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Health Assessment > Valvular Heart Disease (Exam 2) > Flashcards

Valvular Heart Disease (Exam 2) Flashcards

1
Q

How prevalent is Valvular Heart Disease in the US?

A
  • 2.5 % of population
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2
Q

What are the Effects of Valvular Heart Disease?

A
  • Hemodynamic burden on left/right ventricle
  • Pressure overload (MS and AS)
  • Volume Overload (MR, AR)
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3
Q

What Cardiac diseases/processes can co-exist with valvular diseases?

A
  • Valvular heart disease + IHD
  • CAD w/ mitral or aortic valve disease
  • Mitral regurgitaiton d/t ischemic heart diseasse
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4
Q

Pre-Op Evaluation: Assessment

A
  • Severity of Cardiac disease
  • Degree of impaired myocardial contractility
  • Presence of associated major organ system disease
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5
Q

Compensatory Mechanism for Valvular Disease

A
  • Increased SNS – HR is most important
  • Myocardial hypertrophy
  • Current drug Therapy
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6
Q

New York Association Functional Classification of Patient’s with Heart Disease

A
  • 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
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7
Q

What causes a Heart Murmur?

A
  • Turbulent Blood Flow
  • Increased flow across normal valves
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8
Q

What is the difference between a Functional Murmur and Pathological Murmur?

A
  • Functional: Physicological condiction OUTSIDE the heart
  • Pathological: Structural defects in the Heart
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9
Q

Name a Functional Murmur

A
  • Midsystolic
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10
Q

What is a systolic murmur?

A
  • Stenosis of the aortic or pulmonic valves
  • Incompetence (regurg) of the mitral or tricuspid valves
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11
Q

What valves are open and closed during Diastole?

A
  • Closed: Aortic and Pulmonic Valves
  • Open: Mitral and tricuspid valves
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12
Q

What is a Diastolic Murmur?

A
  • Stenosis of the mitral or tricuspid valves.
  • Incompetence of the aortic or pulmonic valves.
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13
Q

Midsystolic murmur

A
  • occur between distinct S1 and S2 heart sounds.
  • Crescendo-decrescendo pattern
  • Can be functional
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14
Q

What does a Diastic Murmur follow?

A
  • S2
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15
Q

Where is a Midsystolic Murmur heard?

A
  • Right Upper Sternal Boarder
  • Radiates to the carotids
  • Suggest Aortic Stenosis
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16
Q

Where is a Holosystolic Murmur Heard?

A

* Apex
* Radiates to the axilla
* * Merges with S1 and S2
* Most Concerning – large Lesions

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17
Q

Aortic Stenosis Murmur

A
  • Location: Rt Upper Sternal Border
  • Increases with squatting
  • Decreases with valsalva and standing
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18
Q

Aortic Regurgitation Murmur

A
  • Location: Left Sternal Border
  • Increases with handgrip or blood pressure cuff inflation
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19
Q

Mitral Stenosis Murmur

A
  • Location: Apex
  • Increases with tachycardia
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20
Q

Mitral Regurgitation Murmur

A
  • Location: Apex
  • increases with handgrip or blood pressure cuff inflation
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21
Q

Tricuspid Regurgitation Murmur

A
  • Lower: Lower left sternal boarder
  • Increases with inspiration
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22
Q

Mitral Valve Prolapse Murmur

A
  • Location: Apex
  • Increases with Valsalva and standing
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23
Q

Hypertropic Cardiomyopathy Murmur

A
  • Location: Lower left sternal border
  • Increased with Valsalva and standing
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24
Q

Functional Murmur

A
  • Location: Left Sternal Border
  • May increase with exercise
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25
Q

Common Auscultatory Site: Aortic Murmur

A
  • 2nd ICS Right Sternal Border
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26
Q

Common Auscultatory Site: Pulmonic Murmur

A
  • 2nd ICS
  • Left Sternal Border
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27
Q

Common Auscultatory Site: Tricuspid Murmur

A
  • 5th ICS
  • Left Sternal Border
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28
Q

Common Auscultatory Site: Mitral Murmur

A
  • 5th ICS
  • Mid-Clavicular Line
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29
Q

What can you diagnosis with an EKG?

A
  • Left Atrial Enlargement
  • Left or Right Axis Deviation
  • Dysrhythmias
  • Possible ischemia/prevous MI
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30
Q

What can you Diagnosis with a CXR?

A
  • Cardiomegaly: more than 1/2 thoracic view
  • Left mainstem bronchus elevation
  • Valvular calcifications – calcium deposits
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31
Q

What can you use an ECHOcardiogram to determine?

A
  • 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.
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32
Q

What can you use an Angiography to diagnose?

A
  • Presence and severity of valvular stenosis and/or regurgitation
  • Coronary artery disease
  • Intracardiac shunting
  • Transvalvular pressure gradients
  • Clinical vs echocardiographic findings
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33
Q

What Type of valves can be place surgically?

