Valvular heart disease 2

Question 1

Which drugs are most likely to contribute to hemodynamic instability in the patient who is symptomatic from severe mitral stenosis? (select 2)
a. nitrous oxide
b. phenylephrine
c. ephedrine
d. furosemide

Answer 1

a. nitrous oxide
c. ephedrine

Question 2

The anesthetic goals for mitral stenosis are

Answer 2

“full, slow, and constricted”

Question 3

The ____________ the mitral valve area, the more pressure the left atrium must produce to move blood into the left ventricle

Answer 3

smaller

Question 4

Normal mitral valve area is

Answer 4

4-6 cm 2

Question 5

Severe mitral valve stenosis is

Answer 5

<1 cm2

Question 6

In the US, the most common cause of mitral stenosis is

Answer 6

endocarditis and mitral calcification

Question 7

In developing nations, the most common cause of mitral stenosis is

Answer 7

rheumatic fevere

Question 8

Increased left atrial pressure can lead to

Answer 8

pulmonary hypertension

Question 9

As mitral stenosis progresses, the left atrium is _____________- while the left ventricle is ______________

Answer 9

chronically overfilled; chronically underfilled

Question 10

Mitral stenosis progresses so that there is ___________– stroke volume, and the body maintains blood pressure by

Answer 10

lower; increasing systemic vascular resistance

Question 11

Anesthetic goals for mitral stenosis in terms of HR, heart rhythm, preload, afterload, contractility, and pulmonary vascular resistance are

Answer 11

heart rate–> low side of normal
heart rhythm–> NSR
preload–> maintain
afterload–> maintain
contractility–> maintain
pulmonary vascular resistance–> avoid increase

Question 12

If the patient has pulmonary hypertension, it is important to avoid

Answer 12

hypoxia, hypercarbia, hypothermia, and acidosis

Question 13

Blood stasis in the left atrium is prone to

Answer 13

thrombus formation

Question 14

Patients with mitral stenosis may be on _______________, so be wary of ______________________

Answer 14

anticoagulants; neuraxial blockade

Question 15

___________ is preferred over ____________ with mitral stenosis because a rapid decline in BP will cause a significant reduction in CO.

Answer 15

epidural; spinal

Question 16

The following can suggest severe mitral stenosis

Answer 16

transvalvular pressure gradient (LA to LV) >10 mmHg
pulmonary artery systolic pressure >50 mmHg

Question 17

Possible etiologies of mitral stenosis include

Answer 17

rheumatoid arthritis
lupus
congenital defect
left atrial myxoma
carcinoid syndrome
iatrogenic following mitral valve repair

Question 18

Tachyarrhythmia treatment for the patient with mitral stenosis includes

Answer 18

amiodarone, beta-blockers, calcium channel blockers, digoxin, and cardioversion

Question 19

After suffering a myocardial infraction, a patient presents with a left ventricular papillary muscle rupture and mitral regurgitation. Which factors will worsen this patient’s condition? (select 3)
a. increased heart rate
b. decreased heart rate
c. increased SVR
d. decreased SVR
e. increased LV to LA pressure gradient
f. decreased LV to LA pressure gradient

Answer 19

b. decreased heart rate
c. increased SVR
e. increased LV to LA pressure gradient

Question 20

Mitral insufficiency causes ______________ & _______________ hypertrophy

Answer 20

volume overload & eccentric

Question 21

Common causes of mitral regurgitation include

Answer 21

mitral valve prolapse, myxomatous of the mitral valve, and ischeic heart disease

Question 22

Mitral insufficiency can be an

Answer 22

acute or chronic problem

Question 23

What four things should be avoided with mitral insufficiency?

Answer 23

slower heart rate
increased pressure gradient between the LV & LA
increased SVR
increased size of valve orifice

Question 24

What are the anesthetic goals for mitral insufficiency?

Answer 24

full, fast and forward

Question 25

What are the anesthetic goals for mitral insufficiency in terms of heart rate, heart rhythm, preload, afterload, contractility, and pulmonary vascular resistance?

