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Health Assessment (spring 2024/mebs) > Spring 2024 (Exam II) Valvular Disease > Flashcards

Spring 2024 (Exam II) Valvular Disease Flashcards

1
Q

Prevalence of valvular heart disease in the U.S. ________ %.

A
  • 2.5%
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2
Q

The most frequently encountered cardiac valve lesions produce ________overload or _______overload on the LA or LV.

A
  • Pressure overload (stenosis)
  • Volume overload (regurgitation)

Most commonly from volume overload or pressure overload
Fairly common to aslo have IHD
>50 yrs have coexisting disease

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3
Q

Preoperative evaluation of patients with valvular heart disease includes assessments of what 3 factors?

A
  • Severity of cardiac disease
  • Degree of impaired myocardial contractility
  • Presence of associated major organ system disease (JVD, Kidneys, DM)
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4
Q

Compensatory mechanisms for valvular disease.

A
  • ↑ SNS activity
  • Myocardial Hypertrophy
  • Current drug therapy
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5
Q

How will you evaluate the History and Physical Examination of Valvular Disease Patients?

A
  • METs score (exercise tolerance)
  • Cardiac reserve
  • NYHA Functional Classification Class
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6
Q

What are the NYHA Functional Classification of Patients with Heart Disease classes and descriptions?

A
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7
Q

What are s/s of impaired myocardial contractility and HF?

A
  • Dyspnea
  • Orthopnea
  • Easily fatigued
  • HF
    -Basilar rales
    -JVD
    -3rd HS
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8
Q

What causes murmurs?

A
  • Turbulent blood flow across abnormal valves (pathological)
  • Increased flow across normal valves (functional/pregnancy)
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9
Q

What is a functional murmur?

A
  • 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
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10
Q

What valve issues will produce a systolic murmur?

A
  • Aortic Stenosis
  • Mitral or Tricuspid Valve Regurgitation
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11
Q

What valve issues will produce a diastolic murmur?

A
  • Aortic Regurgitation
  • Mitral or Tricuspid Valve Stenosis
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12
Q

Describe a mid-systolic murmur.

A
  • Occur between distinct S1 and S2 heart sounds
  • Crescendo (louder)–decrescendo (softer) pattern
  • Can be functional
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13
Q

Where is the best place to hear a mid-systolic murmur

A

Right upper sternal border

If murmur radiates towards right carotids, possible aortic stenosis.

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14
Q

What murmur merges with S1 and S2

A
  • Holosystolic Murmur
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15
Q

Where is the best place to hear a Holosystolic Murmur?

A
  • Apex of the heart
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16
Q

Holosystolic Murmur that radiates to the left axilla correlates to what valvular issue?

A
  • Mitral regurgitation
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17
Q

What murmur follows S2?

A
  • Diastolic Murmur

Lub, Dub, Murmur - easiest one to hear

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18
Q

Aortic Stenosis
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:
Maneuvers:

A
  • Right upper sternal border
  • Midsystolic crescendo-decrescendo mumur
  • Radiation to carotids; ejection click
  • Increases with squatting, decreases with Valsalva and standing
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19
Q

Aortic Regurgitation
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:
Maneurvers:

A
  • Left Sternal border
  • Early diastolic murmur
  • May have ↑ systolic murmur d/t ↑ SV
  • Increases with handgrip of BP cuff inflation
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20
Q

Mitral Stenosis
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:
Maneuvers:

A
  • Apex
  • Mid-diastolic murmur
  • Radiation to left axilla
  • Increases with tachycardia
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21
Q

Mitral Regurgitation
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:
Maneuvers:

A
  • Apex
  • Holosystolic murmur
  • Radiation to the left axilla
  • Increases with handgrip or BP cuff inflation
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22
Q

Tricuspid Regurgitation
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:
Maneuvers:

A
  • Lower left sternal border
  • Holosystolic murmur
  • Prominent JVD, s/s RHF
  • Increases with inspiration
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23
Q

