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Adv. Phys & Health Assessment > Valvular Heart Disease > Flashcards

Valvular Heart Disease Flashcards

1
Q

Which valvular heart diseases result in pressure overload? Volume overload?

A
  • Pressure overload - mitral stenosis, aortic stenosis
  • Volume overload - mitral regurgitation, aortic regurgitation
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2
Q

What are the 4 classes of the NY Heart Association functional classification of patients with heart disease?

A

1 - asymptomatic
2 - symptoms with ordinary activity but comfortable at rest
3 - symptoms with min activity but comfortable at rest
4 - symptoms at rest

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3
Q

What are the S/S of impaired myocardial contractility?

A
  • Dyspnea, anxiety, and resting tachycardia (caused by inc SNS activity)
  • Orthopnea
  • Easy fatigability
  • Heart failure: Basilar rales, JVD, and 3rd heart sound
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4
Q

What is the difference between a functional vs pathologic murmur?

A

Functional - innocent murmur, physiologic murmur
Pathological - structural defects in the heart

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5
Q

What is the difference between a midsystolic and holosystolic murmur?

A

Midsystolic - occurs between distinct S1 and S2 heart sounds
Holosystolic - merges with S1 and S2

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6
Q

What are the causes of a midsystolic murmur?

A

functional, aortic stenosis, or hypertrophic cardiomyopathy

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7
Q

What are the causes of a holosystolic murmur?

A

mitral regurgitation, tricuspid regurgitation

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8
Q

What are the causes of a diastolic murmur? When is it heard?

A

aortic regurgitation, mitral stenosis
S2

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9
Q

What can cause a late systolic murmur?

A

mitral valve prolapse

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10
Q

Which murmurs can be heard at the apex?

A

MS, MR, mitral valve prolapse

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11
Q

Which murmurs can be heard at the left sternal border?

A

functional and AR

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12
Q

Which murmurs can be heard at the lower left sternal border?

A

tricuspid regurg and hypertrophic cardiomyopathy

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13
Q

Which murmur can be heard at the right upper sternal border?

A

AS

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14
Q

Which murmur increases with squatting, decreases with standing and Valsalva?

A

AS

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15
Q

Which murmurs increase with handgrip or BP cuff inflation?

A

AR and MR

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16
Q

Which murmur increases with tachycardia?

A

MS

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17
Q

Which murmur increases with inspiration?

A

Tricuspid regurg

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18
Q

Which murmurs increase with Valsalva and standing?

A

mitral valve prolapse and hypertrophic cardiomyopathy

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19
Q

Which murmur increases with exercise?

A

functional

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20
Q

Which murmur may also have a systolic murmur due to increased SV?

A

AR

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21
Q

Which murmur has an opening snap after S2, loud S1, and radiation to left axilla?

A

MS

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22
Q

Which murmurs radiate to the left axilla?

A

MR and MS

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23
Q

Which murmur has a midsystolic click?

A

mitral valve prolapse

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24
Q

Which murmur is associated with prominent JVD and signs of R HF?

A

tricuspid regurg

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25
Q

Which murmur lacks an aortic regurg murmur or ejection click?

A

hypertrophic cardiomyopathy

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26
Q

Where can the 4 heart valves be auscultated?

A
  • Aortic: 2nd ICS RSB
  • Pulmonic: 2nd ICS LSB
  • Tricuspid: 5th ICS LSB
  • Mitral: 5th ICS MCL
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27
Q

Which valves are open during diastole and closed during systole?

A

mitral and tricuspid

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28
Q

Which valves are closed during diastole and open during systole?

A

aortic and pulmonic

29
Q

What EKG change indicates atrial enlargement?

A

broad, notched P waves

30
Q

What EKG change indicates ventricular hypertrophy?

A

L/R axis deviation

31
Q

How is cardiomegaly defined on x-ray?