Answer 25

heart rate--> elevated heart rhythm--> NSR preload--> maintain or increase afterload--> decrease contractility--> maintain pulmonary vascular resistance--> avoid increase

Question 26

After mitral valve repair, there's a risk of

Answer 26

systolic anterior motion (SAM) of the anterior leaflet, leading to outflow obstruction

Question 27

Treatment for systolic anterior motion includes

Answer 27

increasing intravascular volume and increasing afterload (phenylephrine)

Question 28

Unlike patients with aortic or mitral stenosis, _____________ can be useful because it promotes forward flow and reduces the regurgitant fraction.

Answer 28

sympathectomy

Question 29

Etiologies of mitral insufficiency include

Answer 29

rheumatic fever ischemic heart disease papillary muscle dysfunction ruptured chordae tendineae endocarditis mitral valve prolapse left ventricular hypertrophy SLE RA carcinoid syndrome

Question 30

Which valvular disorders are associated with a systolic murmur? a. mitral insufficiency b. aortic stenosis c. mitral stenosis d. aortic insufficiency

Answer 30

a. mitral insufficiency b. aortic stenosis

Question 31

Where can aortic stenosis murmurs be heard?

Answer 31

systolic murmur heard at the right sternal border think ASSS

Question 32

Where can aortic regurgitation murmurs be heard?

Answer 32

diastolic murmur heard at the right sternal border think ARDS

Question 33

Where can mitral stenosis murmurs be heard?

Answer 33

diastolic murmur heard at the apex and left Axilla think MSDA

Question 34

Where can mitral regurgitation murmurs be heard?

Answer 34

systolic murmur heard at the apex and left axilla think MRSA

Question 35

A murmur may _____________ in intensity with very severe disease

Answer 35

decrease- not enough flow passes through the valve to make a sound

Question 36

Anesthetic considerations for transcatheter aortic valve replacement with a SAPIAN valve include (select 2): a. cardiac standstill b. cardiopulmonary bypass c. rapid ventricular pacing d. ministernotomy

Answer 36

a. cardiac standstill c. rapid ventricular pacing

Question 37

What is a TAVR?

Answer 37

minimally invasive method of replacing the aortic valve in patients with aortic stenosis

Question 38

The most common aortic valve replacements are the

Answer 38

Edwards SAPIAN Medtronic CoreValve anesthetic considerations vary based on the valve selected

Question 39

________________ can occur if the valve doesn't seat properly

Answer 39

acute aortic insufficiency

Question 40

The SAPIAN valve requires

Answer 40

rapid ventricular pacing (to produce cardiac standstill) and valvuloplasty prior to deploying the valve

Question 41

The CoreValue is

Answer 41

self-expanding, so it doesn't require rapid ventricular pacing or valvuloplasty

Question 42

Other complications of TAVR include

Answer 42

stroke acute hemodynamic instability coronary occlusion perivalvular leak dysrhythmias aortic annular injury & hemorrhage due to vascular injury

Question 43

TAVR can be performed under

Answer 43

general anesthesia or MAC

Question 44

Additional anesthetic considerations for TAVR include

Answer 44

perfusion on stand-by if the need for emergent CPB arises fluoroscopy bed- patients will receive dye (risk of allergic reaction and renal injury) & you will need to protect self from radiation

Question 45

What are the three surgical approaches to TAVR?

Answer 45

1. transfemoral 2. transaortic 3. transapical (antegrade)

Question 46

Acute hemodynamic instability should prompt consideration of

Answer 46

vascular injury (hemorrhage)- have plenty of large-bore IV access & blood in the room

Question 47

___________ can occur if the native valve folds to obstruct a coronary artery or if a mispositioned valve obstructs a coronary artery. The patient will present with signs of

Answer 47

coronary occlusion; myocardial ischemia

Question 48

Valvuloplasty can cause ______________________. The patient may require ___________________

Answer 48

annular rupture (pericardial tamponade or CV collapse); aortic root repair or replacement