Mitral Prolapse
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:
Maneuvers:

A
  • Apex
  • Late Systolic
  • Midsystolic Click
  • Increases with Valsave, standing
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24
Q

Functional Murmur
Auscultation Location:
Timing in the cardiac cycle:
Associated Findings:
Maneuvers:

A
  • Left sternal border
  • Midsystolic crescendo-decrescendo
  • none
  • Increases with exercise
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25
Q

Name the auscultation locations.
Aortic:
Pulmonic:
Tricuspid:
Mitral:
Erbs Point:

A
  • Aortic: 2nd ICS RSB
  • Pulmonic: 2nd ICS LSB
  • Tricuspid: 5th ICS LSB
  • Mitral: 5th ICS Left Mid-Clavicular
  • 3rd IS, Left sternal edge
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26
Q

Diagnostics EKG:

Broad notched P waves on the ECG suggest _________ enlargement.

A
  • atrial enlargement
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27
Q

Right ventricular hypertrophy will result in a _________ axis deviation?

A
  • Right
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28
Q

This is the most common dysrhythmia presented in valvular disease.

A
  • Atrial fibrillation
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29
Q

CXR diagnostics for valvular disease patients.

A
  • Cardiomegaly- when heart size is >50% of the internal width of thoraic cage
  • Left mainstem bronchus elevation- caused by LA enlargement
  • Valvular calcifications
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30
Q

Diagnostic echocardiogram can be used to assess:

A
  • 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
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31
Q

Impediments of TTE?

A
  • Body Habitus
  • unable to see ASD v VSD or vegitations on the valves –> TEE is better
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32
Q

What is the purpose of angiography?

A
  • 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
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33
Q

Describe a mechanical valve

A
  • Valve can be metal or carbon alloy
  • Very durable, can last 20-30 years
  • Cons: Highly thrombogenic
  • Younger patients
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34
Q

Describe a bioprosthetic valve.

A
  • Valve can be Porcine or bovine
  • Short lasting. 10-15 years
  • Low thrombogenic potential
  • Elderly patients
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35
Q

Patients with valvular disease undergoing surgery will discontinue what medication 3 to 5 days before surgery?

A
  • Warfarin

Oftentimes, patients are on some sort of bridge therapy (heparin).
Abrupt discontinuation can lead to rebound hypercoagulable state

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36
Q

Warfarin is not recommended in the _______ trimester because it can lead to spontaneous termination of pregnancy.

A
  • First

Pregnant moms are usually on LMHW or ASA.

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37
Q

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

A
  • Mitral Stenosis
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38
Q

Normal mitral valve orifice area:

When will symptoms of mitral valve stenosis develop?

A
  • 4-6 cm2
  • Symptoms develop when the mitral valve orifice is less than 2 cm2
39
Q

How will mitral valve stenosis affect the following
LA volume and pressure:
LV contractility:
SV:

A
  • LA volume ↑/ LA pressure ↑
  • No change in LV contractility
  • SV ↓
40
Q

What is a commisure?
Sub-valvular apparatus?

A
  • 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
41
Q

Mitral Valve Stenosis Signs and Symptoms:

A
  • DOE
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Pulmonary edema
  • Pulmonary HTN
  • Atrial fibrillation

Think fluid backing up into the lungs. LV function usually preserved

42
Q

What will you see on Mitral Valve Stenosis CXR?

A
  • Mitral calcification
  • Pulmonary edema or vascular congestion
  • Elevated left main bronchus
  • Straightening of left heart border
43
Q

What will you see on Mitral Valve Stenosis Echo?

A
  • Calcification
  • Left atrial thrombus
  • Left atrial enlargement
44
Q

Mitral Valve Stenosis will enlarge the left atria, which will show a _________ on the EKG.

