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Physio: Cardiovascular > Valves (Elves) > Flashcards

Valves (Elves) Flashcards

1
Q

What are the major factors that affect flow across any valvular lesion?

A
  • the valve area
  • the square root of hydrostatic pressure gradient across the valve
  • time duration of transvalvular flow (during systole and diastole)
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2
Q

What are the goals in management of patients with regurgitant lesions?

A
  • decrease or minimize regurgitant flow across mitral or aortic valve
  • increase inotropy
  • decrease preload
  • increase HR (shorten diastolic phase)
    • fast, full, forward **
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3
Q

What are the goals in management of patients with stenotic lesions?

A
  • maximize and enhance stenotic flow across the mitral or aortic valve
    —> increase HR: want slow squeeze to push more blood through a narrowed valve
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4
Q

What types of valvular lesions can respond to changes in loading conditions?

A

REGURGITANT lesions (valves) can respond to ∆es in loading conditions—> we want to increase preload and decrease afterload

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5
Q

What types of valvular lesions are generally considered fixed and do not respond to changes in loading conditions?

A

STENOTIC LESIONS

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6
Q

What are some of the causes of Aortic Stenosis (AS)?

A
  • idiopathic Calcific degeneration
  • congenital (bicuspid instead of tricuspid)
  • endocarditis
  • Paget’s Disease (abnormal recycling of bone cells)
  • systemic lupus erythmatosus
    • normally a chronic condition **
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7
Q

What are some of the presenting symptoms in patients with severe Aortic Stenosis (AS)?

A

3 classic symptoms- reflect end stage disease

  1. ) heart failure: dyspnea on exertion, decreased exercise tolerance
  2. ) syncope: or exertional dizziness
  3. ) Angina:: or exertional angina
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8
Q

Would you expect to hear a systolic or diastolic murmur with aortic Stenosis?

A

Systolic

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9
Q

What pathophysiology would you expect in the patient with severe Aortic Stenosis?

A
  • Severe aortic stenosis causes obstruction of LV outflow, resulting in:
  • LV pressure overload
  • concentric hypertrophy
  • diastolic LV dysfunction with decreased SV and CP
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10
Q

What are some of the reasons that patients with severe aortic stenosis develop cardiac ischemia?

A
  • hypertrophied LV= higher metabolic demand
  • increased SBP—> high incidence of concomitant CAD
  • prolongation of ejection—> shortens diastolic time, decreases O2 to cardiac muscle
  • decrease in myocardial capillary density
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11
Q

What is the single most important hemodynamic goal in managing patients with severe aortic stenosis?

A
    • increases preload to fill non-compliant ventricle
  • avoid extremes of HR
  • SVR is elevated—> avoid hypotension
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12
Q

What are some of the causes of Aortic Regurgitation?

A
  • rheumatic heart disease
  • endocarditis
  • aortic root dissection, trauma
  • connective tissue disorders
  • Dexfenfluramine (PhenPhen)
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13
Q

Do patients with aortic regurgitation develop eccentric or concentric hypertrophy?

A

Eccentric hypertrophy (lumen gets larger)

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14
Q

Would you expect to hear a systolic or diastolic murmur with aortic regurgitation?

A

Diastolic

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15
Q

Do patients with Aortic Regurgitation develop volume or pressure overloading?

A

volume

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16
Q

What factors contribute to reduced coronary perfusion pressure in patients with aortic regurgitation?

A
  • increase in myocardial O2 demand because of increased LV mass
  • decreased coronary perfusion pressure—>lower DBP, higher LVEDP (widened pulse pressure)
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17
Q

What are some of the symptoms that patients with aortic regurgitation develop?

A
  • CHF/pulmonary edema

- angina

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18
Q

How would you manage heart rate and blood pressure in a patient with severe aortic regurgitation?

A
  • HR: increase HR—> decreases diastolic time and decreases regurgitant fraction (80-95bpm)
  • BP: increase or maintain preload to maintain forward flow, decrease afterload to improve forward flow
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19
Q

What are some of the causes of mitral stenosis?

A
  • rheumatic fever (women 4xs men)
  • congenital
  • rheumatoid arthritis
  • systemic lupus erythmetosus
  • carcinoid syndrome
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20
Q

What type of a murmur would you expect to hear in a patient with mitral stenosis?

A

Diastolic

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21
Q

What are the most common presenting symptoms in a patient with severe mitral stenosis?

A

Asymptomatic for about 20 years, then:

  • CHF (50%)
  • A-fib
  • dyspnea
  • hemoptysis
  • right HF
  • thromboembolism
22
Q

What pathophysiology would you expect in the patient with severe Mitral Stenosis?

A
  • chromic obstruction to LA emptying during diastole—> LA volume and pressure overload and structures behind it
  • LV chronically under loaded
  • LV usually normal- decreased in 1/3 of patients
  • RV function normal, but with severe pulmonary HTN—> RV failure and LV function abnoral
23
Q

What is the single most important hemodynamic goal in managing patients with severe Mitral Stenosis?

A

HR: decrease Hr to allow ventricle time to fill, prolong diastole

24
Q

What are some of the causes of mitral regurgitation?

