Valvular Heart Disease

Question 1

Mitral Regurgitation

Answer 1

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

Question 2

Regurgitated fraction % for Mitral regurge

Answer 2

Mild =. 20-30
Moderate = 30-50
Severe = >55

Question 3

Treatment for mitral regurge

Answer 3

Acute = nitroprusside (dilates veins and arteries = decreases afterload)

Chronic = ACEi, hydralazine, diuretics, digoxin, antiarrhythmic

Anticoagulant if Afib, prolapse

Surgical valvuloplasty for severe

Question 4

Mitral valve prolapse symptoms

Answer 4

anxiety
orthostatic symptoms 
palpitations dyspnea 
atypical chest pain 
murmur at apex

Question 5

mitral valve prolapse anesthesia management

Answer 5

same as MR except avoid increases in HR

Question 6

aortic valve stenosis causes

Answer 6

degeneration and calcification
early-bicuspid, late-tricuspid valve
rheumatic, infectious endocarditis

Question 7

aortic valve stenosis pathophysiology

Answer 7

obstruction of LV ejection 
concentric hypertrophy (inward growth w/o overall enlargement - thickened walls)
decreased compliance

Question 8

aortic valve stenosis symptoms

Answer 8

angina, syncope, CHF, DOE

Question 9

aortic valve stenosis heart sounds?

Answer 9

diaphragm R side of chest

Question 10

aortic regurgitation/insufficiency causes

Answer 10

rheumatic disease, endocarditis, aortic dissection, CT disorders

50% due to aortic root dilatation

decrease in CO

P&V overload of LV

Question 11

aortic regurgitation/insufficiency CXR

Answer 11

acute = no LVH
chronic = LVH

Question 12

tricuspid regurgitation causes

Answer 12

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

Question 13

tricuspid regurgitation signs and sounds

Answer 13

Afib
No EKG change
will hear in middle of body

Question 14

Pre-op evaluation and care plan valvular HD

Answer 14

H&P 
Drug therapy 
exercise tolerance (METS)
prosthetic valves 
prevention of endocarditis

Question 15

H&P valvular HD

Answer 15

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)

Question 16

Drug therapy valvular HD

Answer 16

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

Question 17

cardiac dysarrhythmias

Answer 17

Afib most common

LAH-myocyte stretching causes collagen deposits
most common with mitral disease

Question 18

Labs - ECG

Answer 18

LVH, RVH = left or right axis shift

broad, notch P waves

Question 19

Labs - CXR

Answer 19

heart greater than 50% internal width of chest

LAH = elevation of left mainstem bronchus

Question 20

Labs - cardiac cath

Answer 20

LA pressures > 25 mmHg
acute pulmonary edema
increased PVR

Question 21

prosthetic valves

• Types
• Complications
• what meds are they always on?

Answer 21

mechanical 20-30 yrs
bioprosthetic 10-15 yrs

thrombosis 5-8%
structural failure
endocarditis
hemolysis

always on anticoagulants

Question 22

Anticoagulation - what meds and any indications?

Answer 22

Warfarin (Coumadin) - discontinue 3-5 days pre-op

start on IV unfractionated or subQ LMW heparin

DC heparin day before or day of surgery

Question 23

Bacterial endocarditis

Answer 23

ABx prophylaxis for dental procedures
ABx prophylaxis for invasive procedures

NOT ABx prophylaxis for GI and GU procedures

2007 AHA guidelines

Question 24

Anesthesia Management Mitral Regurgitation

Answer 24

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

Question 25

Anesthesia Management Aortic Regurgitation/Insufficiency

Answer 25

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

Question 26

Anesthesia Management Aortic Stenosis

Answer 26

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

Question 27

Anesthesia Management Mitral Stenosis

Answer 27

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

Question 28

Anesthesia Management Tricuspid Stenosis

Answer 28

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