A

When the heart is > 50% of internal width of thoracic cage

32
Q

What causes a left mainstem bronchus elevation on xray?

A

enlargement of left atrium

33
Q

How can the presence and severity of valvular heart disease be diagnosed?

A

Angiography

34
Q

Differentiate between the 2 types of valves. What kinds of patients get each?

A

Mechanical - young pts with longer life expectancy (can last 20-30 years) and need anticoagulation (highly thrombogenic)
Bioprosthetic - older patients (lasts 10-15 years) that do not need anticoagulation (low thrombogenic potential)

35
Q

What can pregnant women take for anticoagulation?

A

subcutaneous standard/LMWH and low-dose aspirin instead of warfarin
- warfarin can cause fetal defects/death

36
Q

Which valvular issue is associated with rheumatic heart disease?

37
Q

MS is asymptomatic for ______ and primarily effects women or men?

A

20-30 years, women

38
Q

What is the normal mitral valve orifice area? When do symptoms of MS develop?

A

4-6 cm^2
when valve < 2 cm^2

39
Q

What does the sub-valvular apparatus of the mitral valve consist of?

A

left ventricular free wall, two papillary muscles, and the chordae tendineae

40
Q

What causes a funnel-shaped, “fish-mouth” mitral valve?

A

Calcification of the annulus and leaflets d/t turbulent flow through deformed valve → narrowing at apex

41
Q

What are the S/S of MS?

A

Orthopnea, paroxysmal nocturnal dyspnea, pulmonary edema, increased WOB, dyspnea on exertion, pulmonary HTN, inc LA pressure and pulmonary venous pressure, Right-sided HF, Atrial fibrillation

42
Q

How can mitral stenosis be diagnosed?

A

CXR and echo show calcification, elevated left main bronchus, left arterial enlargement and thrombus
EKG - notched P waves and AF

43
Q

How is mitral stenosis treated?

A

Control HR - BB, CCB, digoxin
Dec LAP - diuretics
Anticoagulation
Surgical intervention - Percutaneous valvotomy, surgical commissurotomy, or valve replacement

44
Q

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

A
  • normal HR, normal volume, normal afterload
  • avoid pulmonary edema and HTN
  • avoid ketamine d/t inc HR and histamine releasing NMBs
45
Q

What is mitral regurg associated with?

A
  • IHD
  • Ruptured papillary muscle
  • Endocarditis
  • Mitral valve prolapse
  • Cardiomyopathy
46
Q

Describe the patho of MR

A

Eccentric hypertrophy of LA and LV to inc compliance
Dec in forward LV SV and CO
LA volume overload causes pulmonary congestion

47
Q

What are the S/S of MR?

A

IHD hx, endocarditis, papillary muscle dysfunction, cardiomegaly, a-fib, holosystolic murmur at apex that radiates to axilla

48
Q

How is MR diagnosed?

A

EKC and CXR show LA and LV hypertrophy, cardiomegaly, and a-fib
- echo shows LA thrombus

49
Q

Differentiate between the treatment of Asymptomatic vs symptomatic MR

A
  • Symptomatic→ mitral valve surgery even if normal EF or if EF > 30% and LV end-systolic dimension is less than 55 mm
  • Asymptomatic → surgery if LV EF 30-60% or LV end-systolic dimension greater than 40 mm
50
Q

Differentiate between MV repair vs replacement. Which one is preferred?

A

repair restores valve competence and maintains the functional aspects of the mitral valve apparatus
MV repair > MV replacement

51
Q

EF < ___% has little improvement with MV surgery

52
Q

What are the alternative treatments other than surgery for MR?

A

Vasodilators, biventricular pacing, ACE-I, β-blockers (carvedilol)

53
Q

______ is the minimally invasive surgery for severe MR when open surgery is not option

A

Transcatheter mitral valve repair (TMVR)
MitraClip

54
Q

What are the anesthesia goals for a patient undergoing surgery with MR?

