Valvular Heart Disease (Exam 2) Flashcards
How prevalent is Valvular Heart Disease in the US?
- 2.5 % of population
What are the Effects of Valvular Heart Disease?
- Hemodynamic burden on left/right ventricle
- Pressure overload (MS and AS)
- Volume Overload (MR, AR)
What Cardiac diseases/processes can co-exist with valvular diseases?
- Valvular heart disease + IHD
- CAD w/ mitral or aortic valve disease
- Mitral regurgitaiton d/t ischemic heart diseasse
Pre-Op Evaluation: Assessment
- Severity of Cardiac disease
- Degree of impaired myocardial contractility
- Presence of associated major organ system disease
Compensatory Mechanism for Valvular Disease
- Increased SNS – HR is most important
- Myocardial hypertrophy
- Current drug Therapy
New York Association Functional Classification of Patient’s with Heart Disease
- Class 1: Asymptomatic
- Class 2: Symptoms with ordinary activity, but comfortable at rest
- Class 3: Symptoms with minimal activity, but comfortable at rest
- Class 4: Symptoms at Rest
What causes a Heart Murmur?
- Turbulent Blood Flow
- Increased flow across normal valves
What is the difference between a Functional Murmur and Pathological Murmur?
- Functional: Physicological condiction OUTSIDE the heart
- Pathological: Structural defects in the Heart
Name a Functional Murmur
- Midsystolic
What is a systolic murmur?
- Stenosis of the aortic or pulmonic valves
- Incompetence (regurg) of the mitral or tricuspid valves
What valves are open and closed during Diastole?
- Closed: Aortic and Pulmonic Valves
- Open: Mitral and tricuspid valves
What is a Diastolic Murmur?
- Stenosis of the mitral or tricuspid valves.
- Incompetence of the aortic or pulmonic valves.
Midsystolic murmur
- occur between distinct S1 and S2 heart sounds.
- Crescendo-decrescendo pattern
- Can be functional
What does a Diastic Murmur follow?
- S2
Where is a Midsystolic Murmur heard?
- Right Upper Sternal Boarder
- Radiates to the carotids
- Suggest Aortic Stenosis
Where is a Holosystolic Murmur Heard?
* Apex
* Radiates to the axilla
* * Merges with S1 and S2
* Most Concerning – large Lesions
Aortic Stenosis Murmur
- Location: Rt Upper Sternal Border
- Increases with squatting
- Decreases with valsalva and standing
Aortic Regurgitation Murmur
- Location: Left Sternal Border
- Increases with handgrip or blood pressure cuff inflation
Mitral Stenosis Murmur
- Location: Apex
- Increases with tachycardia
Mitral Regurgitation Murmur
- Location: Apex
- increases with handgrip or blood pressure cuff inflation
Tricuspid Regurgitation Murmur
- Lower: Lower left sternal boarder
- Increases with inspiration
Mitral Valve Prolapse Murmur
- Location: Apex
- Increases with Valsalva and standing
Hypertropic Cardiomyopathy Murmur
- Location: Lower left sternal border
- Increased with Valsalva and standing
Functional Murmur
- Location: Left Sternal Border
- May increase with exercise
Common Auscultatory Site: Aortic Murmur
- 2nd ICS Right Sternal Border
Common Auscultatory Site: Pulmonic Murmur
- 2nd ICS
- Left Sternal Border
Common Auscultatory Site: Tricuspid Murmur
- 5th ICS
- Left Sternal Border
Common Auscultatory Site: Mitral Murmur
- 5th ICS
- Mid-Clavicular Line
What can you diagnosis with an EKG?
- Left Atrial Enlargement
- Left or Right Axis Deviation
- Dysrhythmias
- Possible ischemia/prevous MI
What can you Diagnosis with a CXR?
- Cardiomegaly: more than 1/2 thoracic view
- Left mainstem bronchus elevation
- Valvular calcifications – calcium deposits
What can you use an ECHOcardiogram to determine?
- Cardiac anatomy and function
- Presence of hypertrophy
- Cavity dimensions
- Valve area.
- Transvalvular pressure gradients
- Magnitude of valvular regurgitation
- Significance of murmurs
- Ventricular EF
- Evaluate prosthetic valve function.
