines and medications - Careful positioning due to skin related steroid changes - consider stress dosing steroids - Maintain preload and cardiac output - Maintain SVR and afterload from coronary perfusion - Maintain MAP - judicious dosing of adrenaline/noradrenaline
49
What are some post op considerations for a patient with heart transplant?
- Restarting immunosuppression - Disposition - Early removal of lines - Discussion with ID regarding ongoing ABx - Careful fluid monitoring to avoid overload/dry - Monitor renal function
50
What are the causes of QT prolongation?
- Electrolytes eg, Hypokalaemia, Hypomagnesaemia, Hypocalcaemia - Hypothermia - Medications/drugs Less common: - Myocardial ischemia -ROSC Post-cardiac arrest -Raised intracranial pressure -Congenital long QT syndrome
51
What is the risk of QT prolongation?
Can become torsades de point and degnerate into VF - treated with 2g Mg
52
What drugs prolong QT?
- Ondansetron, droperidol - Amiodarone - Methadone - Erythromycin/azithromycin - Sux - Atropine/glyco
53
How do you calculate QTc?
QTc = QT/square root of RR, where RR = 60/HR
54
What is a normal QT?
Men < 440ms Women < 460ms >500 is concerning for torsades
55
What are the anaesthetic issues with prolonged QT?
- Minimise stress (triggers arrythmias): anxiolysis, analgesia - Avoid hypothermia - Maintain normal electrolytes - Avoid meds that prolong QT - Reversal may prolong QT so use atracurium/cisat that don't need reversal
56
What are causes of a systolic murmur?
- Flow mumur (usually young people) - Aortic stenosis - Aortic sclerosis - Mitral regurg - HOCM
57
Whats eisenmenger syndrome?
- Severe pulm HTN due to left to right shunt (and pulm vol overload) - If pulm BP > sys BP can cause reversal of this shunt and systemic hypoxia
58
What are the key anaesthetic goals in a patient with eisenmenger syndrome?
- Maintain Systemic pressure (SVR) - Minimise pulm vasc resistance (to ensure its above pulm pressure and you don't reverse the shunt)
59
What factors increase pulm vasc resistance?
- Catecholamines - Hypoxia - Hypercarbia - Hypothermia - High lung volumes - Acidosis
60
What is the physiology behind a post fontan repair patient?
- Blood flow to and through the lungs is passive - Needs high CVP, low PVR and low LA and LV diastolic pressures
61
What is important in managing post fontan repair patient?
- SR is critical, do not tolerate arrythmias - Tolerate hypovolaemia poorly - Are preload dependent - Low Pulm vasc resistance
62
What are significant TTE finds on a patient with severe Aortic stensois?
- Qualititative: calcified leaflets with reduced mobility, LV hypertrophy, Raised LAP, post stenotic aortic dilation, +/- late changes RV/LV - Quantitiative: valve area <1cm2, transvavlular gradient >40 amd Vmax >4m/s and diastolic dysfunction
63
What are the types of cardiomyopathy?
- Dilated - hypertrophic - Restrictive - Arrhythmogenic right ventricular - Unclassified
64
What are the causes of dilated cardiomyopathy?
- Idiopathic - Toxins eg alcholol, drugs - Post viral - Post partum - Duchenne's muscular dystrophy
65
What are the anaesthetic implications of dilated cardiomyopathy?
- Rate: Normal - Rhythm: maintain sinus - Preload: Maintain - Afterload: Maintain - Contractility: Avoid myocardial depression, often require dobutamine/PDE inhibitors eg milrinone
66
What are the causes of restrictive cardiomyopathy?
- amyloid myocardial infiltration most common - other rare causes (idiopathic, endomyocardial fibrosis)
67
What is the anaesthetic management of restrictive cardiomyopathy?
- very challening - avoid peripheral vasodilation, decreased preload or decreased inotropy - Spont vent is preferred to maintain Venus return - ketamine is a useful induction drug - Rate: Normal - Rhythm: Sinus - Preload: normal/high - Afterload: High/normal - Contractility: Avoid negative inotropes

Part 2 exam (15 decks)

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