Valvular Heart Disease

Question 1

Stenotic valves are ___________ related

Answer 1

pressure

Question 2

Regurgitant valves are _________ related

Answer 2

volume

Question 3

Aortic stenosis may occur at 3 levels. What are they?

Answer 3

valvular, subvalvular, supravalvular

Question 4

Valvular Aortic Stenosis variations (3)

Answer 4

1. Calcification + fibrosis of normal aortic valve (very common) 2. Calcification + fibrosis of congenital bicuspid AV 3. Rheumatic - uncommon since antibiotics

Question 5

Say you have a 40 year old that starts to have problems with SOB, faftigue, syncope, dyspnea and angina, it is probably a due to a symptomatic what?

Answer 5

congenital bicuspid valve

Question 6

Normal AVA

Answer 6

2-4 cm2

Question 7

Severe AS

Answer 7

< 1 cm2

Question 8

If someone has low EF, don’t use _____ _______ as an indicator for AS

Answer 8

pressure gradient

Question 9

If normal LV function, the mean PG should be

Answer 9

> 50 mmHg

Question 10

Pathophysiology of Aortic Stenosis

Answer 10

Chronic LV pressure overload that leads to EARLY concentric LVH to DECREASE wall stress. LVH leads to DECREASED diastolic compliance, decreased coronary blood flow and imbalance of MV02 supply-demand. Decreased diastolic compliance leads to INCREASED LVEPD and LVEDV. Myocardial ischemia b/c of LVH leads to INCREASED wall stress (late AS), DECREASED diastolic coronary perfusion and DECREASED coronary flow reserve

Question 11

Review slide 9

Answer 11

AS path

Question 12

Hemodynamic goals for AS: ____ is crucial. Cardiovert _____ promptly. Optimal HR is __to ____. Tachycardia will lead to ischemia and ectopy. Bradycardia will lead to low CO due to a FIXED SV.

Answer 12

SR / SVTs / 60 to 80

Question 13

Hemodynamic goals for AS: Adequate ______ is essential but difficult to predict b/c diastolic dysfunction. _____ can be useful. Maintain contractility and avoid myocardial _________.

Answer 13

preload / TEE / depresssants

Question 14

How and when would you treat hypotension with someone with AS

Answer 14

PROMPTLY with phenylephrine, volume, trendelenburg

Question 15

Any stenotic problems you want to maintain ______

Answer 15

SR

Question 16

The two most difficult problems to resuscitate on the floor are

Answer 16

AS and hypertrophic cardiomyopathy

Question 17

Drugs to maintain CPP in a patient with AS

Answer 17

phenylephrine, norepinephrine

Question 18

T/F Atrial kick is crucial in someone with AS as well as maintaining a HR 60-80

Answer 18

TRUE

Question 19

Spinal and epidural anesthesia are ______ tolerated in the patient with AS if the preload is decreased and HR increased

Answer 19

poorly

Question 20

What happens when someone receives a spinal that can affect AS?

Answer 20

Drops the BP from vasodilation and increases HR in response to low BP. All this is bad for someone with AS

Question 21

Premedication for AS

Answer 21

young and anxious get benzos but if frail and elderly decrease the dose or avoid benzos all together

Question 22

Intraopertive considerations

Answer 22

Arterial line pre-induction

Question 23

What is the best tool for AS intraopertively

Answer 23

TEE

Question 24

Considerations for weaning someone with AS from bypass

Answer 24

Thick, hypertrophied heart may be difficult to protect (stone heart still occurs but it is rare). Noncompliant LV dependent on stable rhythm. Consider inotropes if preop LV dysfunction. Dynamic subaortic or cavitary obstruction after AVR if septal LVH. Treat with volume, Beta-blockers. Rarely need myomectomy [inotropes can worsen obstruction]

Question 25

In AS, Beta-blockers work by lowering the HR to increase _______ filling times

Answer 25

diastolic

Question 26

Aortic regurgitation etiology

Answer 26

1. Aortic root dilation from HTN, aorta dissection, cystic medial necrosis, Marfans, syphilitic aortitis, ankylosing spondylitis, osteogenesis imperfecta 2. deformed + thickened cusps from rheumatic, IE, bicuspid valve 3. cusp prolapse and dissection

Question 27

In AR, basically the leaflets are ________ apart. Any ______ ______ disorder can cause aortic root dilation. You can also have AS with a perforated cusp which causes _________

Answer 27

thethered / connective tissue / regurgitation

Question 28

With CHRONIC AR, the patient may be ________ for years. LV volume and pressure ________ occurs. LV maintains systolic fxn by ________ and increased compliance. LV decompensates at later stages with INCREASED LVEDP + LVEDV which leads to ______, arrhythmias and sudden death.

Answer 28

asymptomatic / overload / dilation / CHF

Question 29

With ACUTE AR, the LV is unable to ________ ACUTELY so LV volume ________ occurs. This INCREASED LVEDP + LVEDV manifests as acute _____ _________ and emergency surgery is often required.

Answer 29

dilate / overload / pulmonary edema

Question 30

Hemodynamic goals for AR

Answer 30

Optimal HR is 90. Avoid bradycardia because that will increase regurgitation. Avoid high afterload so SNP (nipride) is preferred. Acute AR often need inotropes + vasodilator [epi + SNP/milrinone]. IABP is contraindicated.

