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6902 test 2 > Valvular Disease > Flashcards

Valvular Disease Flashcards

1
Q

What valves are open in systole?

A

Aortic & Pulmonic

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2
Q

What valves are open in diastole?

A

Mitral & Tricuspid

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3
Q

Murmur btwn S1 and S2

A

Stenosis of AV or PV

Regurg of TV or MV

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4
Q

Path of blood flow through the heart

A 
Superior/Inferior Vena Cava to 
RA
through Tricuspid valve
to RV
through pulmonic valve to
Pulmonary arteries to lungs to
Pulmonary veins to
LA
through the Mitral Valve to
LV
through Aortic valve to the aorta
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5
Q

Murmur btwn S2 and S1

A

Regurg of AV or PV

Stenosis of MV or TV

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6
Q

What is the most common arrhythmia produced by valvular disease?

A

Afib

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7
Q

Patients can have _____ with normal coronaries?

A

Angina

Due to the inability to meet O2 demand vs. CA stenosis. Ventricles hypertrophy creating further demand ischemia

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8
Q

Stenotic lesions require

A

suppressing HR to prolong diastole

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9
Q

Regurgitant lesions require

A

reducing afterload to reduce the regurgitant fraction

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10
Q

Hypertrophy is diagnosed by CXR when

A

heart size is > 50% of internal width of the thoracic cage

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11
Q

Mechanical valves pros and cons

A

Last 20-30 years but require anticoagulation

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12
Q

Lab values with mechanical valves

A

elevated LDH
decreased haptoglobin
increased reticulocytes (increased RBC turnover)

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13
Q

AHA recommendation for first line prevention of bacterial endocarditis

A

oral and physical hygiene

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14
Q

Specific verbiage on abx endocarditis prophylaxis

A

Administered NOT to individuals with high cumulative lifetime risk of contracting endocarditis but to pts with highest risk of adverse outcomes if they dvlp endocarditis

heart valve pts
previous hx of endocarditis
congenital heart disease
heart transplant pts

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15
Q

Which valve is bicuspid?

A

Mitral-

4-6 cm2

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16
Q

Mitral stenosis

A

rheumatic heart disease - very rare in US
Iatrogenic - heart catheterization

S/S:
DOE, orthopnea, PND from high left atrial pressures

Murmur:
Snap in diastole and rumbling diastolic murmur hart at the apex or left axilla

Diagnosis: ECHO
< 1.0 cm is severe and LAP is > 25 mmHg (also = PHTN)

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17
Q

Pathophys as MS progresses

A

pulmonary venous pressure rises to counter increased LA pressure

As the orifice narrows, ever-increasing pressure gradient is created which creates transudation fluid in the pulmonary interstitial space and increases work of breathing

Pulmonary edema when pulmonary venous pressure > plasma oncotic pressure

afib
PHTN

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18
Q

Treatment of MS

A

diuretics to reduce LAP and volume
Afib treated by rate control using BB, CCB, dig
Require anticoag
Surgery indicated when PHTN develops

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19
Q

Goal with MS

A

Prevent decreases in CO or produce pulmonary edema

A sudden SVR decrease results in tachycardia, which results in a CO decrease

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20
Q

MS causing CHF

A

precipitated with excessive fluids
trende
autotransfusion via uterine contractions

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21
Q

Which pressor is preferred in MS?

A

Vasopressin bc has minimal effects on pulmonary artery pressure

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22
Q

Things to avoid with MS

A 
increasing pulmonary artery pressure by:
hypercarbia
hypoxemia
lung hyperinflation
lung water increases
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23
Q

Anesthetic types in MS

A 
Neuraxial if not anticoagulated
GA - not ketamine pancuronium  bc HR increase, histamine release (atracurium, succ)
N2O can increase PVR
DES with sudden large changes 
Lg amts of fluid

Infusion of drugs that maintain bradycardia - fentanyl helpful

Light anesthesia can evokes sympathetic stimulation and SVR/PVR increases

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24
Q

Mitral Valve Regurg

A

More common than MS

decrease in CO and SV as forward flowing volume flows backwards into the LA.

