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AP: Summer Test 1 > Sara: Anesthesia for Left Side Valve Disease > Flashcards

Sara: Anesthesia for Left Side Valve Disease Flashcards

1
Q

What 2 conditions can lead to pulmonary issues?

A

regurge

stenosis

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2
Q

With stenosis, what is important?

A

contractility

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3
Q

With regurge, what is important?

A

Decreased afterload is really important.

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4
Q

What is important in all valve lesions?

A

preload

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5
Q

What are important during the preoperative evaluation? (3)

A

Detailed history of disease, listen to heart

AHA protocol and guidelines

Echo w/in 6 months for all valvular lesions

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6
Q

What is the most common MAJOR valve lesion?

A

aortic stenosis

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7
Q

What are the common causes of aortic valve lesions? (3)

A

congenital bicuspid valve

degeneration

atherosclerotic/rheumatic

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8
Q

You note LVH on preop ECG and you hear a systolic murmur.

Systolic mumur = _____________.

A

related to flow

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9
Q

All diastolic murmurs are pathological. True or false?

A

True

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10
Q

In normal valves, no real pressure gradient across the valve. True or false?

A

true

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11
Q

What happens as a result of stenosis relating to pressure gradient?

A

Increase stenosis = increase pressure gradient

Otherwise, there is no real pressure gradient in normal valves.

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12
Q

What are consequences of aortic stenosis? (5)

A

Avoid hypotension!

Atrial kick contributes to 25% of filling instead of 15-20%

Increase in LV systolic and diastolic presssures

Longer ejection time

Decrease in aortic pressure

Note: All lead to decreased O2 supply → ischemia

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13
Q

What is the triad of stenosis?

A

Angina (even with patent coronaries)

Syncope

Heart failure

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14
Q

What is normal EF?

A

55%

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15
Q

How do you anesthetically manage AS pts in relation to preload? (4)

A

Keep intravascular volume normal to high

Avoid venous dilation (NO EPIDURAL/SPINAL)

HR slow to normal ( to allow greater diastole time to increase filling)

Aggressive treatment of atrial rhythm

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16
Q

How do you anesthetically manage AS pts in relation to afterload? (2)

A

Keep diastolic pressure up to perfuse coronaries

Aggressively treat hypotension with alpha agonist

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17
Q

Causes of valvular disease due to: (3)

A

congenital

rheumatic

degenerative (calcification is most common)

18
Q

Critical aortic stenosis is when the aortic valve orifice is reduced to ____-_____ cm2.

A

0.5 - 0.7

Normal is 2.5-3.5 cm2

19
Q

What is hypertrophic cardiomyopathy characterized by? (2)

A

dynamic obstruction of left ventricular outflow tract

associated with mitral valve abnormality

  • systolic anterior motion (SAM)
  • mitral regurgitation
20
Q

What factors tend to worsen hypertrophic cardiomyopathy ventricular outflow? (3)

A

increased contractility

decreased ventricular volume

decreased left ventricular afterload

21
Q

Anesthetic management of HOCM? (5)

A

Volume loading

Decrease contractility

Beta blockade

Keep systemic pressure high

TEE vs PA catheter

Note: Phenylephrine and other pure alpha agonists are ideal vasopressors.

22
Q

What is known as “disease of diastole”?

A

aortic regurge

23
Q

Aortic regurgitation can be chronic or acute. True or false?

A

True

24
Q

What changes to the ventricle for pt with aortic regurge?

A

hugely dilated heart

produces volume overload of the left ventricle

25
Q

What are the consequences of aortic regurge? (3)

A

“Eccentric” hypertrophy dilatation

Very high LV CO, but low SV

Tachycardia and peripheral vasodilation to maintain forward flow is good

26
Q

How is acute vs. chronic regurge characterized by? (

A

Chronic allows LV to dilate and acute does not → LVED

Chronic sees higher volumes vs acute sees higher pressures

27
Q

What is aortic regurge also known as?

A

aortic insufficiency

28
Q

Anesthetic management of AI/AR relating to preload: (4)

A

Keep volume high

Keep SVR high

High normal heart rate is best

Avoid bradycardia, want more time in diastole

29
Q

Anesthetic management of AI/AR relating to contractility: (2)

A

Maintain contractility

Use epi, dobutamine

30
Q

Anesthetic management of AI/AR relating to afterload: (1)

A

Reduced afterload is essential

Use arterial not venous dilators

Note: Arterial dilator (nicardipine). Avoid nitros.

31
Q

Mitral stenosis is most commonly ____________.

Affects more males/females?

A

rheumatic

pregnant females (2:1)

32
Q

In mitral stenosis, what anatomic changes occur?

A

dilated atrium resulting in SVT, particularly afib

blood stasis promotes thrombi to form

loss of normal atrial systole

33
Q

What in short do you need to remember relating to mitral stenosis?

A

pressure gradient b/n LA and LV needed to get through the thickened valve

34
Q

What do you think happens to ventricular filling when there is mitral stenosis?

What happens as a result? (3)

A

decreased

  • Left atrial dilatation
  • A-fib
  • Pulmonary edema
35
Q

Anesthetic management relating preload for MS: (4)

A

Keep volume high, but not too high (fine line)

Avoid venodilation

Low heart rate is best (tachy leads to PEdema)

Aggressive treatment for tachycardia

36
Q

Anesthetic management of MS relating to afterload: (1)

A

maintain in normal range

**Unloading is pathology of LV

37
Q

What are the consequences of MR? (4)

A

Left atrial dilatation → a fib

Left ventricular dilatation (eccentric)

Low forward CO syndrome

Biventricular failure

38
Q

Anesthetic management of MR relating to preload: (1)

A

high normal HR is best

39
Q

Anesthetic management of MR relating to contractility: (1)

A

Keep ventricular size down to maintain forward CO.

40
Q

Anesthetic management of MR relating to afterload: (1)

A

Reducing afterload is important!

41
Q

To summarize, for stenotic lesions: (2)

for regurgitant lesions: (2)

A

preload dominates (CPP in AS), HR low

reduce afterload, HR high

AP: Summer Test 1 (3 decks)

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