Spring 2024 (Exam II) Valvular Disease Flashcards
Prevalence of valvular heart disease in the U.S. ________ %.
- 2.5%
The most frequently encountered cardiac valve lesions produce ________overload or _______overload on the LA or LV.
- Pressure overload (stenosis)
- Volume overload (regurgitation)
Most commonly from volume overload or pressure overload
Fairly common to also have IHD
>50 yrs have coexisting disease
Preoperative evaluation of patients with valvular heart disease includes assessments of what 3 factors?
- Severity of cardiac disease
- Degree of impaired myocardial contractility
- Presence of associated major organ system disease (JVD, Kidneys, DM)
Compensatory mechanisms for valvular disease.
- ↑ SNS activity
- Myocardial Hypertrophy
- Current drug therapy
How will you evaluate the History and Physical Examination of Valvular Disease Patients?
- METs score (exercise tolerance)
- Cardiac reserve
- NYHA Functional Classification Class
What are the NYHA Functional Classification of Patients with Heart Disease classes and descriptions?
What are s/s of impaired myocardial contractility and HF?
- Dyspnea
- Orthopnea
- Easily fatigued
- HF
-Basilar rales
-JVD
-3rd HS
What causes murmurs?
- Turbulent blood flow across abnormal valves (pathological)
- Increased flow across normal valves (functional/pregnancy)
What is a functional murmur?
- A heart murmur that is primarily due to physiologic conditions outside the heart, as opposed to structural defects in the heart itself
- Midsystolic murmurs can be functional whereas any other is very likely pathologic
What valve issues will produce a systolic murmur?
- Aortic Stenosis
- Mitral or Tricuspid Valve Regurgitation
What valve issues will produce a diastolic murmur?
- Aortic Regurgitation
- Mitral or Tricuspid Valve Stenosis
Describe a mid-systolic murmur.
- Occur between distinct S1 and S2 heart sounds
- Crescendo (louder)–decrescendo (softer) pattern
- Can be functional
Where is the best place to hear a mid-systolic murmur
Right upper sternal border
If murmur radiates towards right carotids, possible aortic stenosis.
What murmur merges with S1 and S2
- Holosystolic Murmur
Where is the best place to hear a Holosystolic Murmur?
- Apex of the heart
Holosystolic Murmur that radiates to the left axilla correlates to what valvular issue?
- Mitral regurgitation
What murmur follows S2?
- Diastolic Murmur
Lub, Dub, Murmur - easiest one to hear
Aortic Stenosis
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:
Maneuvers:
- Right upper sternal border
- Midsystolic crescendo-decrescendo mumur
- Radiation to carotids; ejection click
- Increases with squatting, decreases with Valsalva and standing
Aortic Regurgitation
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:
Maneurvers:
- Left Sternal border
- Early diastolic murmur
- May have ↑ systolic murmur d/t ↑ SV
- Increases with handgrip of BP cuff inflation
Mitral Stenosis
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:
Maneuvers:
- Apex
- Mid-diastolic murmur
- Radiation to left axilla
- Increases with tachycardia
Mitral Regurgitation
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:
Maneuvers:
- Apex
- Holosystolic murmur
- Radiation to the left axilla
- Increases with handgrip or BP cuff inflation
Tricuspid Regurgitation
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:
Maneuvers:
- Lower left sternal border
- Holosystolic murmur
- Prominent JVD, s/s RHF
- Increases with inspiration
Mitral Prolapse
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:
Maneuvers:
- Apex
- Late Systolic
- Midsystolic Click
- Increases with Valsave, standing
Functional Murmur
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:
Maneuvers:
- Left sternal border
- Midsystolic crescendo-decrescendo
- none
- Increases with exercise
Name the auscultation locations.
Aortic:
Pulmonic:
Tricuspid:
Mitral:
Erbs Point:
- Aortic: 2nd ICS RSB
- Pulmonic: 2nd ICS LSB
- Tricuspid: 5th ICS LSB
- Mitral: 5th ICS Left Mid-Clavicular
- 3rd IS, Left sternal edge
Diagnostics EKG:
Broad notched P waves on the ECG suggest _________ enlargement.
