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Apex > Valvular Heart Disease > Flashcards

Valvular Heart Disease Flashcards

1
Q

1st Heart Sound/S1

A

Closure of Mitral and Tricuspid Valves

Sound is louder w/ vigorously contracting left ventricle and softer with a poorly contracting ventricle

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2
Q

What marks onset of systole?

A

S1

End of LV filling and beginning of isovolumetric contraction

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3
Q

2nd Heart Sound/S2

A

Closure of Aortic and Pulmonary valves
Sound is louder with HTN
Sound is softer with Hypotension

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4
Q

What marks onset of diastole?

A

S2

  • End of LV ejection and beginning of isovolumetric relaxation
  • Volume proportionate to LV pressure decrease at end of systole
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5
Q

3rd Heart Sound/S3

A

Suggests flaccid and inelastic heart - think heart failure
Heard during middle 1/3 of diastole - after S2
Gallop rhythm - “rumbling” sound

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6
Q

4th Heart Sound / S4

A

Cause by atrial systole

Heard before S1

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7
Q

Stenosis

A

fixed obstruction to forward flow during chamber systole. This requires a higher transvalvular pressure gradient

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8
Q

Stenosis causes what kind of hypertrophy?

A

Concentric hypertrophy

Stenosis > pressure overload > concentric hypertrophy

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9
Q

How does stenosis cause hypertrophy?

A

fixed obstruction to forward flow

  • In order to overcome, the chamber must generate a higher transvalvular pressure gradient
  • Blood flow passing through a more narrow opening becomes turbulent
  • Heart compensates by adding more sarcomeres in parallel > thicker > reduces radius
  • CONCENTRIC hypertrophy
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10
Q

Regurgitation

A

The valve is incompetent, so some blood flows forward and some blood flows backwards during the chamber systole

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11
Q

Regurgitation causes what kind of hypertrophy?

A

Eccentric hypertrophy

Regurgitation > Volume overload > Eccentric hypertrophy

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12
Q

How does regurgitation cause hypertrophy?

A

The valve is incompetent

  • When the chamber contracts, some blood flows forward and some blood flows backward
  • During chamber diastole, there are two quantities of blood entering the chamber - blood returning from circulation and the regurgitant fraction
  • this causes overload
  • Heart compensates by adding more sarcomeres in series
  • Chamber radius increases
  • ECENNTRIC hypertrophy
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13
Q

Mitral stenosis measurements

A

Normal: 4-6 cm^2
Severe: < 1 cm^2

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14
Q

Pathology of mitral stenosis

A

“Full, Slow, Constricted”

Obst to blood flow across MV

  • Early on increase in left Atrial Pressure maintains LV filling, but stenotic valve narrows more, pressure gradient btwn LA and LV increases and LV is chronically underfilled (with overfilled LA)
  • Stretch of conduction on LA causes Afib
  • Afib reduces LV filling and decreases CO
  • Overtime, causes concentric hypertrophy of LV
  • Increase in pulmonary pressure > causes dyspnea
    > increases RV work > causes PHTN
  • Also causes lower EDV, SV and CO > this means the body compensates with increasing SVR
  • Peripheral vasoconstriction maintains BP
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15
Q

Causes of Mitral Stenosis

A

Endocarditis

Calcification

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16
Q

Regional anesthesia and mitral stenosis

A

Pts with afib will be anti-coagulated and therefore, no needles!
If INR < 1.5, epidural is better option than spinal

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17
Q

Aortic Stenosis measurements

A

Normal: 2.5-3.5
Severe: < .8 cm^2

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18
Q

S/S of Aortic Stenosis

A

SAD
Syncope
Angina
Dyspnea

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19
Q

Aortic Stenosis Key facts

A

Concentric hypertrophy of LV
-Risk of subendocardial ischemia
Afterload is fixed at the Aortic Valve
CO is HR dependent - a decrease in SVR will decrease CPP
Atrial kick necessary to prime the non-compliant ventricle
CO is HR dependent - If HR is 70-80 avoid drugs that will increase HR
Hypotension is treated aggressively with alpha-1 agonist - this will increase SVR and CPP
Chest compressions will not generate enough force
-look for narrow PP
-Dampened artline waveform

