Valvular disease Exam 2 Flashcards
What is the incidence of valvular disease in the US population?
2.5%
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
What causes a murmur?
Turbulent or increased flow across a heart valve
What is a midsystolic murmur? holosystolic? diastolic?
- midsystolic = between S1 and S2, crescendo/decrescendo
- holosystolic = merges S1 and S2
- diastolic = after S2
Systolic murmurs are caused by what valve pathologies?
Aortic/Pulmonic Stenosis
Mitral/Tricuspid Regurgitation
Diastolic murmurs are caused by what pathologies?
Aortic/Pulmonic Regurgitation
Mitral/Tricuspid Stenosis
_____ murmurs follow S2.
Diastolic
Midsystolic murmurs occur when?
Between S1 and S2 sounds
Which murmur type exhibits a crescendo-decrescendo pattern?
Mid-systolic Murmurs
What characterizes holosystolic murmurs?
S1 and S2 merging (whole period)
Where is the aortic valve auscultated?
2ⁿᵈ ICS, right sternal border
Where is the pulmonic valve auscultated?
2ⁿᵈ ICS, left sternal border
Where is the tricuspid valve auscultated?
5th ICS, left sternal border
Where is the mitral valve auscultated?
5th ICS, mid-clavicular line
What factors seen on a chest x-ray would indicate valvular disease?
- Cardiomegaly
- Left Bronchus Elevation
- Valvular Calcifications
What signs seen on an EKG could indicate valvular disease?
- LA enlargement (broad, notched p-wave)
- Axis deviations
- Dysrhythmias
- Ischemia
What type of valve replacement is highly thrombogenic?
Mechanical
(metal or carbon alloy)
What are bioprosthetic valves made from?
- Porcine (pig)
- bovine (cow)
Which type of prosthetic valve is longer lasting?
Mechanical (20-30 yr) vs Bioprosthetic (10-15 yr)
Who is most commonly affected by mitral stenosis?
Women
Rheumatic patients/rheumatic fever
What are characteristics of MS?
- Hx of rheumatic fever
- asymptomatic for 20-30 years
What is the normal mitral valve orifice surface area?
4 - 6 cm²
At what surface area do symptoms for mitral valve stenosis start to develop?
< 2 cm²
What are the s/s of mitral stenosis?
- Exertional dyspnea
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Pulmonary edema
- Pulmonary HTN
- A-Fib
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)
- phenylephrine
- 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