- atrial enlargement
Right ventricular hypertrophy will result in a _________ axis deviation?
- Right
This is the most common dysrhythmia presented in valvular disease.
- Atrial fibrillation
CXR diagnostics for valvular disease patients.
- Cardiomegaly- when heart size is >50% of the internal width of thoraic cage
- Left mainstem bronchus elevation- caused by LA enlargement
- Valvular calcifications
Diagnostic echocardiogram can be used to assess:
- Cardiac anatomy and function
- Presence of hypertrophy
- Cavity dimensions
- Valve area
- Transvalvular pressure gradients
- Magnitude of valvular regurgitation
- Significance of murmurs
- Ventricular EF
- Evaluate prosthetic valve function
Impediments of TTE?
- Body Habitus
- unable to see ASD v VSD or vegitations on the valves –> TEE is better
What is the purpose of angiography?
- Assess for presence and severity of valvular stenosis and/or regurgitation
- Diagnose CAD
- Assess for Intracardiac shunting
- Assess Transvalvular pressure gradients
- Delineate clinical vs echocardiographic findings
Describe a mechanical valve
- Valve can be metal or carbon alloy
- Very durable, can last 20-30 years
- Cons: Highly thrombogenic
- Younger patients
Describe a bioprosthetic valve.
- Valve can be Porcine or bovine
- Short lasting. 10-15 years
- Low thrombogenic potential
- Elderly patients
Patients with valvular disease undergoing surgery will discontinue what medication 3 to 5 days before surgery?
- Warfarin
Oftentimes, patients are on some sort of bridge therapy (heparin).
Abrupt discontinuation can lead to rebound hypercoagulable state
Warfarin is not recommended in the _______ trimester because it can lead to spontaneous termination of pregnancy.
- First
Pregnant moms are usually on LMHW or ASA.
Name this valve disorder:
* Rare in the US
* Usually occurs d/t Rheumatic heart disease
* Primarily affects women
* Asymptomatic for 20-30 years
* May not have any other symptoms other than vision changes
- Mitral Stenosis
Normal mitral valve orifice area:
When will symptoms of mitral valve stenosis develop?
- 4-6 cm2
- Symptoms develop when the mitral valve orifice is less than 2 cm2
How will mitral valve stenosis affect the following
LA volume and pressure:
LV contractility:
SV:
- LA volume ↑/ LA pressure ↑
- No change in LV contractility
- SV ↓
What is a commisure?
Sub-valvular apparatus?
- A distinct area where the anterior and posterior leaflets come together at their insertion into the annulus
- Consists of LV free wall, two papillary muscles, and the chordae tendineae
Mitral Valve Stenosis Signs and Symptoms:
- DOE
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Pulmonary edema
- Pulmonary HTN
- Atrial fibrillation
Think fluid backing up into the lungs. LV function usually preserved
What will you see on Mitral Valve Stenosis CXR?
- Mitral calcification
- Pulmonary edema or vascular congestion
- Elevated left main bronchus
- Straightening of left heart border
What will you see on Mitral Valve Stenosis Echo?
- Calcification
- Left atrial thrombus
- Left atrial enlargement
Mitral Valve Stenosis will enlarge the left atria, which will show a _________ on the EKG.
- notched P-wave
- A-fib
Mitral Valve Stenosis Treatment
- Rate control w/ β-blockers, CCB, digoxin
- ↓ Left atrial pressure w/ Diuretics
- Anticoagulation therapy
- Surgical correction- Valve replacement
Mitral Valve Stenosis Anesthetic Considerations
- Normal HR (80), Volume, and Afterload
- Prevent/Treat ↓CO or pulmonary edema (No Trendelenburg, can ↑CHF)
- Maintain SVR and BP (Neo, Vaso)
- Avoid Pulmonary HTN
- Treat diuretic-induced complications (low K+)
- Pulmonary edema with MVS is a high risk- limit IVF
Neuraxial Anesthesia Considerations for Mitral Valve Stenosis Pts.
- Maintain BP
- Maintain Normal HR
- Make sure the patient has adequate preload
What induction agents do you want to avoid in patients with mitral valve stenosis?