What can you use an Angiography to diagnose?
- Presence and severity of valvular stenosis and/or regurgitation
- Coronary artery disease
- Intracardiac shunting
- Transvalvular pressure gradients
- Clinical vs echocardiographic findings
What Type of valves can be place surgically?
- Mechanical
- Bioprosthetic
Mechanical Valve
- Metal or carbon alley
- Very durable …. 20-30 years
- Highly thrombogenic
- Younger patients
Bioprosthetic Valve
- Porcine or bovine
- Shorter lasting….. 10-15 years
- Low thrombogenic potential
- Elderly patients
Which valve has a higher risk for for infection?
Mechanical Valves
Anticoagulation Concerns for Surgical cases
- Discontinue of warfarin (minor vs major surgery)
- Rebound hypercoagulable state
- Bridge to surgery
- Heparin to warfarin restart
- Anticoagulation during pregnancy
What does the temporary discontinuation of anticoagulation therapy do for someone with a mechanical heart valve or a-fib?
- increases risk of an art/venous thrombotic event.
Why is warfarin administration during pregnancy discouraged? And when do we stop it? Alternatives?
- 1st Trimester
- associated with fetal defects and death
- LMWH or Low-dose ASA
What Valve disease is rare in the US? and Why?
- MItral Stenosis
- Caused by Rheumatic Diseases
Who typically suffers from Mitral Stenosis and what is the onset?
- Women
- Slow Onset: can be asymptomatic for 20-30 years
What is the normal size of a Mitral Valve orifice area? and when do symptoms start to develope?
**
- Normal: 4-6 cm2
- Symptoms: < 2 cm2
Mitral Stenosis Pathophysiology
- Mechanical obstruction to LV filling
- Mitral orfice size of < 2cm
- Diffuse thickening/fibrosis of cusps
- Calcification of the annulus and leaflets
What cardiac values does Mitral Stenosis Affect in the Heart?
- Lt Atrial volume/pressure
- LV Contractility
- SV
Mitral Valve Stenosis symptoms
- Dyspnea on exertion
- Orthopnea
- paroxysmal noctural dyspnea
- Pulmonary Edema
- Pulmonary HTN
- Atrial fibrillation
What Valve Problem causes Pulmonary Edema?
Mitral Valve Stenosis
What will Mitral Valve Stenosis Show up as on a CXR?
- Mitral Calcification
- Pulmonary Edema/Vascular congestion
- Elevated Left Main Bronchus
- Straightening of Left Heart Boarder
What will Mitral Stenosis show up as on an Echocardiogram?
- Calcification
- Left Atrial Thrombus
- Left Atrial enlargement
On your assessment, what sounds are associated with Mitral Stenosis?
- Rumbling diastolic murmur at apex
- Radiates to left axilla
How does Mitral Stenosis show up on an EKG?
- Notched P-wave
- Atrial Fib
Mitral Stenosis Treatment
- Rate Control
* BB, CCB, Digoxin - Left Atrial Pressure
* Diuretics - Anticoagulation
* 7-15% risk of stroke - Surgical Correction
* Percutaneous valvotomy
* Surgical commissureotomy
* valve replacement
Mitral Stenosis Anesthesic Considerations
- Goal: Normal HR, volume and Afterload
1. Control HR
2. Maintain SVR and BP –Phenylephrine
3. Avoid Pulm HTN exacerbation
4. Treat diuretic induced complications
5. Neuraxial anesthesia
What does Pulmonary HTN exacerbation cause?
- Hypoventilation
- Hypercarbia
- Hypoxemia
What is the DOC for Induction for Mitral Valve Stenosis? Which should you avoid?
- Etomidate
- Avoid: Ketamine and Histamine releasing NMB
Who is Mitral Regurgitation most common in?
- More common in men
- 2% of the population
What cardiac conditions are associated with Mitral Regurgitation?
- IHD
- Ruptured papillary muscle
- Endocarditis
- Mitral valve prolapse
- Cardiomyopathy
Mitral Regurg Pathophysiology
- Decreased in forward LV, SV and CO
- Left atrial volume overload and Pulmonary Congestion
- Regurgitant volume
What type of LV hypertrophy will Mitral Reguritation cause?
