Valvular Heart Disease Flashcards
Test 2
The most worrisome valve disease is ________
Aortic stenosis
__________ produces pressure overload and ___________ produces volume overload
Stenosis
Regurgitation
50% of pt with aortic stenosis over the age of 50 years old have ________
IHD
_______ pts with mitral or aortic valve disease worsen the prognosis
CAD
What could be a presenting symptom in someone with severe aortic stenosis?
Syncope
What are compensatory mechanisms with valve diseases?
Increased SNS
Myocardial hypertrophy
What is the NY Heart Association Functional Heart Disease table evaluate? Describe the classes.
It evaluated exercise tolerance and cardiac reserve
Class I: asymptomatic
Class II: Symptomatic with regular activity but comfortable at rest
Class III: Symptomatic with minimal activity but comfortable at rest
Class IV: Symptomatic at rest
Mitrial stenosis/regrugitation may present with what type of rhythm on the EKG?
Atrial rhythms –> A fib
_________ is common to see in valve diseases
Angina pectoris
HF can produce a ____ heart sound
3rd
T/F: elective surgery is deferred until CHF can be treated and myocardial contraction is optimized
T
What causes murmurs?
Turbulent blood flow
What causes systolic murmurs?
Aortic/Pulmonic stenosis
Mitral/tricuspid regurgitation
What causes diastolic murmurs?
Aortic/Pulmonic regurgitation
Mitral/tricuspid stenosis
Which type of murmurs are more worrisome?
systolic
Aortic stenosis has a __________ murmur and has a ________ sound pattern
Midsystolic
Crescendo
Where is a midsystolic murmur best heard at? What does this indicate?
R upper sternal border
Aortic stenosis
Mitral regurgitation has a _________ murmur. Where is this best heard at? Where does it radiate to?
Holosystolic
At the apex
Axilla
What are the auscultation sites?
Aortic: 2nd ICS RSB
P: 2nd ICS LSB
T: 5th ICS LSB
M: 5th ICS MCL
What additional EKG changes might you see with valve diseases?
Broad, notched P waves –> L atrial enlargement
What CXR findings might indicate valve disease?
Cardiomegaly
L mainstem bronchus elevation
Valvular calcification
What is Cardiomegaly?
Cardiac sillouette is >50% of thorax from rib to rib
What are the tests used to Dx valve diseases?
EKG
CXR
ECHO
Angiography
Whats the major difference between angiography and ECHO with valve diseases?
Angiography is able to tell you the flow through the coronaries
What type of ECHO would you use to detect thrombus?
TEE
How long do Mechanical valves last? Bioprosthetic?
Mechanical: 20-30 years
Bioprosthetic: 10-15 years
Mechanical heart valves can be made of _______
Metal or Carbon alloy
Think MRI
T/F: Warfarin is given up until the 3rd trimester in pregnancy
F
Warfarin is associated with fetal defects/death
What is normal protocol for warfarin in pts with prosthetic valves who need Sx?
If minor Sx w minimal blood loss: continue
If major Sx: d/c 3-5 days preop and bridge with heparin until the day before or day of Sx. –> restart heparin postop
Mitral stenosis is associated with what disease? What are s/s of this?
Rheumatic heart disease: unDx childhood fever
-vision changes
Mitral stenosis primarily affects ________
women
T/F: Mitral stensosis can be asymptomatic for 20-30 years
T
What is the normal size of a mitral valve? What is the size that symtpoms develop?
Normal: 4 - 6 cm2
Symptoms: < 2 cm2
What are s/s of mitral stenosis?
pulmonary symptoms
Dyspnea on exertion
-orthopnea
-paroxysmal nocturnal dyspnea
-pulmonary edema
-pulmonary HTN
A-FIB
In mitral stenosis, what happens with the L ventricle?
L ventricle function is preserved
What is the Tx for mitral stenosis?
Rate control: BB, CCB, Digoxin
Diuretics
Anticoags
Sx
What are anesthesia considerations for mitral stenosis?
Goal: Keep normal hemodynamics
-dont fluid overload/tredelenburg
-avoid tachycardia (epi, ephedrine, gylcoprrolate, ketamine)
-BP/SVR: Neo/vaso
- avoid pulm HTN –> no hypoventilation, hypercarbia, hypoxemia (induction/emergence)
-Treat diuretic complications –> low K+, orthostatic hypotension
What reversal do we use with mitral stenosis?
Sugamadex
What NMB do we avoid in mitral stenosis? Why?