Volumes of 60% or more are severe MR

Chronic MR results in remodeling of LV in attempt to compensate for loss of CO. the LA remodels to become more compliant for increase filling volume. Acute MR, the presentation is pulmonary edema and/or cardiogenic shock bc these remodeling have taken place

systolic apic murmur that radiates to the axilla

ECHO

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25
Q

Survival with MR

A

Survival better if surgery when EF is > 60%

Pts with EF <30% do not improve with surgery

Symptomatic pts should have surgery

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26
Q

Repair vs replacing Mitral valve

A

Repair. Mitral apparatus is part of normal LV chamber and replacement changes this geometry. Repair preserves LV unction

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27
Q

Treatment of MR

A

Vasodilators to reduce afterload in acute MR but not chronic

Symptomatic pts - ACEI and BB and pacing

28
Q

Goals of anesthesia in MR

A
  1. prevent bradycardia - increases the regurg fraction
  2. prevent increase in SVR - prevent the LV from increasing forward flow
  3. minimize cardiac depression
  4. monitor the regurgitant volume

Volume is extremely important

Fast, full, forward - HR elevated, full volume, maintain forward flow through SVR reduction

29
Q

Anesthesia meds in MR

A

Afterload can be reduced with SNP or NTG
Regional provides decrease in SVR

PIA can decrease SVR and increase HR (but do depress contractility and may need to consider narcotic induction with anticholinergics for HR control)

30
Q

Vent settings in MR

A

normal rate - too fast will result in poor venous return

31
Q

MitraClip

A

percutaneous valve repair

prominent in elderly high risk pts

32
Q

Mitral valve prolapse

A

most common valvular disorder in the US

typically benign

dx ECHO with 2 mm or more prolapse

Anesthesia the same as MR

33
Q

If you detect in preop a pt with systolic click, and pt is asymptomatic, does this warrant a cardiac consult?

A

Nope

34
Q

Aortic valve

A

separates the LV from the aorta, preventing the backflow of blood into the heart during ventricular relaxation

Normal is 2.5-3.5 cm2

35
Q

Aortic stenosis

A

Common
Dvlps due to degeneration and calcification of the aortic leaflets which narrows the aortic valve

Risks:
atherosclerosis, htn, DM, smoking, male, bicuspid aortic valve

36
Q

Pts with BAV and aortic aneurysms

A

should have repair when the diameter reaches 55 mm of the aneurysm or 50 mm if family hx of rupture

37
Q

AS symptoms

A

angina
syncope
DOE
CHF

<5 year life expectancy

Independent risk factor for perioperative risk

Sytolic murmur that radiates into the neck

ECG shows LVH

38
Q

Pathophys of AS

A

the need to increase LV pressure to maintain SV
LVT obstruction - causes increase systolic pressure, causing LV failure due to remodeling

angina bc of the increased O2 demand of the enlarged LV

Subendocardial blood flow is depressed from the compression from the increased LVP

39
Q

Critical AS

A

AR gradient >50
.8 cm2

ECHO

Surgical AVR - most combined with CABG

40
Q

AS and BNP

A

increases from pt baseline can predict worsening of symptoms

41
Q

After aortic valve replacement - and AS

A

LV remodeling begins to reverse and the EF increases

42
Q

Aortic stenosis

A

high risks for perioperative complications
most pts also have CAD

Want pt in sinus rhythm bc loss of atrial kick and dramatically reduce CO

Hypotension reduces CA flow and potentiates a failing LV

Aggressive treatment of hypotension is warranted

43
Q

CPR in aortic stenosis pts

A

ineffective bc cannot generate enough stroke volume across a stenotic valve to perfuse the heart

44
Q

Anesthesia in AS

A

no neuraxial bc of sympathetic blockade leading to hypotension and preload reduction

Induction should be with drugs that do not lower SVR - opioids are useful. Benzos and etomidate

Push drugs slowly

Volume

Alpha agonists preferred bc do not cause tachycardia

Ketamine avoided due to HR increases

Avoid NTG bc reduces preload

Avoid PIA bc sino-atrial-depressing

Maintenance should be aimed at maintain SVR and CO

*N2O with opioids

cerebral oximetry due to emboli breaking off

45
Q

Hypertrophic cardiomyopathy

A

managed like AS

46
Q

Repairing the AV

A

mechanical or bovine/porcine/human

The Ross procedures uses the pat’s pulmonic valve to replace the aortic valve

47
Q

Aortic Regurg

A

Failure of the aortic leaflets to couple together

Inflammatory or connective tiussue disease

Acute AR from endocarditis or aortic dissection

diastolic murmur along right sternal border and signs of volume overload

LVH on ECG

48
Q

Pathophys of AR

A

CO reductions from regurgitant blood flow during diastole. Produces volume overload. As time increases for backflow, so does the regurg. The pressure gradient also determines the amt of back flow (SVR).