Eccentric hypertropy
Mitral Regurgitation Symptoms
- History of IHD (ischemic Heart disease)
- Holosytolic murmur at apex – radiates to axilla
- Cardiomegaly
- Atrial Fibrillation
What can we see on an EKG that will indicate Mitral Stenosis?
- Left Atrial and LV hypertrophy
- Atrial fibrillation
What can we see on a CXR that will indicate Mitral Stenosis?
- Cardiomegaly
- Left Atrial and LV hypertrophy
What can we see on an Echocardiogram that will indicate Mitral Stenosis?
- Left atrial thrombus
______________________ patient’s should undergo mitral valve surgery, even if EF is normal
Symptomatic
When should an asymptomatic patient be taken for surgery for Mitral regurge?
- LV EF of 30-60%
- LV end-systolic dimension less than 55 mm.
When should surgery be done on a Mitral valve to reduce the risk of heart failure?
- Before the EF is less than 60%
Which surgery is prefered: Mitral Valve Repair or Replacement? Why?
- MV Repair
- maintains the functional aspects of the mitral valve apparatus —important for LV function and contractility
At what EF will MR surgery not be as effective?
30%
What is placed during a Transcatheter Mitral valve Repair (TAVR)?
- Mitral Clip
What can we do for patient’s with Mitral Regurg to improve symptoms and increase exercise tolerance?
- ACE-i
- BB (carvedilol)
- Bi-ventricular pacing
Mitral Reguritation Goals
- Improve LV SV and decrease regurgitant fraction
- Prevent and treated decreased CO
- normal to slightly increase HR — avoid bradycardia
- Avoid increased SVR — vasodilators (nitro)
- Neuraxial annesthesia
What does bradycardia in a MR patient cause?
LV volume overload
Mitral Regurg Anesthetic Considerations
- Induction/muscle relaxant — adjust to prevent increased SVR or decreased HR
- Volatile anesthetics – prevent increased BP/SVR
- Maintain intravascular fluid volume.
KEEP PATIENT FULL, FAST, and FORWARD
Per lecture, what vasopressor do we not want to give a patient with Mitral Regurg?
- Phenylephrine
- give ephedrine
Aortic Stenosis is associated with…
- Calcific Aortic stenosis
- Bicuspid aortic valve
When does Aortic Valve stenosis occur earlier in life?
- When you are born with a Bicuspid Aoritic Valve
- Age 30 -50
What is the most common congenital valvular abnormality?
Biscupid Aortic Valve.
What is the normal Valve area of the Aortic Valve?
- 2.5 -3.5 cm
- Severe AS has < 1 cm
Aortic Stenosis Pathophysiology
- Obstruction to ejection of blood into the aorta
- Increased LV pressure
- Aortic Valve area < 1 cm
- Always associated with Aortic Regurg
- Concentric hypertrophy
What does LV Concentric Hypertrophy cause?
- increase in Myocardial O2 requirements
- increase in myocardial work
- myocardial O2 delivery is reduced
What are the symptoms of Aortic Stenosis?
- Systolic or midsystolic murmur
- Rt Upper sternal border
- Cresendo- decrescendo pattern
- Radiates to neck, mimics carotid bruit
Symptoms of Critical Aortic Stenosis
- Angina Pectoris – increased risk of peri-op mortality and MI
- Syncope
- Dyspnea on exertion
AS Symptom correlation w/ an average time to death:
* 5 years
* 3 years
* 2 years
- 5 years - angina
- 3 years - syncope
- 2 years - dyspnea on exertion
______ % of symptomatic AS patients will die in 3 years with out valve replacement.
75%
Aortic Stenosis Diagnosis: CXR
- Prominent ascending aorta
- Aortic Valve calcification
Aortic Stenosis Diagnosis: ECG
- LV hypertropy
- ST depression
- T-wave inversion
Aortic Stenosis Diagnosis: Echocardiogram
- Tri-leaflet vs bi-leaflet
- Thickened and calcified
- Valve area and transvalvular pressure gradients
Aortic Stenosis Diagnosis: Excercise Stress Test
* Poor exercise tolerance
* and/or abnormal BP with exercise
Aortic Stenosis Treatments
- Balloon Valvotomy for adolescent/young adults
- Transcatheter aortic valve replacement (TAVR)
What is the #1 thing to prevent in Aortic Stenosis patient’s during surgery?
