Valvular Heart Disease Flashcards
Exam 2 content
How common is valvular heart disease in the US? What is the risk of coexisting IHD?
2.5%
50% of patient with aortic stenosis > 50 years old have IHD
What are a few common comorbidities with valvular heart disease?
HF, afib, angina
What is the New York Heart Association Functional Classification of Patients with Heart Disease? 4 classes and descriptions…
I: asymptomatic
II: symptoms w/ ordinary activity, comfortable at rest
III: symptoms w/ minimal activity, comfortable at rest
IV: symptoms at rest
What are some signs and symptoms of HF?
basilar rales, JVD, 3rd HS, orthopnea, dyspnea, fatigue
If you hear a systolic murmur, what should you be most worried about? What other valvular issues are associated with systolic murmurs?
Aortic stenosis. Pulmonic stenosis. Incompetent mitral or tricuspid valves.
What valvular issues are associated with diastolic murmurs?
mitral stenosis, tricuspid stenosis. Also incompetent aortic and pulmonic valves.
What is a midsystolic murmur and what is it heard with?
occurs between S1 and S2. If heard at the right sternal border and radiates to carotids–> aortic stenosis
What is a holosystolic murmur and what is it normally heard with?
Merged S1 and S2, best heard at the apex of the heart and radiates to axilla–> mitral regurg
When do you hear diastolic murmurs?
These follow S2
Where can you auscultate aortic valve?
R sternal border, 2nd ICS
Where can you auscultate the pulmonic valve?
L sternal border, 2nd ICS
Where can you auscultate the tricuspid valve?
L sternal border, 5th ICS
Where can you auscultate the mitral valve?
5th ICS at the midclavicular line
What diagnostic tools can you use to see valvular disease?
EKG –> not very specific
CXR –> cardiomegaly and calcifications
Echo –> the best diagnostic tool
Angiography –> the most specific test
What are mechanical valves made of, how long do they last, cons?
Made of metal or carbon alloy
Very durable! Lasts 20-30 years–> good for younger patients
Highly thrombogenic–> require long-term AC
What are bioprosthetic valves made of, how long do they last?
These are porcine or bovine.
Shorter lasting 10-15 years –> good for elderly patients
Low thrombogenic potential
When do you typically DC warfarin prior to surgery if your patient has a mechanical valve?
3-5 days prior to surgery (consult with cardiologist) bridge to heparin or LMWH
What is the more rare valvular disease in the US? What typically causes it?
Mitral stenosis is pretty rare in the US. Typically caused by rheumatic heart disease. More common in women, and may be asymptomatic for 20-30 years
What dysrhythmia is commonly associated with pulmonary complications?
afib or paroxysmal afib
Treatment options for mitral stenosis?
rate control (BBs, CCBs)
diuretics
anticoagulation
valve replacement with more severe disease
What are anesthesia concerns related to mitral stenosis?
maintain normal HR (avoid ephedrine) and volume. Avoid excessive pre-op fluids (albumin may be a good option), caution with Trendelenburg positioning. Cardiovert afib w/ RVR. Avoid NDMBs that release histamines like cis. Use caution with neuraxial anesthesia. Treat hypotension.
What conditions is mitral regurgitation most commonly associated with?
IHD, endocarditis, mitral valve prolapse, cardiomyopathy
What are treatment options for mitral regurg?
MV repair (transcatheter mitraclip) or MV replacement. Biventricular pacing, ACEi or BBs.
What are some anesthesia concerns with mitral regurgitation?
avoid bradycardia and anything that would decrease CO. Avoid phenylephrine and increasing SVR. Neuraxial anesthesia tends to be well tolerated. Ketamine = good (increased HR).
Two causes of aortic stenosis…
- Bicuspid aortic valve
- Calcified aortic stenosis (usually a associated with AS diagnosed later in life)
What is the normal valve area for the aortic valve? Stenotic aortic valve?
Normal: 2.5-3.5 cm2
Stenotic: <2.5 cm2
Severe stenosis: <1cm2
What are typical AS symptoms?
systolic or midsystolic murmur RSB that radiates to the neck
Angina
Syncopal episodes
Dyspnea on exertion
What are aortic stenosis treatments?
Balloon valvotomy for young adults or adolescents
Transfemoral TAVR (need to have a tricuspid aortic valve to be a candidate)
What are some anesthetic considerations for patients with AS?
Avoid hypotension and anything that would decrease CO. Avoid bradycardia and especially tachycardia (no Ketamine or Ephedrine). CPR is not as effective. Place arterial line prior to induction to closely monitor BP. Phenylephrine is good. Long circulatory times, go slow, use infusions over boluses and try not to chase numbers.
What are some causes of aortic regurgitation?
Endocarditis
Rheumatic fever
Bicuspid aortic valve
Acute aortic regurg w/ aortic dissection
What are some symptoms you may see with aortic regurg?
Eccentric hypertrophy
Increased LVEDP
EF declines
Early midsystolic murmur at LSB -low pitched “Austin-Flint” murmur
Hyperdynamic- Widened PP, bounding pulses
Symptoms may not present until left ventricular dysfunction is present (end-stage)
Treatment for aortic regurg?
Medical: decrease systolic HTN and improve LV function via diuretics, ACEi and CCBs
Surgical: aortic valve replacement or aortic root repair
What are some anesthetic considerations for AR?
avoid bradycardia (HR>80), avoid increased SVR. GA is usually a good choice and NMBDs with minimal effect on BP. Provide adequate preload.
What is the most sensitive indicator of left ventricular myocardia ischemia?
wall motion abnormalities on Echo
Cardiac tamponade is associated with what?
pulsus paradoxus and electrical alternans
Which of the following would be the best intraoperative TEE view to monitor for myocardial ischemia?
Transgastric mid-papillary left ventricular short axis view
Which of the following medications blocks angiotensin at the receptor?
Losartan (ARBs)
Sildenafil belongs to the same drug class as what?
Milrinone
What is the minimum amount of time after angioplasty with a drug eluting stent that DAPT therapy is continued with elective surgery?
1 year
The effects of clopidogrel can be reversed with what?
Nothing… platelets can be given
Severe aortic stenosis is associated with a valve are less than __cm2?
1 cm2