A
  • notched P-wave
  • A-fib
45
Q

Mitral Valve Stenosis Treatment

A
  • Rate control w/ β-blockers, CCB, digoxin
  • ↓ Left atrial pressure w/ Diuretics
  • Anticoagulation therapy
  • Surgical correction- Valve replacement
46
Q

Mitral Valve Stenosis Anesthetic Considerations

A
  • 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
47
Q

Neuraxial Anesthesia Considerations for Mitral Valve Stenosis Pts.

A
  • Maintain BP
  • Maintain Normal HR
  • Make sure the patient has adequate preload
48
Q

What induction agents do you want to avoid in patients with mitral valve stenosis?

A
  • Ketamine (↑HR)
  • Atracurium, Pancuronium (↑ Histamine release)- cause SNS surge tachycardia and hypotension
  • Etomidate is the DOC
49
Q

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

A
  • Mitral Regurgitation
50
Q

What is SV, LA, CO, LV of MVR?

A
  • Decreased SV and CO
  • LA volume overload –>Pulm. congestion
  • LV hypertrophy
51
Q

What conditions will you see eccentric hypertrophy?

A
  • Mitral Valve regurgitation
  • Aortic Valve regurgitation
52
Q

What type of heart wall thickening happens with aortic stenosis?

A
  • Concentric Hypertrophy
53
Q

Mitral valve regurgitant volume is dependent on:

A
  • Size of the mitral valve orifice
  • The pressure gradient across the mitral valve
54
Q

Mitral Valve Regurgitation Symptoms

A
  • Holosystolic murmur at apex that radiates to the axilla
  • Cardiomegaly
  • Atrial fibrillation
55
Q

Causes of Mitral Valve Regurgitation

A
  • History of IHD
  • Endocarditis
  • Papillary muscle dysfunction/ rupture
56
Q

Mitral Valve Regurgitation Findings
EKG
CXR
ECHO

A
  • EKG: A-fib
  • CXR: Cardiomegaly, LA/LV hypertrophy
  • ECHO: Left atrial thrombus
57
Q

Mitral Valve Regurgitation repair is recommended for patients with EF between ____ to ____ % .

A
  • 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

58
Q

What device is used to repair mitral valve regurgitation?

A
  • Mitraclip
59
Q

What are the pharmacological/medical treatments for mitral valve regurgitation?

A
  • Vasodilators
  • Biventricular Pacing
  • ACE-inhibitors
  • B-Blockers: Carvedilol
60
Q

Anesthetic Considerations for Mitral Valve Regurgitation:
* Goal
* What do you want to prevent?
* HR:
* What do you want to avoid?

A
  • 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”
61
Q

How will neuraxial anesthesia affect the SVR of Mitral Valve Regurgitation Patients?

A
  • ↓ SVR
62
Q

What are the two factors that cause Aortic Stenosis?

A
  • Calcifed aortic leaflets d/t aging
  • Bicuspid aortic valve (BAV)
63
Q

_______is the most common congenital valvular abnormality, and it affects 1%–2% of the population.

A
  • Bicuspid Aortic Valve
64
Q

Area of the healthy aortic valve: _____cm2

Area of a severely stenotic aortic valve: less than _____ cm2

A
  • 2.5 - 3.5 cm2
  • < 1 cm2
65
Q

Aortic Stenotic Symptoms

A
  • Systolic or mid-systolic murmur at right upper sternal border
  • Crescendo–decrescendo pattern
  • Murmur radiates to the neck, mimics carotid bruit
66
Q

Classic Symptoms of Critical Aortic Stenosis

A
  • 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.

67
Q

______ % of symptomatic pts with aortic stenosis die within 3 years without valve replacement

A
  • 75%
68
Q

Aortic Stenosis Diagnostic Findings
CXR:
ECG:

A

CXR
Prominent ascending aorta
Aortic valve calcification
LV hypertrophy
ECG
ST Depression
T wave inversion

69
Q

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)
* Usually a slow onset

A
  • Aortic Regurgitation
70
Q

Aortic Stenosis Diagnostic Findings
ECHO:
Exercise Stress Test:

A

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

71
Q

Aortic Stenosis Surgical Treatment

A
  • Treatment is usually started when patients become symptomatic
  • Balloon valvotomy for adolescents/young adults
  • Transcatheter aortic valve replacement (TAVR)
72
Q

What are the four factors that must be considered for high risk TAVR-SAVR patients?

