Valvular disease Exam 2 Flashcards by Raymond Bas

What is the incidence of valvular disease in the US population?

2.5%

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What is the NYHA Functional Classification of Patients with Heart Disease?

I - Asymptomatic.
II - s/s with ORDINARY activity but relieved by rest.
III - s/s w/ MINIMAL activity but relieved by rest.
IV - s/s at rest

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What causes a murmur?

Turbulent or increased flow across a heart valve

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What is a midsystolic murmur? holosystolic? diastolic?

midsystolic = between S1 and S2, crescendo/decrescendo
holosystolic = merges S1 and S2
diastolic = after S2

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Systolic murmurs are caused by what valve pathologies?

Aortic/Pulmonic Stenosis
Mitral/Tricuspid Regurgitation

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Diastolic murmurs are caused by what pathologies?

Aortic/Pulmonic Regurgitation
Mitral/Tricuspid Stenosis

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_____ murmurs follow S2.

Diastolic

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Midsystolic murmurs occur when?

Between S1 and S2 sounds

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Which murmur type exhibits a crescendo-decrescendo pattern?

Mid-systolic Murmurs

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What characterizes holosystolic murmurs?

S1 and S2 merging (whole period)

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Where is the aortic valve auscultated?

2ⁿᵈ ICS, right sternal border

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Where is the pulmonic valve auscultated?

2ⁿᵈ ICS, left sternal border

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Where is the tricuspid valve auscultated?

5th ICS, left sternal border

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Where is the mitral valve auscultated?

5th ICS, mid-clavicular line

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What factors seen on a chest x-ray would indicate valvular disease?

Cardiomegaly
Left Bronchus Elevation
Valvular Calcifications

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What signs seen on an EKG could indicate valvular disease?

LA enlargement (broad, notched p-wave)
Axis deviations
Dysrhythmias
Ischemia

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What type of valve replacement is highly thrombogenic?

Mechanical
(metal or carbon alloy)

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What are bioprosthetic valves made from?

Porcine (pig)
bovine (cow)

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Which type of prosthetic valve is longer lasting?

Mechanical (20-30 yr) vs Bioprosthetic (10-15 yr)

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Who is most commonly affected by mitral stenosis?

Women
Rheumatic patients/rheumatic fever

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What are characteristics of MS?

Hx of rheumatic fever
asymptomatic for 20-30 years

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What is the normal mitral valve orifice surface area?

4 - 6 cm²

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At what surface area do symptoms for mitral valve stenosis start to develop?

< 2 cm²

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What are the s/s of mitral stenosis?

Exertional dyspnea
Orthopnea
Paroxysmal nocturnal dyspnea
Pulmonary edema
Pulmonary HTN
A-Fib

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What sound is auscultated for MS?

* Rumbling **diastolic murmur** * 5th ICS, left MCL * radiates to left axilla

How is mitral stenosis treated?

* Rate control (80bpm goal) * ↓LAP (diuretics) * Anticoagulation * Surgical correction (valvotomy, commissurotomy, replace)

What EKG abnormalities are common with mitral stenosis?

* Notched P waves * A-Fib

What are the anesthetic goals for a patient with mitral stenosis?

Maintain normal parameters for: HR volume status afterload

What drugs would be used for hypotension in MS? (2)

1. **phenylephrine** 2. **vasopressin**

What drugs would be avoided for induction? (3)

* **ketamine** = increased HR * **pancuronium/atracurium** = tachycardia or hypotension

What is more common, mitral stenosis or regurgitation?

**Regurgitation** (2% of US population)

What type of murmur would be auscultated with mitral regurgitation?

* **Holosystolic murmur** at the cardiac apex * radiates to axilla

What do we see in EKG, CXR, and echo for MR?

* LA hypertrophy * LV hypertrophy * A-fib

What treatment is best for asymptomatic pts with EF 30-60%?

Surgical intervention MV repair > MV replacement

What procedure is preferred for pts with severe MR and not a candidate for surgery?

**Transcatheter Mitral Valve Repair (TMVR)** minimally invasive MitraClip

What drugs are preferred for mitral regurgitation?

* ACE inhibitors * Carvedilol

What are the anesthetic goals for mitral regurgitation patients?

* Improve forward LV stroke volume (decrease afterload) * Decrease Regurgitation * Avoid increased SVR = **nitroprusside** * **Normal to increased HR** * normal fluid volume

What heart rate would you want to maintain with mitral regurgitation?

* **Normal to slightly increase HR** * Bradycardia will increase LV volume overload.

What type of pathology would cause early-life development of **aortic stenosis**?

**Bicuspid Aortic Valve**

What is the normal surface area of the aortic valve?

2.5 - 3.5 cm²

What is the surface area of a severely stenotic aortic valve?

< 1 cm²

What pathology would be expected for a systolic or mid-systolic murmur heard in the right upper sternal border?

* Aortic Stenosis * **crescendo-decrescendo** * radiates to neck

What symptoms are seen when aortic stenosis becomes critical?

* Angina * Syncope * Dyspnea on exertion

What % of AS patients die within **three years** without a valve replacement?

75%

What EKG characteristics would be seen for a patient with aortic stenosis?

- LV hypertrophy - ST depression - T-wave inversion

What changes in the aorta are seen in pts with AS?

* prominant ascending aorta * post-stenotic aortic dilation

What can be seen in TTE/TEE in AS pts?

* Tri-leaflet vs bi-leaflet valve * Thickened and calcified * Valve area and transvalvular pressure gradients

Which treatment for AS is preferred for **young patients**? How about **older**?

**Balloon valvotomy** = young patients **TAVR + PCI** = older patients

What is the criteria for TAVR procedure?

* > 65 y/o * trileaflet valve * femoral approach is feasible * abscence of high risk anatomy

Why is **CPR** ineffective in AS patents?

impossible to create an adequate **stroke volume** across a stenotic aortic valve

What type of anesthetic technique is preferred for AS? What drugs are not preferred?

* General Anesthesia > epidural/spinal * ketamine = **increased HR** * histamine releasing opioids = **hypotension** * pancuronium, atracurium = **hypotension**

Treatment for bradycardia in AS pts? tachycardia? hypotension?

* Ephedrine, atropine, glycopyrrolate * esmolol = tachycardia * phenylephrine = hypotension

What are common causes of **chronic aortic regurgitation**?

* Endocarditis/rheumatic fever * Bicuspid Aortic Valve * Anorexigenic drugs (phentermine, methamphetamine)

What are the two common causes of **acute aortic regurgitation**?

* Endocarditis * Aortic dissection

What determines the severity of regurgitant blood flow from AR?

* **Time** available for flow (HR) * **Pressure** gradient (SVR)

What type of murmur would be heard with aortic regurgitation?

Early diastolic murmur +/- systolic murmur left sternal border

What blood pressure abnormalities are often seen with aortic regurgitation?

* Widened pulse pressure * decreased dBP * Bounding pulses

What are some things that echocardiogram can evaluate?

cardiac anatomy cavity dimensions ventricular EF Valve function

What kind of history would be associated with MR?

IHD hx endocarditis papillary muscle dysfunction

What CV anesthesia management for AR vs AS?

AR: **avoid bradycardia**, **keep HR >80bpm** (Fast, Full, Forward) AS: avoid brady and tachycardia, avoid decreased SVR