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20
Q

Regional anesthesia and Aortic stenosis

A

Spinal anesthesia is avoided with severe AS b/c decrease in SVR will cause hypotension, decrease CPP, and CV collapse

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21
Q

Mitral Stenosis
Anesthetic Mgmt
HR and Rhythm

A

Low end of Normal w/ NSR
Tachycardia will decrease diastolic filling time > this will decrease time for blood to pass through stenotic valve > increasing LAP
-Amiodarone, BB, Ca+ channel blockers, digoxin, cardioversion
-Avoid drugs that will increase CO or HR > this will incrase LAP > which will increase Pulm edema

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22
Q

Mitral Stenosis
Anesthetic Mgmt
Preload

A

*Maintain preload
LV is chronically underfilled > this causes decrease in preload > this causes a decrease in SV and a decrease in CO
Hypervolemia wil increase LAP > this causes Pulmonary congestion
-Diuretics

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23
Q

Mitral Stenosis
Anesthetic Mgmt
Contractility

A

*Maintain contractility

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24
Q

Mitral Stenosis
Anesthetic Mgmt
SVR

A
  • Maintain SVR
  • Increase in SVR maintains BP
  • Rapid decrease in BP > BRR to incrase HR > NOT GOOD
  • Treat hypotension with phenylephrine or vasopressin
25
Q

Mitral Stenosis
Anesthetic Mgmt
PVR

A

Avoid Increase in PVR

  • PHTN incrase work of the R heart
  • Avoid conditions that increase PVR
26
Q

What conditions increase PVR?

A
  1. Acidosis
  2. Hypercarbia
  3. Hypoxia
  4. N20
  5. Trendelenburg
27
Q

Aortic Stenosis
Anesthetic Mgmt
HR and Rhythm

A

70-80 bpm
NSR
-Loss of atrial kick will decrease ventricular filling > causing decrease in SV
-Tachycardia will decrease time for filling > this will cause a decrease in LVEDV > causing a decrease in SV and a decrease in CO

28
Q

Aortic Stenosis
Anesthetic Mgmt
Preload

A

Increase Preload
-Adequate LVEDP is required to fill
Administer IVF to ensure adequate volume

29
Q

Aortic Stenosis
Anesthetic Mgmt
Contractility

A

Maintain Contractility

  • Usually not an issue until too late
  • Inotropes if LV dysfunction occurs
30
Q

Aortic Stenosis
Anesthetic Mgmt
SVR

A

Maintain or Increase
SV is fixed by stenotic valve >Therefore co-dependent on HR
Hypotension will decrease aortic root pressure > this will cause a decrease in CPP and possible MI !!!

31
Q

Aortic Stenosis
Anesthetic Mgmt
PVR

A

Normal

  • Usually not an issue until late
  • Diastolic failure > will cause increase in LAP > causing increase in pulmonary congestion
32
Q

Mitral Regurgitation

Pathology

A

Stroke volume goes in two directions - towards aorta and through incompetent mitral valve towards left atrium > causing volume overload

  1. Pulmonary congestion
  2. Volume overloaded LA
  3. Eccentric hypertrophy of LV
  4. Bidirectional flow
  5. Volume overload of LV
  6. SV split
  7. Afterload decrease improves forward flow
33
Q

What causes regurgitant volume increases with MR?

A
  1. Slower HR
  2. Increase pressure gradient btwn LV and LA
  3. Increase in SVR
  4. Increase size of valve orifice
34
Q

Regional anesthesia and mitral regurgitation

A

Sympathomemectomy decreases SVR and promotes forward flow > this decreases regurgitant fraction
Drastically reducing AoDBP can decrease CPP

35
Q

Aortic Regurgitation

Pathology

A

A portion of ejected SV re-enters the LV during diastole > this volume overload and eccentric hypertrophy will decrease CO

Eccentric hypertrophy of LV
Volume overload LV
Bid-directional flow
SV split
Decrease in Afterload improves forward flow
36
Q