A
  1. Age >65 years
  2. Transfemoral TAVR is feasible
  3. Aortic valve is trileaflet
  4. Absence of high-risk anatomic features: adverse aortic root, low coronary ostia height, LV outlflow tract calcification
73
Q

Anesthetic Considerations for Aortic Stenosis:
What do you want to prevent or avoid?
HR:
What do you want to optimize?

A
  • 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.
74
Q

Which medication should you use for induction with AS? Avoid?

A
  • Fenatanyl or etomidate
  • Avoid opioids that may cause histamine release (morphine, hydromorphone), Ketamine (increases HR), pancuronium and atracurium (also histamine releasing)
75
Q

CPR is not effective for this valvular disorder.

A
  • Aortic Stenosis
76
Q

Why is General Anesthesia preferred over epidural or spinal for aortic stenotic patients?

A

because the sympathetic blockade produced by regional anesthesia can lead to significant hypotension.

77
Q

What pressor would you want to use if an aortic stenosis patient experience hypotension?

A
  • Phenylephrine (α-agonist)

α-agonist do not cause tachycardia and therefore maintain diastolic filling time.

78
Q

What drug would you want to use if an aortic stenosis patient experience tachycardia?

A
  • Esmolol (short-acting β1 selective-blocker)
79
Q

The magnitude of aortic regurgitation is dependent on:

A
  • Time available for regurgitant flow (HR)
  • Pressure gradient across the aortic valve (SVR)
80
Q

Acute AR is almost always a result of ____ ____ or ____ ____.

A

Infective endocarditis or aortic dissection

81
Q

↑ SVR in Aortic Valve regurgitation =

A
  • more regurgitant

Lower SVR, more flow forward

82
Q

Aortic Valve Regurgitation’s Effect on EF.

A
  • Decrease EF over time
83
Q

In what valvular condition will you hear a low-pitched diastolic rumble called an Austin-Flint murmur?

A
  • Aortic Regurgitation
84
Q

Aortic Regurgitation effect on
Pulse Pressure
DBP
Pulse Characteristics

A
  • Widened Pulse Pressure
  • Decrease DBP
  • Bounding Pulses
85
Q

What are the manifestations of LV failure in aortic regurgitation patients?

A
  • Dyspnea
  • Orthopnea
  • Fatigue
  • Coronary ischemia
86
Q

Acute Aortic Regurgitation will result in severe ______ volume overload.

A
  • LV
87
Q

Symptoms of Acute Aortic Regurgitation.

A
  • Coronary Ischemia
  • Rapid Deterioration of LV function
  • Immediate Heart Failure
88
Q

Aortic Regurgitation Dx Findings
EKG
CXR
ECHO

A

EKG/CXR
LV enlargement and hypertrophy

ECHO
Leaflet prolapse or perforation

89
Q

What are the medical treatments for aortic regurgitation?

A
  • Decrease systolic HTN
  • Decrease LV wall stress
  • Improve LV function
  • Diuretics, ACE-I, CCB
90
Q

What are the surgical treatments for aortic regurgitation?

A
  • Aortic Valve Replacement
  • Aortic Root Replacement
91
Q

Anesthetic considerations for aortic regurgitation.
Goal:
Avoid:
HR:
Minimize

A
  • 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”
92
Q

What type of anesthesia is preferred for Aortic Regurgitation?

A
  • General Anesthesia
93
Q

What induction agents and other anesthetic considerations should be used with AR?

A
  • Inhaled anesthetics or IV drugs
  • Avoid decreased HR or increased SVR
  • NMBDs have minimal or no effect on BP

Health Assessment (spring 2024/mebs) (29 decks)

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