- Ketamine (↑HR)
- Atracurium, Pancuronium (↑ Histamine release)- cause SNS surge tachycardia and hypotension
- Etomidate is the DOC
Name this valve disorder:
* Occurs in 2% of the US population
* Associated with IHD, Endocarditis, and Cardiomyopathy
* Most often with sequelae of CAD: where myocardial ischemia and infarction cause papillary muscle dysfunction and may rupture
- Mitral Regurgitation
What is the pathophysiology of MVR?
- Decreased SV and CO
- LA volume overload –>Pulm. congestion
- LV hypertrophy
What conditions will you see eccentric hypertrophy?
- Mitral Valve regurgitation
- Aortic Valve regurgitation
What type of heart wall thickening happens with aortic stenosis?
- Concentric Hypertrophy
Mitral valve regurgitant volume is dependent on:
- Size of the mitral valve orifice
- The pressure gradient across the mitral valve
Mitral Valve Regurgitation Symptoms
- Holosystolic murmur at apex that radiates to the axilla
- Cardiomegaly
- Atrial fibrillation
Causes of Mitral Valve Regurgitation
- History of IHD
- Endocarditis
- Papillary muscle dysfunction/ rupture
Mitral Valve Regurgitation Findings
EKG
CXR
ECHO
- EKG: A-fib
- CXR: Cardiomegaly, LA/LV hypertrophy
- ECHO: Left atrial thrombus
Mitral Valve Regurgitation repair is recommended for patients with EF between ____ to ____ % .
- 30 to 60% or LV-ES dimension > 40 mm
-For EF < 30%, sugurical intervention will not help
-Surgery before EF<60% will prolong survival
-Symptomatic patients should undergo surgery even if EF is normal
What device is used to repair mitral valve regurgitation?
- Mitraclip
What are the pharmacological/medical treatments for mitral valve regurgitation?
- Vasodilators
- Biventricular Pacing
- ACE-inhibitors
- B-Blockers: Carvedilol
Anesthetic Considerations for Mitral Valve Regurgitation:
* Goal
* What do you want to prevent?
* HR:
* What do you want to avoid?
- Goal: Improve forward SV and ↓ regurgitant fraction
- Prevent ↓ CO
- HR: Normal to slightly increased HR (90 bpm)
- Avoid Bradycardia can lead to LV volume overload
- Avoid increased SVR (use nitro)
- “Full, fast, forward”
How will neuraxial anesthesia affect the SVR of Mitral Valve Regurgitation Patients?
- ↓ SVR
What are the two factors that cause Aortic Stenosis?
- Calcifed aortic leaflets d/t aging
- Bicuspid aortic valve (BAV)
_______is the most common congenital valvular abnormality, and it affects 1%–2% of the population.
- Bicuspid Aortic Valve
Area of the healthy aortic valve: _____cm2
Area of a severely stenotic aortic valve: less than _____ cm2
- 2.5 - 3.5 cm2
- < 1 cm2
Aortic Stenotic Symptoms
- Systolic or mid-systolic murmur at right upper sternal border
- Crescendo–decrescendo pattern
- Murmur radiates to the neck, mimics carotid bruit
Classic Symptoms of Critical Aortic Stenosis
- Angina pectoris (↑Risk of peri-op mortality and MI)
- Syncope
- DOE
The onset of these symptoms has been shown to correlate with an average time to death of 5, 3, and 2 years, respectively.
______ % of symptomatic pts with aortic stenosis die within 3 years without valve replacement
- 75%
Aortic Stenosis Diagnostic Findings
CXR:
ECG:
CXR
Prominent ascending aorta
Aortic valve calcification
LV hypertrophy
ECG
ST Depression
T wave inversion
Name the valve disorder.