Regurg is decreased by tachycardia and peripheral vasodilation

LV hypertrophies in response to increased filling volumes, consuming more O2 and reducing subendocardial blood flow

Chronic changes are tolerate though remodeling

As the LV fails, pulmonary edema dvlps

Pts with acute AR manifest with ischemia and rapid deterioration into HF

49
Q

signs of volume overload

A

widened PP
Decreased DBP
Bounding pulses
Pulmonary congestion

50
Q

Regurgitant jet volume

A

Regurgitantvolume=Leftventriclestrokevolume − Rightventriclestrokevolume

Regurgitantvolume=(LVOTarea×LVOTVTI)−(Pulmonaryarteryarea × pulmonaryarteryVTI)

ascending aortic SAX view

51
Q

Surgery for AR

A

indicated with EF < 55% and LVESV increases to 55 mL or more (regurgitant volume)

Acute AR is an emergency
Ross procedure
Aortic valve repair

52
Q

Medical mgmt. for AR

A

Reduce HTN and improve LV function

Vasodilators and inotropic agents like dobutamine

Nifedipine or hydralazine

53
Q

Anesthesia for AR

A

Fast, Full, Forward

HR > 80 to reduce amt of time in diastole

Abrupt SVR increases can cause LV failure - treat with vasodilator and inotrope

GA - induction should not decrease HR or increase SVR to minimize regurg volume

Maintenance with N2- plus PIA and/or opioid
All PIA increase HR and decrease SVR

Fluid status should be normal

54
Q

Bradycardia and junctional rhythms and AR

A

Atropine or glycol before ephedrine bc ephedrine will incrase SVR

55
Q

Tricuspid valve

A

separates the right atrium from the right ventricle

papillary muscles/chordae tendinae prevent the prolapse of leaflets into the atria

56
Q

TV regurg

A

Endocarditis
PHTN
RVH

common - especially in athletes

TV can be removed without much of an effect

Signs are JVP increases, hepatomegaly, ascites, edema

Treatment aimed at the cause of the TR and surgery is rare

57
Q

TV regurg anesthesia

A

maintain IV volume in the high-normal range to ensure preload

PPV and vasodilators bad if reduce venous return

Avoid incrase in PVR
Avoid hypoxemia, hypercarbia, N2O

RAP monitoring for CVP trends

58
Q

TV stenosis

A

very rare and usually exists with TR and MV/AV disease

RAP is increased and RV effects are usually dependent on concurrent TR for remodeling of the ventricle

eCHO

59
Q

Pulmonic regurg

A

PHTN

rarely symptomatic

60
Q

Pulmonic stenosis

A

congenital and corrected in childhood

RHD, carcinoid, endocarditis, trauma

Surgical valvotomy is used to relieve symptoms

61
Q

TAVR

A

TAVR - severe symptomatic AS pts that inoperable or high risk

higher risk of stroke, complete HB, LBBB, paravalvular regurg

contraindicated in pts with BV

lower 30 day and 1 year mortality, greater improvement in cardiac symptoms, reduced repeat procedures

62
Q

SAVR

A

median sternotomy

often with CABG

apply defib pads

TEE

associated with higher bleeding risks and fib

63
Q

Balloon valvotomy

A

MS

MR symptomatic pts with LV dysfunction (open heart with bypass)

64
Q

MV repair

A

traditional sternotomy with CPB
Partial sternotomy
Right mini-thoracotomy
Endoscopic approach

Robotic procedure - take extra care for padding
*all require GA

65
Q

Left atrial appendage closure

A

combat the fact that most afib strokes occur from thrombus formation in the LAA

Watchman LAAC device dvlped as an alternative to oral anticoag for nonvalve afib

GA - takes 1 hr. anticoag needed, fluroscopy, TEE

Must stay anticoagulated for 2 months

6902 test 2 (8 decks)

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