A
  • rheumatic disease
  • endocarditis
  • mitral valve prolapse
  • mitral/annular enlargement
  • ischemia—> loss of muscle around valve will ∆ how valve functions
  • MI
  • trauma
  • ## phen phen
25
Q

What type of murmur would you expect to hear in a patient with mitral regurgitation?

A

Systolic

26
Q

What type of valvular lesion would benefit from IABP?

A

Mitral regurgitation

27
Q

If a patient with severe mitral regurgitation has a preoccupation LVEF of 35% and undergoes a mitral valve replacement, would you expect to see an increase or decrease in postop LVEF after the valve procedure?

A

Decrease

28
Q

What pathophysiology would you expect in the patient with severe mitral regurgitation?

A
  • LV “unloads” itself into LA (chronic atrial overload)
29
Q

How would you manage the heart rate and blood pressure in the patient with severe mitral regurgitation?

A

Fast, full, forward

  • HR: increase Hr—> decrease in LV volume, increased forward flow and decrease regurgitant fraction
  • contractility: increase or maintain
  • SVR: decreasing afterload is helpful
30
Q

What is hypertrophic cardiomyopathy?

A 
Increase in size and mass of ventricle-most common cause is HTN, 2nd cause is aortic stenosis)
Characteristics:
- LVH
- decreased diastolic compliance
- sub valvular pressure gradient
- ventricular arrhythmias
31
Q

What are the goals for hypertrophic cardiomyopathy?

A
  • increase preload
  • decrease HR
  • decrease contractility
32
Q

What is systolic anterior motion (SAM) of the mitral valve?

A

When blood is ejected in to LV @ high velocities, Venturi effect is created, which pulls the mitralve valve leaflet towards the anterior septum during systole—> outflow tract obstruction and mitral regurgitation (into RA)

33
Q

What do you want to avoid in the patient with hypertrophic cardiomyopathy?

A

Avoid anything that causes decrease in LV volume, such as:

  • decreasing preload
  • increasing contractility
  • decreased afterload
  • want to decrease determinants of myocardial O2 consumption as thickened myocardium is predisposed to ischemia
34
Q

What is a stenotic lesion?

A

Narrowing of valve orifice caused by thickening and increased rigidity of valve

  • valve does not open completely
  • hard to squeeze blood past
35
Q

What is a regurgitant valve?

A

Incompetent valve- no longer keeps blood flowing unidirectional
- valve doesn’t completely close

36
Q

Valvular disease can occur secondarily to which diseases?

A

CAD
Cardiac hypertrophy
Cardiac dilation

37
Q

What s/s will lead you to suspect defective valves?

A
  • Dyspnea
  • fatigue
  • decreased exercise capacity
  • HF
  • pulmonary HTN
  • edema (pulmonary or systemic)
  • CP
  • arrhythmias
  • blood clots
38
Q

In a stenotic valve, pressure _____________in the chamber proximal to the valve and _____________ in the chamber or artery distal to the valve.

A

Increases

Decreases

39
Q

Aortic stenosis is considered an independent risk factor for what?

A

Periop mortality

40
Q

Symptomatic patients with out surgical valve replacement have the following life spans:

  • Angina:_____
  • syncope: _____
  • CHF: ______
A

-Angina: 5 years
- syncope: 3 years
- CHF: 2 years
* they have compensated for years, no longer working
This is why you should get AVR at the onset of symptoms

41
Q

LV hypertrophy causes:

A

Diastolic stiffness

42
Q

When is aortic stenosis considered “critical stenosis”?

A

When aortic valve area is reduced to 1/4 of its natural size, before significant changes start to occur

43
Q

What are some consequences of Aortic Regurgitation?

A
  • severe chronic aortic regurgitation causes volume overload of LV with gradually developing eccentric LV dilation
  • dilated cardiomyopathy present in advanced stages
  • LV failure manifests as progressive decreased EF and CO, increased LA and PA pressures
  • severe aortic regurgitation results in low DBP and a wide pulse. Pressure
    —> usually well tolerated unless CAD present
    Low morbidity during long asymptomatic phase
44
Q

What is concentric hypertrophy?

A

Narrowing of chamber and thickening of wall around it

- muscle hypertrophy and decreased volume

45
Q

What is eccentric hypertrophy?

A

Dilation and enlargement

- LUMEN elongates relative to muscle mass

46
Q

Which valvular lesion is use of IABP contraindicated in?

A

aortic regurgitation—> would increase regurgitation across aortic valve and exacerbate LV dilation

47
Q

What do you need to do in valvular insufficiency?

A

Keep it fast, full and moving forward

- keep BP maybe a little low to promote forward flow

48
Q

What are some consequences of mitral stenosis?

A
  • causes impaired LV function d/t fixed obstruction to LA outflow
    • LA, PA, PVR pressures increased
    • A fib is common
      —> chronic pulmonary HTN and ultimately RV failure
  • LV chronically “underloaded”
49
Q

In mitral regurgitation, volume of regurgitant flow is determined by:

A
  • ventriculo-atrial gradient
  • diastolic time
  • size of regurgitant orifice
50
Q

Cardiac remodeling leads to:

A

Hypertrophy and dilation

-ß-blocker, ACE inhibitors, ARBS can prevent or partially reverse remodeling under pathologic conditions

Physio: Cardiovascular (5 decks)

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