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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
Mitral Stenosis Anesthetic Mgmt PVR
Avoid Increase in PVR - PHTN incrase work of the R heart - Avoid conditions that increase PVR
26
What conditions increase PVR?
1. Acidosis 2. Hypercarbia 3. Hypoxia 4. N20 5. Trendelenburg
27
Aortic Stenosis Anesthetic Mgmt HR and Rhythm
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
Aortic Stenosis Anesthetic Mgmt Preload
Increase Preload -Adequate LVEDP is required to fill Administer IVF to ensure adequate volume
29
Aortic Stenosis Anesthetic Mgmt Contractility
Maintain Contractility - Usually not an issue until too late - Inotropes if LV dysfunction occurs
30
Aortic Stenosis Anesthetic Mgmt SVR
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
Aortic Stenosis Anesthetic Mgmt PVR
Normal - Usually not an issue until late - Diastolic failure > will cause increase in LAP > causing increase in pulmonary congestion
32
Mitral Regurgitation | Pathology
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 3. Bidirectional flow 4. Volume overload of LV 5. SV split 6. Afterload decrease improves forward flow
33
What causes regurgitant volume increases with MR?
1. Slower HR 2. Increase pressure gradient btwn LV and LA 3. Increase in SVR 4. Increase size of valve orifice
34
Regional anesthesia and mitral regurgitation
Sympathomemectomy decreases SVR and promotes forward flow > this decreases regurgitant fraction Drastically reducing AoDBP can decrease CPP
35
Aortic Regurgitation | Pathology
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
AS - regurgitant made worse by:
1. Bradycardia 2. Increase in SVR 3. Lg valve orifice
37
Acute aortic insufficiency/regurg
CV instability - LV dilated and impaired contractility | Usually caused by endocarditis
38
Chronic insufficiency/regurg
Volume overload compensate with LV dilation -increase LVEDP with decrease in AoBP will cause decrease in CPP > this will cause LV failure
39
Regional and Aortic Insufficiency
Will decrease SVR and decrease regurgitant factor
40
Aortic Insufficiency Anesthetic Mgmt HR and Rhythm
Increase with NSR - Faster HR will decrease regurgitant volume with incrase AoBP and incrase CPP - Slower HR will decrease CO
41
Aortic Insufficiency Anesthetic Mgmt Preload
Maintain or Increase | Some of SV is lost to LV, so avoid hypovolemia
42
Aortic Insufficiency Anesthetic Mgmt Contractility
Maintain | LV failure treated with inotrope
43
Aortic Insufficiency Anesthetic Mgmt SVR
Decrease - Lower afterload promotes forward flow - Phenylephrine and vasopressin NOT ideal
44
Aortic Insufficiency Anesthetic Mgmt PVR
Maintain | -Acute LV dilation stretches MV > LV pressure will reflect in LA > Pulmonary congestion
45
Mitral Regurgiation Anesthetic Mgmt HR and Rhythm
High HR with NSR - Regurg occurs during systole (contraction). - Faster HR decreases time spent in systole > decreasing regurgitant fraction
46
Mitral Regurgiation Anesthetic Mgmt Preload
Maintain or Increase | -High preload helps compensate for SV lost to LA
47
Mitral Regurgiation Anesthetic Mgmt Contractility
Maintain
48
Mitral Regurgiation Anesthetic Mgmt SVR
Decrease | -Systemic vasodilation promotes forward flow
49
Mitral Regurgiation Anesthetic Mgmt PVR
Avoid Increase in PVR | -acidosis, hypercarbia, hypoxemia, t-burg, N20, PEEP
50
Following MV repair . . .
``` Risk of SAM Systolic Anterior Motion of the anterior leaflet It obstructs LVOT during systole Treatment: -Increase IVF -Increase afterload with phenylephrine ```
51
Pathologic Murmurs | Aortic Stenosis
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
Aortic stenosis murmur | Where is sound transmitted?
"ASSS" | Aortic Stenosis is Systolic murmur heart at right Sternal border
53
Pathologic Murmurs | Aortic Insufficiency
Diastole Turbulent retrograde flow High pitched "blowing" murmur
54
Pathologic Murmurs | Mitral Stenosis
Diastole LA generates increase in pressure to overcome stenotic MV LA pressure > 35 mmHg Opening snap followed by low intensity rumbling murmur
55
Aortic Insufficiency | Where is sound transmitted?
"ARDS" | Aortic Regurgitation is a Diastolic murmur heard at right Sternal border
56
Mitral Stenosis | Where is sound transmitted?
"MSDA" | Mitral Stenosis is a Diastolic murmur at the Apex and the left Axilla
57
Pathologic Murmurs | Mitral Regurgitation
Systole Retrograde flow Holosystolic murmur Characterized by loud "swishing" sound
58
Mitral Regurgitation | Where is sound transmitted?
"MRSA" | Mitral Regurgitation is a Systolic murmur heard at the Apex and left Axilla

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