AS - regurgitant made worse by:

A
  1. Bradycardia
  2. Increase in SVR
  3. Lg valve orifice
37
Q

Acute aortic insufficiency/regurg

A

CV instability - LV dilated and impaired contractility

Usually caused by endocarditis

38
Q

Chronic insufficiency/regurg

A

Volume overload compensate with LV dilation
-increase LVEDP with decrease in AoBP will cause decrease in CPP
> this will cause LV failure

39
Q

Regional and Aortic Insufficiency

A

Will decrease SVR and decrease regurgitant factor

40
Q

Aortic Insufficiency
Anesthetic Mgmt
HR and Rhythm

A

Increase with NSR

  • Faster HR will decrease regurgitant volume with incrase AoBP and incrase CPP
  • Slower HR will decrease CO
41
Q

Aortic Insufficiency
Anesthetic Mgmt
Preload

A

Maintain or Increase

Some of SV is lost to LV, so avoid hypovolemia

42
Q

Aortic Insufficiency
Anesthetic Mgmt
Contractility

A

Maintain

LV failure treated with inotrope

43
Q

Aortic Insufficiency
Anesthetic Mgmt
SVR

A

Decrease

  • Lower afterload promotes forward flow
  • Phenylephrine and vasopressin NOT ideal
44
Q

Aortic Insufficiency
Anesthetic Mgmt
PVR

A

Maintain

-Acute LV dilation stretches MV > LV pressure will reflect in LA > Pulmonary congestion

45
Q

Mitral Regurgiation
Anesthetic Mgmt
HR and Rhythm

A

High HR with NSR

  • Regurg occurs during systole (contraction).
  • Faster HR decreases time spent in systole > decreasing regurgitant fraction
46
Q

Mitral Regurgiation
Anesthetic Mgmt
Preload

A

Maintain or Increase

-High preload helps compensate for SV lost to LA

47
Q

Mitral Regurgiation
Anesthetic Mgmt
Contractility

A

Maintain

48
Q

Mitral Regurgiation
Anesthetic Mgmt
SVR

A

Decrease

-Systemic vasodilation promotes forward flow

49
Q

Mitral Regurgiation
Anesthetic Mgmt
PVR

A

Avoid Increase in PVR

-acidosis, hypercarbia, hypoxemia, t-burg, N20, PEEP

50
Q

Following MV repair . . .

A 
Risk of SAM 
Systolic Anterior Motion of the anterior leaflet
It obstructs LVOT during systole
Treatment:
-Increase IVF
-Increase afterload with phenylephrine
51
Q

Pathologic Murmurs

Aortic Stenosis

A

Systole
LV generates sig pressure to overcome stenotic valve
-LV pressure > 350 mmHg
Upper aorta and carotid arteries
May be palpated as a thrill
May decrease in intensity with severe disease

52
Q

Aortic stenosis murmur

Where is sound transmitted?

A

“ASSS”

Aortic Stenosis is Systolic murmur heart at right Sternal border

53
Q

Pathologic Murmurs

Aortic Insufficiency

A

Diastole
Turbulent retrograde flow
High pitched “blowing” murmur

54
Q

Pathologic Murmurs

Mitral Stenosis

A

Diastole
LA generates increase in pressure to overcome stenotic MV
LA pressure > 35 mmHg
Opening snap followed by low intensity rumbling murmur

55
Q

Aortic Insufficiency

Where is sound transmitted?

A

“ARDS”

Aortic Regurgitation is a Diastolic murmur heard at right Sternal border

56
Q

Mitral Stenosis

Where is sound transmitted?

A

“MSDA”

Mitral Stenosis is a Diastolic murmur at the Apex and the left Axilla

57
Q

Pathologic Murmurs

Mitral Regurgitation

A

Systole
Retrograde flow
Holosystolic murmur
Characterized by loud “swishing” sound

58
Q

Mitral Regurgitation

Where is sound transmitted?

A

“MRSA”

Mitral Regurgitation is a Systolic murmur heard at the Apex and left Axilla

Apex (2 decks)

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