Valvular heart disease 2 Flashcards
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
a. nitrous oxide
c. ephedrine
The anesthetic goals for mitral stenosis are
“full, slow, and constricted”
The ____________ the mitral valve area, the more pressure the left atrium must produce to move blood into the left ventricle
smaller
Normal mitral valve area is
4-6 cm 2
Severe mitral valve stenosis is
<1 cm2
In the US, the most common cause of mitral stenosis is
endocarditis and mitral calcification
In developing nations, the most common cause of mitral stenosis is
rheumatic fevere
Increased left atrial pressure can lead to
pulmonary hypertension
As mitral stenosis progresses, the left atrium is _____________- while the left ventricle is ______________
chronically overfilled; chronically underfilled
Mitral stenosis progresses so that there is ___________– stroke volume, and the body maintains blood pressure by
lower; increasing systemic vascular resistance
Anesthetic goals for mitral stenosis in terms of HR, heart rhythm, preload, afterload, contractility, and pulmonary vascular resistance are
heart rate–> low side of normal
heart rhythm–> NSR
preload–> maintain
afterload–> maintain
contractility–> maintain
pulmonary vascular resistance–> avoid increase
If the patient has pulmonary hypertension, it is important to avoid
hypoxia, hypercarbia, hypothermia, and acidosis
Blood stasis in the left atrium is prone to
thrombus formation
Patients with mitral stenosis may be on _______________, so be wary of ______________________
anticoagulants; neuraxial blockade
___________ is preferred over ____________ with mitral stenosis because a rapid decline in BP will cause a significant reduction in CO.
epidural; spinal
The following can suggest severe mitral stenosis
transvalvular pressure gradient (LA to LV) >10 mmHg
pulmonary artery systolic pressure >50 mmHg
Possible etiologies of mitral stenosis include
rheumatoid arthritis
lupus
congenital defect
left atrial myxoma
carcinoid syndrome
iatrogenic following mitral valve repair
Tachyarrhythmia treatment for the patient with mitral stenosis includes
amiodarone, beta-blockers, calcium channel blockers, digoxin, and cardioversion
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
b. decreased heart rate
c. increased SVR
e. increased LV to LA pressure gradient
Mitral insufficiency causes ______________ & _______________ hypertrophy
volume overload & eccentric
Common causes of mitral regurgitation include
mitral valve prolapse, myxomatous of the mitral valve, and ischeic heart disease
Mitral insufficiency can be an
acute or chronic problem
What four things should be avoided with mitral insufficiency?
slower heart rate
increased pressure gradient between the LV & LA
increased SVR
increased size of valve orifice
What are the anesthetic goals for mitral insufficiency?
full, fast and forward
What are the anesthetic goals for mitral insufficiency in terms of heart rate, heart rhythm, preload, afterload, contractility, and pulmonary vascular resistance?
heart rate–> elevated
heart rhythm–> NSR
preload–> maintain or increase
afterload–> decrease
contractility–> maintain
pulmonary vascular resistance–> avoid increase
After mitral valve repair, there’s a risk of
systolic anterior motion (SAM) of the anterior leaflet, leading to outflow obstruction
Treatment for systolic anterior motion includes
increasing intravascular volume and increasing afterload (phenylephrine)
Unlike patients with aortic or mitral stenosis, _____________ can be useful because it promotes forward flow and reduces the regurgitant fraction.
sympathectomy
Etiologies of mitral insufficiency include
rheumatic fever
ischemic heart disease
papillary muscle dysfunction
ruptured chordae tendineae
endocarditis
mitral valve prolapse
left ventricular hypertrophy
SLE
RA
carcinoid syndrome
Which valvular disorders are associated with a systolic murmur?
a. mitral insufficiency
b. aortic stenosis
c. mitral stenosis
d. aortic insufficiency
a. mitral insufficiency
b. aortic stenosis
Where can aortic stenosis murmurs be heard?
systolic murmur heard at the right sternal border
think ASSS
Where can aortic regurgitation murmurs be heard?
diastolic murmur heard at the right sternal border
think ARDS
Where can mitral stenosis murmurs be heard?
diastolic murmur heard at the apex and left Axilla
think MSDA
Where can mitral regurgitation murmurs be heard?
systolic murmur heard at the apex and left axilla
think MRSA
A murmur may _____________ in intensity with very severe disease
decrease- not enough flow passes through the valve to make a sound
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
a. cardiac standstill
c. rapid ventricular pacing
What is a TAVR?
minimally invasive method of replacing the aortic valve in patients with aortic stenosis
The most common aortic valve replacements are the
Edwards SAPIAN
Medtronic CoreValve
anesthetic considerations vary based on the valve selected
________________ can occur if the valve doesn’t seat properly
acute aortic insufficiency
The SAPIAN valve requires
rapid ventricular pacing (to produce cardiac standstill) and valvuloplasty prior to deploying the valve
The CoreValue is
self-expanding, so it doesn’t require rapid ventricular pacing or valvuloplasty
Other complications of TAVR include
stroke
acute hemodynamic instability
coronary occlusion
perivalvular leak
dysrhythmias
aortic annular injury
& hemorrhage due to vascular injury
TAVR can be performed under
general anesthesia or MAC
Additional anesthetic considerations for TAVR include
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
What are the three surgical approaches to TAVR?
- transfemoral
- transaortic
- transapical (antegrade)
Acute hemodynamic instability should prompt consideration of
vascular injury (hemorrhage)- have plenty of large-bore IV access & blood in the room
___________ 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
coronary occlusion; myocardial ischemia
Valvuloplasty can cause ______________________. The patient may require ___________________
annular rupture (pericardial tamponade or CV collapse); aortic root repair or replacement