Hypotension
What makes someone a high risk for a TAVR?
> 65 years old
Aortic Stenosis Anesthetic Considerations
- Prevent/avoid Hypotension and decreased CO —phenylephrine
- Maintain NSR — NO BRADYCARDIA
- Optimize intravascular fluid volume –preload dependent
* avoid tachycardia
* GA > epidural or spinal
AS: Hypotension Medications
- Alpha - agonists: Phenylephrine
AS: Junction Rhythm/bradycardia medications
- Ephedrine
- Atropine
- glycopyrrolate
AS: Tachycardia Medications
- Beta - blockers: Esmolol
Is CPR affective in patient’s with Aortic Stenosis?
NO
Induction for a patient with Aortic Stenosis
- Opiods induction if LV function is compromised
- Avoid opioids that release histamines (morphine, hydromorphone)
- Avoid Ketamine d/t tachycardia
- Avoid Pancuronium and atracurium
What is Aortic Regurgitation?
- Failure of aortic leaflets caused by disease of the aortic leaflet or aortic root
What disease process can cause Aortic Regurgitation?
- endocarditis
- rheumatic fever
- bicuspid aortic valve (BAV)
- Anorexigenic drugs (meth)
What can cause ACUTE aortic regurgitation?
- endocarditis
- aortic dissection
Aortic Regurgitation Pathophysiology
- Decreased CO d/t regurgitant SV
- Combined LV pressure and volume overload
*
What is the Onset of Aortic Regurgitation?
Slow onset
What does the magnitude of Aortic reguritation depend on?
- Time available for regurgitant flow (HR)
- Pressure gradient across the aortic valve (SVR)
When does Aortic Regurg happen during the cardiac cycle?
Diastole
What is pulse pressure proportional?
- Stroke volume and aortic elastance
- Increase SV = increases SBP = increased afterload
Aortic Regurgitation Pathophysciology
- SV eject into the aorta
- Increased LV end-diastolic volume and pressure
- Eccentric hypertropy and enlarging to accomodate volume overload
- Increased SV and increased systemic blood flow
- EF declines
What does Eccentric hypertrophy cause?And what Valve issue is it associated?
- Volume overload –> causes dilation
- impaired contraction
- susceptibile to arrhythmias
- Aortic Regurg
Aortic Regurg Symptoms
- Early/mid-diastole murmur on left sternal border
- low-pitch diastolic rumble
Aortic Regurg: Hyperdynamic Circulation
- Widened Pulse Pressure
- Decreased DBP
- Bounding Pulses
What does End-Stage Aortic Regurgitation cause?
- LV failure
- Dyspnea, orthopnea, fatigue, coronary ischemia
When do the majority of Aortic Regurgitation symptoms occur?
- After LV dysfunction occurs
Aortic Regurgitation Diagnosis: EKG and CXR
- LV enlargement
- Hypertrophy
Aortic Regurgitation Diagnosis :Echocardiogram
- Leaflet prolapse
- Associated with aortic abnormalities
Aortic Regurg Treatment: Medical
- Decrease systolic HTN and LV wall stress; Improve LV function
- Diuretics, ACE-i, CCB
Aortic Regurgitation Treatment: Surgical
- AVR
- Aortic Root Replacement
Aortic Reguritation Anesthetic Considerations
GOAL: Maintain forward LV, SV
* Avoid Bradycardia — HR > 80
* Avoid increased SVR (ephedrine > phenylephrine)
* minimize myocardial depression (vasodilators and inotropes)
What must you keep the heart rate above wirh Aortic Reguritation?
> 80 HR
What is the best anesthesia option for Aortic Reguritation? Induction choices?
- GA is the best choice
- Use: inhaled/IV drugs
- Avoid: decreased HR or increased SVR
Intravascular fluids to maintain adequate preload.