Pancuronium
Atracurium
They release histamine causing increase in HR
Mitral ______ is more common than mitral _______
regurgitation
stenosis
What is mitral regurgitation commly associated with?
IHD
Ruptured papillary muscle
Endocarditis
Mitral valve prolapse
Cardiomyopathy
Direct cardiac trauma
mitral regurgitation decreases what 3 things?
forward LV flow
SV
CO
mitral regurgitation is associated with _______ hypertrophy. What does this mean?
eccentric
LV is larger and more compliant –> able to deliver a larger stroke volume
What are mitral regurgitation Tx?
Repair or replacement
Transcathether mitral valve repair (MitraClip)
Vasodilators (ACE-I, BB)
Biventricular pacing
What is the prefered BB used in mitral regurgitation?
Carvedilol
T/F: With mitral regurgitation, there is great improvement with Sx if EF < 30%
F
There is little improvement with Sx
What do we want to avoid in mitral regurgitation? Why?
Bradycardia and increasing SVR
Want a normal to slightly increased HR –> To prevent decreased CO
Avoid increasing SVR –> will cause increased backflow
Avoid phenylephrine
Why is Neuraxial anesthesia good for mitral regurgitation?
Causes vasodilation which allows for better forward flow
__________ decreases SVR and increases __________ in mitral regurgitation. What is an example of this medication?
vasodilators
forward flow
Nitroprusside
Aortic stenosis can ALSO be dt _________. When does this develop?
buscupid aortic valve
Early in life compared w/ tricuspid
Aortic stenosis is associated with increased ________
mortality
What is the normal aorta valve area? What is the severe aortic stenosis area?
Normal: 2.5 - 3.5 cm2
Symptomatic: < 1 cm2
Aortic stenosis results in __________ hypertrophy. What does this mean?
Concentric
LV is less compliant. Contractility is decreased.
SV is decreased
What are the symptoms that correlate with average time of death in Aortic stenosis?
Angina pectoris = 5 years
Syncope = 3 years
dsypnea on exertion = 2 years
What can you possible see on the CXR w Aortic stenosis?
Prominent ascending aorta Aortix aneurysm
What EKG changes would you see in Aortic stenosis?
ST depression
T wave inversion
WHat is signicant regarding Aortic stenosis and stress tests?
Generally dont tolerate exercise stress test –> have to do chemical/nuclear
What is Tx for Aortic stenosis?
If symptomatic: Ballon valvotomy
-Transcatheter aortic valve replacement (TAVR)
What are the factors that must be met for Transcatheter aortic valve replacement (TAVR)?
> 65 yo
transfemoral TAVR is feasible
Aortic valve must be trileaflet
No high risk anatomy
Asymptomatic aortic stenosis has a risk of what?
sudden death
What are the anesthesia considerations in aortic stenosis?
Maintain NSR
Optimize intravascular fluid volume
Aggressive tx of hypotension
GA > Epidural/spinal (Use etomidate/fentanyl)
Put in A-line for gradual induction
Consider not NPO for 8 hours for fluid volume
For low BP –> Neo
Tachy –> BB: esmolol
Brady –> ephedrine, atropine, glycopyrrolate
T/F: CPR is trypically not effective in aortic stenosis
T
Need to prevent them from getting to this point!!!
What causes aortic regurgitation?
Endocarditis
-rheumatic fever
-bicuspid aortic valve
-anorexigenic drugs (meth & phentermine)
-aortic dissection
aortic regurgitation has a ______ onset. Why is this relevant?
Slow
they can compensate well
aortic regurgitation is associated with _________ hypertrophy.
eccentric
In aortic regurgitation, SV _______ and EF _________
increases
decreases
What are s/s of aortic regurgitation?
Widened PP
Bounding pulses
Another name for the aortic regurgitation murmur is the ___________
Austin-Flint murmur
How do you treat aortic regurgitation?
decrease systolic HTN, LV wall stress, and improve LV function
Diuretics
ACE-I
CCB
Sx
-AVR
-aortic root replacement
What are the anesthesia considerations with aortic regurgitation?
avoid bradycardia
-want HR 80-100
avoid increase in SVR
use vasodilators to decrease afterload –> nitroglycerin/nitroprusside
use inotropes –> milrinone
What type of anesthesia do you want to use withaortic regurgitation?
GA
inhaled or IV
Use NMBD with minimal or no effect on BP
Keep full volume normal and adequate preload