* Failure of aortic leaflets caused by disease of the aortic leaflets or aortic root
* Caused by Endocarditis, Rheumatic fever, Bicuspid aortic valve (BAV), Anorexigenic drugs (phen-phen)
* Decrease CO d/t regurgitant SV
* Usually a slow onset
- Aortic Regurgitation
Aortic Stenosis Diagnostic Findings
ECHO:
Exercise Stress Test:
Echocardiogram
Discern b/w 3 or 2-leaflet valve
Thickened and calcified
Valve area and transvalvular pressure gradients
Exercise stress testing
Poor exercise tolerance &/or abnormal BP with exercise
Aortic Stenosis Surgical Treatment
- Treatment is usually started when patients become symptomatic
- Balloon valvotomy for adolescents/young adults
- Transcatheter aortic valve replacement (TAVR)
What are the four factors that must be considered for high risk TAVR-SAVR patients?
- Age >65 years
- Transfemoral TAVR is feasible
- Aortic valve is trileaflet
- Absence of high-risk anatomic features: adverse aortic root, low coronary ostia height, LV outlflow tract calcification
Anesthetic Considerations for Aortic Stenosis:
What do you want to prevent or avoid?
HR:
What do you want to optimize?
- Prevent and avoid hypotension, ↓CO, bradycardia, tachycardia, ↓SVR
- Maintain NSR (80 bpm)
- Phenyl is preferred vasopressor
- General anesthesia is preferred; not epi or spinal
- Optimize intravascular fluid volume.
Which medication should you use for induction with AS? Avoid?
- Fenatanyl or etomidate
- Avoid opioids that may cause histamine release (morphine, hydromorphone), Ketamine (increases HR), pancuronium and atracurium (also histamine releasing)
CPR is not effective for this valvular disorder.
- Aortic Stenosis
Why is General Anesthesia preferred over epidural or spinal for aortic stenotic patients?
General anesthesia is often preferred to epidural or spinal anesthesia because the sympathetic blockade produced by regional anesthesia can lead to significant hypotension.
What pressor would you want to use if an aortic stenosis patient experience hypotension?
- Phenylephrine (α-agonist)
α-agonist do not cause tachycardia and therefore maintain diastolic filling time.
What drug would you want to use if an aortic stenosis patient experience tachycardia?
- Esmolol (short-acting β1 selective-blocker)
The magnitude of aortic regurgitation is dependent on:
- Time available for regurgitant flow (HR)
- Pressure gradient across the aortic valve (SVR)
Acute AR is almost always a result of ____ ____ or ____ ____.
Infective endocarditis or aortic dissection
↑ SVR in Aortic Valve regurgitation =
- more regurgitant
Lower SVR, more flow forward
Aortic Valve Regurgitation’s Effect on EF.
- Decrease EF over time
In what valvular condition will you hear a low-pitched diastolic rumble called an Austin-Flint murmur?
- Aortic Regurgitation
Aortic Regurgitation effect on
Pulse Pressure
DBP
Pulse Characteristics
- Widened Pulse Pressure
- Decrease DBP
- Bounding Pulses
What are the manifestations of LV failure in aortic regurgitation patients?
- Dyspnea
- Orthopnea
- Fatigue
- Coronary ischemia
Acute Aortic Regurgitation will result in severe ______ volume overload.
- LV
Symptoms of Acute Aortic Regurgitation.
- Coronary Ischemia
- Rapid Deterioration of LV function
- Immediate Heart Failure
Aortic Regurgitation Dx Findings
EKG
CXR
ECHO
EKG/CXR
LV enlargement and hypertrophy
ECHO
Leaflet prolapse or perforation
What are the medical treatments for aortic regurgitation?
- Decrease systolic HTN
- Decrease LV wall stress
- Improve LV function
- Diuretics, ACE-I, CCB
What are the surgical treatments for aortic regurgitation?
- Aortic Valve Replacement
- Aortic Root Replacement
Anesthetic considerations for aortic regurgitation.
Goal:
Avoid:
HR:
Minimize
- Goal is to maintain forward LV SV
- Avoid ↓HR, avoid ↑SVR
- HR: > 80 bpm
- Minimize myocardial depression (use vasodilator to ↓ afterload and Inotrope to ↑ contractility)
- “Fast, forward, full”
What type of anesthesia is preferred for Aortic Regurgitation?
- General Anesthesia
What induction agents and other anesthetic considerations should be used with AR?
- Inhaled anesthetics or IV drugs
- Avoid decreased HR or increased SVR
- NMBDs have minimal or no effect on BP
