valvular heart disease Flashcards
TAVR and type of anesthesia
aortic valve replacement for aortic stenosis (GA or MAC)
TAVR and SAPIAN valve
requires balloon valvuloplasty
need for rapid ventricular pacing (160-200BPM)
apnea during deployment
pacing pads in case pacing goes unwell
valve in valve (another valve) if deployment doesn’t go great
TAVR and core valve
if core valve is used, dont need valvuloplasty or rapid ventricular pacing
if it doesn’t deploy properly, retrieve and re deploy
best place to listen for aortic stenosis
A
2nd ICS at right sternal border
s1 and where to listen
C (tricuspid area) or D (mitral area)
left of sternal border at 4th ICS (apex) or
mid clavicular line on left at 5th ICS (apex)
closure of mitral and tricuspid valves, end of LV filling and beginning of isovolumic contraction
s2 and where to listen
A (aortic) or B (pulmonic area)
right or left sternal border at 2nd ICS
closure of pulmonic and aortic valves
beginning of diastole, onset of isovolumic relaxation
s3
suggests flaccid and inelastic heart- think HF
s4
caused by atrial systole, heart before s1, think poor compliance
what happens to EF with concentric hypertrophy
normal
what happens to EF with eccentric hypertrophy
reduced
replication of sarcomeres with concentric hypertrophy are in
parallel
replication of sarcomeres with eccentric hypertrophy are in
series
normal aortic valve orifice
2.5-3.5cm^2
severe aortic stenosis aortic valve orifice
<0.8cm^2
etiologies of aortic stenosis (3)
bicuspid aortic valve and calcification of valve leaflets
rheumatic fever
infective endocarditis
what does this pressure volume loop indicate?
aortic stenosis
PV loop height increases
EDV and ESV also increase (shift to the right)
classic presentation of aortic stenosis (pneumonic)
SAD
syncope, angina, dyspnea
anesthetic management of AS patient
(preload, contractility, HR, SVR, PVR)
“full slow and constricted”
slower side of NSR
increase preload
maintain contractility
maintain or increase SVR
maintain PVR (dont increase)
this arterial waveform is indicative of a patient with
aortic stenosis
lower systolic upstroke, delayed peak
pulsus parvus (waveform of small amplitude and narrow PP)
dichrotic notch may not be present, may look “dampened” overall
pulsus tardus
what does this pressure volume wave form represent
chronic aortic regurgitation
what does this pressure volume wave form represent
mitral stenosis
what does this pressure volume wave form represent
chronic mitral regurgitation
what does this pressure volume wave form represent
chronic mitral regurgitationc
conditions associated with chronic AI (4)
valvular calcification, marfan, ehlers danlos, ankylosing spondylitis
anesthetic management of a patient (type) with AI
(HR, preload, contractility, SVR, PVR)
“full fast forward”
HR increase
preload maintain or increase
contractility maintain
SVR decrease
PVR maintain
regional anesthesia: sympathectomy will reduce after load and regurgitant fraction (this is beneficial)
what is this arterial line waveform indicative of
aortic insufficiency
sharp upstroke, low DBP, wide PP
biphasic systolic peaks (biferens pulse)
normal mitral valve orifice
4-6cm^2
which trans valvular gradient pressure and PASP are indicative of MS (and orifice size)
LA-LV gradient above 10mmHg with PASP >50mmHg
(severe MS orifice <1cm^2)
most common cause of MS
rheumatic fever
other etiologies of MS include (6)
RA, SLE, congenital defect, left atrial myxoma, carcinoid syndrome, iatrogenic following mitral valve repair
pathophysiology of MS
(including compensation)
lower EDV, SV, CO–> body compensates by increasing SVR (since BP=COxSVR)
anesthetic management of MS (HR, preload, contractility, SVR, PVR)
full slow and constricted
slower side of normal HR
maintain preload
maintain contractility
maintain SVR (tx HoTN with vasoconstrictor like neo or vaso)
avoid increase in PVR
if INR <1.5, neuraxial anesthesia ok (stasis in LA means increased risk of thrombosis)
after suffering an MI, a patient presents with LV papillary muscle rupture and MR. what should the anesthetic management be? think HR, pressure gradient, SVR
increased to normal HR (avoid bradycardia)
decrease LV to LA pressure gradient
decrease SVR
“full fast and forward for MR”
etiologies of mitral insufficiency (10)
rheumatic fever
ischemic heart disease
papillary muscle dysfunction
ruptured chordae tendinae
endocarditis
mitral valve prolapse
LVH
SLE
RA
carcinoid syndrome
what does the pressure volume loop look like for acute versus chronic mitral insuffeciency?
conditions that would worsen mitral insufficiency
slower HR
increased pressure gradient between LV and LA
increased SVR
increased size of valve orifice
anesthetic management of mitral regurg (HR, preload, contractility, SVR, PVR)
anesthesia type that is beneficial
full, fast, fwd
HR: increased
preload: maintain or increase
contractility: maintain
SVR: decrease
PVR: avoid increase
Regional anesthesia: sympathectomy reduces SVR, promotes forward flow, and reduces regurg. however, reducing aortic DBP can compromise CPP
which valvular disorders are associated with a systolic murmur?
mitral insufficiency (atrial systole/atrial kick problem)
aortic stenosis
ASSS mnemonic
aortic stenosis is a systolic murmur heard at the right sternal border
may be able to be palpated as a thrill, LVP can exceed 350mmHg
ARDS mnemonic
aortic regurgitation and diastolic murmur heard at the right sternal border
characterized as a high pitched blowing murmur
MSDA mnemonic
mitral stenosis is a diastolic murmur heard at the apex and the left axilla
opening snap followed by an intensely rumbling murmur (pressure of LA can reach up to 35mmHg)
MRSA mnemonic
mitral regurg is a systolic murmur heard at the apex and left axilla
holosystolic, characterized by a swishing sound