A

Improve forward LV SV and decrease regurgitant fraction
- maintain CO, normal-inc HR (avoid bradycardia), avoid inc SVR (vasopressors to reduce afterload)
- volatiles - prevent inc BP and SVR

55
Q

What is AS associated with?

A

Aging (60-80 years old) and bicuspid aortic valve (30-50 years old)

56
Q

____ is the most common congenital valvular abnormality

A

BAV - bicuspid aortic valve

57
Q

What is the patho of AS?

A

Obstruction to ejection of blood into the aorta causes inc LV pressure, inc myocardial oxygen requirements and dec myocardial oxygen delivery
- AR and LV hypertrophy

58
Q

What is a normal aortic valve area? What area indicates AS?

A
  • Normal valve area 2.5-3.5 cm^2
  • Severe AS valve area < 1cm2
59
Q

What are the S/S of AS?

A
  • Symptomatic when severe/critical - angina, syncope, dyspnea on exertion
  • symptoms correlate with avg time to death; 75% of symptomatic pts die within 3 years w/o valve replacement
60
Q

How is AS diagnosed?

A
  • CXR - prominent ascending aorta d/t post-stenotic aortic dilation, AV calcification
  • ECG - LV hypertrophy, ST depression, T wave inversion
  • echo - shows BAV vs TAV, thick/calcificed, valve area and pressure gradients
  • exercise testing for asymptomatic pt with known AS
  • elevated BNP and dec EF
61
Q

What are the treatment options for AS?

A
  • Balloon valvotomy for adolescents/young adults with congenital or rheumatic aortic stenosis
  • Transcatheter aortic valve replacement(TAVR) - relieves symptoms of AS - regression of LV hypertrophy and inc EF
62
Q

What are the anesthetic goals for a patient undergoing surgery with AS?

A
  • Prevention of hypotension (phenylephrine) and decreased CO
  • maintain NSR: avoid bradycardia (need atrial contraction for CO) and tachycardia (dec LV filling; tx w/ esmolol)
  • GA > epidural or spinal
  • avoid opioids that cause histamine release, ketamine, pancuronium, and atracurium
63
Q

What is associated with aortic regurg?

A
  • Endocarditis
  • Rheumatic fever
  • Bicuspid aortic valve (BAV)
  • Anorexigenic drugs (phentermine, methamphetamine)
  • Acute AR: Endocarditis or aortic dissection
64
Q

What is the patho of AR?

A
  • Decreased CO d/t regurgitant SV during diastole
  • Combined LV pressure and volume overload
  • magnitude depends on HR and SVR
65
Q

What are the S/S of AR?

A
  • Low-pitched diastolic rumble - Austin-Flint murmur
  • Hyperdynamic circulation: wide PP, dec DBP, bounding pulses
  • end-stage involves LV failure - dyspnea, orthopnea, fatigue and coronary ischemia
  • acute AR - Acute AR – severe LV volume overload, coronary ischemia, rapid deterioration LV function, and HF
66
Q

How is AR diagnosed?

A

EKG and CXR - LV enlargement and hypertrophy
Echo - Leaflet prolapse or perforation and associated aortic abnormalities

67
Q

How is AR treated?

A
  • Medical - dec systolic HTN, LV wall stress, and improve LV function (diuretics, ACE-I, CCB)
  • Surgical - depends on etiology of AR; AVR for pathologies of valve; Aortic root replacement for etiology related to the aortic root
  • acute AR - immediate surgical intervention
68
Q

What are the anesthetic goals for a patient with AR?

A
  • maintain forward LV SV
  • avoid bradycardia - HR > 80 bpm
  • avoid inc SVR (LV failure)
  • min myocardial depression (vasodilator to reduce afterload and inotrope to inc contractility)
  • GA, pancuronium could be useful
  • maintain fluid volume to provide adequate proload

Adv. Phys & Health Assessment (12 decks)

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