Valvular Heart Disease Flashcards
Mitral Regurgitation
most common form of valvular heart disease
mitral valve prolapse
damaged tissue cords
Causes: rheumatic fever, endocarditis, prior MI, untreated HTN, congenital heart defects, Marfan’s
Regurgitated fraction % for Mitral regurge
Mild =. 20-30
Moderate = 30-50
Severe = >55
Treatment for mitral regurge
Acute = nitroprusside (dilates veins and arteries = decreases afterload)
Chronic = ACEi, hydralazine, diuretics, digoxin, antiarrhythmic
Anticoagulant if Afib, prolapse
Surgical valvuloplasty for severe
Mitral valve prolapse symptoms
anxiety orthostatic symptoms palpitations dyspnea atypical chest pain murmur at apex
mitral valve prolapse anesthesia management
same as MR except avoid increases in HR
aortic valve stenosis causes
degeneration and calcification
early-bicuspid, late-tricuspid valve
rheumatic, infectious endocarditis
aortic valve stenosis pathophysiology
obstruction of LV ejection concentric hypertrophy (inward growth w/o overall enlargement - thickened walls) decreased compliance
aortic valve stenosis symptoms
angina, syncope, CHF, DOE
aortic valve stenosis heart sounds?
diaphragm R side of chest
aortic regurgitation/insufficiency causes
rheumatic disease, endocarditis, aortic dissection, CT disorders
50% due to aortic root dilatation
decrease in CO
P&V overload of LV
aortic regurgitation/insufficiency CXR
acute = no LVH chronic = LVH
tricuspid regurgitation causes
right ventricle enlargement
causes: rheumatic fever, tricuspid endocarditis, ebsteins Anatoly, carcinoid tumors, pulmonary HTN, lupus, myxomatous degeneration, marfan (weakening CT), cardiac injury (ex: hit by airbag), rheumatoid arthritis, radiation therapy, pathological weakening of CT
tricuspid regurgitation signs and sounds
Afib
No EKG change
will hear in middle of body
Pre-op evaluation and care plan valvular HD
H&P Drug therapy exercise tolerance (METS) prosthetic valves prevention of endocarditis
H&P valvular HD
experiencing increased sympathetic tone (anxiety, diaphoresis, tachycardia) - ask about at night???
CHF (basilar rates, jugular venous distention if rowels at base of lung, third heart sound, normal young, athletes gone by 40)
usually Lub dub, but if Lub dub dub - should be gone by 40
impairment on myocardial contractility (dyspnea, orthopnea, fatigue, angina??) angina could be CAD or valvular
angina (may not be CAD, due to increased O2 demands from ventricular hypertrophy overcome stenosis or regurge, sets up available and required imbalance –> chest pain)
Drug therapy valvular HD
BB, CCB, digitalis for HR control
ACEi and vasodilators to control BP and after load
diuretics and inotropes for HF
slow HR if stenotic
faster HR if regurgitant
cardiac dysarrhythmias
Afib most common
LAH-myocyte stretching causes collagen deposits
most common with mitral disease
Labs - ECG
LVH, RVH = left or right axis shift
broad, notch P waves
Labs - CXR
heart greater than 50% internal width of chest
LAH = elevation of left mainstem bronchus
Labs - cardiac cath
LA pressures > 25 mmHg
acute pulmonary edema
increased PVR
prosthetic valves
- Types
- Complications
- what meds are they always on?
mechanical 20-30 yrs
bioprosthetic 10-15 yrs
thrombosis 5-8%
structural failure
endocarditis
hemolysis
always on anticoagulants
Anticoagulation - what meds and any indications?
Warfarin (Coumadin) - discontinue 3-5 days pre-op
start on IV unfractionated or subQ LMW heparin
DC heparin day before or day of surgery
Bacterial endocarditis
ABx prophylaxis for dental procedures
ABx prophylaxis for invasive procedures
NOT ABx prophylaxis for GI and GU procedures
2007 AHA guidelines
Anesthesia Management Mitral Regurgitation
Preload - maintain to slight increase Afterload - reduce HR - elevated (ideally 80-100bpm) Contractility - maintain or increase Avoid: -hypoxemia, hypercarbia and acidosis they increase PVR -oversedation in pre-op
Anesthesia Management Aortic Regurgitation/Insufficiency
Preload - maintain to slight increase
Afterload - reduce
Decrease SVR
HR - elevated at least 80bpm, avoid sudden decreases
Contractility maintained - NO DEPRESSION
if LV failure:
-decrease BP - nitroprusside
inotrope - dobutamine
VAs: decrease SVR, low dose phenylephrine for hypotension (high doses increase regurge)
Severe- high dose narcotics
-careful of bradycardia, N2O, Benzos
Vent - slow and low
Anesthesia Management Aortic Stenosis
CANNOT LET THEM TANK Maintain BP (decreased has no LV afterload) Afterload - increase CPP Preload - maintain NSR 70-80bpm, maintain atrial kick Avoid arrhythmias, tachycardia contractility = maintain regional - severe is contraindicated CPR nearly impossible, don't go there
Anesthesia Management Mitral Stenosis
Preload - increase
Afterload - maintain
HR - slower (sinus)
Avoid:
-depressing contractility - needed to maintain CO
-hypoxemia, hypercarbia and acidosis they increase PVR
-oversedation in pre-op
-marked increase in central blood volume (transfusion/position)
-drug induced drops in SVR
Anesthesia Management Tricuspid Stenosis
Avoid N2O Tolerate spinal/epidural some pulmonary vasodilation maintain venous return spontaneous respiration -if vent: slow and low -normal CO2, O2 NO AIR IN LINES - PATENT FORAMEN OVALE: STROKE MODE BAD BAD BAD