Question 31

Why is IABP contraindicated in someone with AR?

Answer 31

It would worsen the regurgitation

Question 32

IN AR we want to think FAST, FORWARD and FULL. What does this mean?

Answer 32

Fast HR, forward flow, and full heart.

Question 33

Anesthetic management for AR

Answer 33

premed with benzos, routine monitoring (a-line, CVP, PAC), TEE beneficial, narcotic based technique if impaired LV. If acute AR you will want to do an RSI with ketamine and succinylcholine. Inotropes may be needed if acute AR or preop LV dysfunction

Question 34

Mitral stenosis is usually __________ - thickening, calcification + fusion of MV leaflets + commissures

Answer 34

rheumatic

Question 35

Mitral stenosis may be combined with ___ and ___

Answer 35

MR and AR

Question 36

What is the indication for Mitral Stenosis surgery?

Answer 36

If MVA < 1 cm2 with NYHA class III or IV dyspnea [or embolus like a LAA clot]

Question 37

With mitral stenosis the pressure gradient betweeen the ___ and ____ prevents LV filling

Answer 37

LA and LV

Question 38

Mitral stenosis pathophysiology

Answer 38

Pressure gradient between LA and LV prevents LV filling. Manifests as pulmonary HTN with increased LAP. An increased LAP leads to LAE and atrial arrhythmias like afib. Pulmonary HTN also leads to RV dysfunction, RVE, and tricuspid regurg which may required TV repair. LV dysfunction uncommon unless the patient has CAD as well.

Question 39

Review slide 26

Answer 39

mitral stenosis

Question 40

**Hemodynamic goals with mitral stenosis

Answer 40

**Preserve SR if present. Avoid tachycardia which decreases diastolic filling of LV and worsens MS. AVOID FACTORS THAT WORSEN PULMONARY HTN (hypercarbia, acidosis, hypothermia, SNS activation, hypoxia)

Question 41

Anesthetic management for MS

Answer 41

Premedicate with benzos to avoid tachycardia. If pulmonary HTN present supplemental 02 should be used. Control of HR with beta blockers, digoxin, CCB and amiodarone

Question 42

Intraoperative management for MS

Answer 42

Esmolol is the single most useful drug with severe MS, even if CHF and pulm edema present. 10-20 mg bolus, 50-100mcg/kg/min infusion. N20 should be avoided b/c effects on pulm htn. Pancuronium should be avoided because it causes tachycardia

Question 43

Weaning from Bypass: MS

Answer 43

With MV replacement hemodynamics usually improved b/c obstruction to LV filling has been resolved. If preop pulm HTN and RV dysfxn present may need milrinone or nitric oxide

Question 44

Mitral Regurgitation is usually over time from _______ or long term from _______

Answer 44

degeneratioin / ischemia

Question 45

Other causes for MR

Answer 45

infective endocarditis and trauma

Question 46

MR pathophysiology

Answer 46

Volume overload of LV leads to LVE and LAE. The LA can massively dilate which leads to atrial arrhythmias and LAE. Dilated LV decompensates at later stages with INCREASED LVEDV

Question 47

Severity of MR is based on the pressure gradient between the ___ and ___, the size of the _____ ________ and the duration of _______ systole.

Answer 47

LA and LV / regurgitant orifice / ventricular

Question 48

Hemodyanmic goals for MR

Answer 48

Vasodilators like NTG, SNP. Decrease afterload + regurgitant fraction and increase forward flow. High normal HR to increase time of ventricular systole. Maintain contractility.

Question 49

Advantages of MV repair vs. replacement

Answer 49

preserved papillary muscle and chordae, enhanced LV function, requires TEE to assess repair

Question 50

Anesthetic management of MV repair

Answer 50

LV dysfunction can be unmasked after MV surgery b/c LV cannot offload into LA. So, may need inotropes and vasodilators.

Question 51

Tricuspid Regurgitation primary causes

Answer 51

rheumatic, infective endocarditis, carcinoid, Ebstein's, trauma

Question 52

Tricuspid Regurgitation secondary causes

Answer 52

Chronic RV dilation, often with MV disease

Question 53

Tricuspid Regurgitation though is most often from what?

Answer 53

IV drug use because it's the valve closest to the point of injection

Question 54

TR pathophysiology: RV + RA overloaded and dilated. RA very compliant so RAP rises only with ___ ___ disease. Pulmonary HTN due to concominant ____ disesase which increases RV afterload and worsens TR. RVE leads to paradoxical motion of LV septum with impaired LV filling and compliance. You will see right heart failure with it backing up to the liver causing _______ and ________.

Answer 54

end stage / MV / hepatomegaoly / ascites

Question 55

If TR is secondary to MV disease, you want to treat the ____ heart lesion.

Answer 55

left

Question 56

TR hemodaynamic goals

Answer 56

avoid pulm htn, avoid high PVR. Want a normal to high preload for RV stroke volume. Hypotension should be treated with inotropes + volume b/c vasoconstrictors may worsen pulm HTN

Question 57

TR anesthetic management

Answer 57

Premedicate with benzos , PAC if pulm htn + MV pathology but CO can be overestimated with severe TR. It also may be impossible to float a swan.

Question 58

TR weaning from CPB

Answer 58

If preop RV dysfunction/dilation consider inotropes, inodilators, vasodilators, and nitric oxide.