A
  • Mechanical
  • Bioprosthetic
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34
Q

Mechanical Valve

A
  • Metal or carbon alley
  • Very durable …. 20-30 years
  • Highly thrombogenic
  • Younger patients
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35
Q

Bioprosthetic Valve

A
  • Porcine or bovine
  • Shorter lasting….. 10-15 years
  • Low thrombogenic potential
  • Elderly patients
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36
Q

Which valve has a higher risk for for infection?

A

Mechanical Valves

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37
Q

Anticoagulation Concerns for Surgical cases

A
  1. Discontinue of warfarin (minor vs major surgery)
  2. Rebound hypercoagulable state
  3. Bridge to surgery
  4. Heparin to warfarin restart
  5. Anticoagulation during pregnancy
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38
Q

What does the temporary discontinuation of anticoagulation therapy do for someone with a mechanical heart valve or a-fib?

A
  • increases risk of an art/venous thrombotic event.
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39
Q

Why is warfarin administration during pregnancy discouraged? And when do we stop it? Alternatives?

A
  • 1st Trimester
  • associated with fetal defects and death
  • LMWH or Low-dose ASA
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40
Q

What Valve disease is rare in the US? and Why?

A
  • MItral Stenosis
  • Caused by Rheumatic Diseases
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41
Q

Who typically suffers from Mitral Stenosis and what is the onset?

A
  • Women
  • Slow Onset: can be asymptomatic for 20-30 years
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42
Q

What is the normal size of a Mitral Valve orifice area? and when do symptoms start to develope?

**

A
  • Normal: 4-6 cm2
  • Symptoms: < 2 cm2
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43
Q

Mitral Stenosis Pathophysiology

A
  • Mechanical obstruction to LV filling
  • Mitral orfice size of < 2cm
  • Diffuse thickening/fibrosis of cusps
  • Calcification of the annulus and leaflets
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44
Q

What cardiac values does Mitral Stenosis Affect in the Heart?

A
  • Lt Atrial volume/pressure
  • LV Contractility
  • SV
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45
Q

Mitral Valve Stenosis symptoms

A
  • Dyspnea on exertion
  • Orthopnea
  • paroxysmal noctural dyspnea
  • Pulmonary Edema
  • Pulmonary HTN
  • Atrial fibrillation
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46
Q

What Valve Problem causes Pulmonary Edema?

A

Mitral Valve Stenosis

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47
Q

What will Mitral Valve Stenosis Show up as on a CXR?

A
  • Mitral Calcification
  • Pulmonary Edema/Vascular congestion
  • Elevated Left Main Bronchus
  • Straightening of Left Heart Boarder
48
Q

What will Mitral Stenosis show up as on an Echocardiogram?

A
  • Calcification
  • Left Atrial Thrombus
  • Left Atrial enlargement
49
Q

On your assessment, what sounds are associated with Mitral Stenosis?

A
  • Rumbling diastolic murmur at apex
  • Radiates to left axilla
50
Q

How does Mitral Stenosis show up on an EKG?

A
  • Notched P-wave
  • Atrial Fib
51
Q

Mitral Stenosis Treatment

A
  1. Rate Control
    * BB, CCB, Digoxin
  2. Left Atrial Pressure
    * Diuretics
  3. Anticoagulation
    * 7-15% risk of stroke
  4. Surgical Correction
    * Percutaneous valvotomy
    * Surgical commissureotomy
    * valve replacement
52
Q

Mitral Stenosis Anesthesic Considerations

A
  • 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
53
Q

What does Pulmonary HTN exacerbation cause?

A
  • Hypoventilation
  • Hypercarbia
  • Hypoxemia
54
Q

What is the DOC for Induction for Mitral Valve Stenosis? Which should you avoid?

A
  • Etomidate
  • Avoid: Ketamine and Histamine releasing NMB
55
Q

Who is Mitral Regurgitation most common in?

A
  • More common in men
  • 2% of the population
56
Q

What cardiac conditions are associated with Mitral Regurgitation?

A
  • IHD
  • Ruptured papillary muscle
  • Endocarditis
  • Mitral valve prolapse
  • Cardiomyopathy
57
Q

Mitral Regurg Pathophysiology

A
  • Decreased in forward LV, SV and CO
  • Left atrial volume overload and Pulmonary Congestion
  • Regurgitant volume
58
Q

What type of LV hypertrophy will Mitral Reguritation cause?

A

Eccentric hypertropy

59
Q

Mitral Regurgitation Symptoms

A
  • History of IHD (ischemic Heart disease)
  • Holosytolic murmur at apex – radiates to axilla
  • Cardiomegaly
  • Atrial Fibrillation
60
Q

What can we see on an EKG that will indicate Mitral Stenosis?

A
  • Left Atrial and LV hypertrophy
  • Atrial fibrillation
61
Q

What can we see on a CXR that will indicate Mitral Stenosis?

A
  • Cardiomegaly
  • Left Atrial and LV hypertrophy
62
Q

What can we see on an Echocardiogram that will indicate Mitral Stenosis?

A
  • Left atrial thrombus
63
Q

______________________ patient’s should undergo mitral valve surgery, even if EF is normal

A

Symptomatic

64
Q

When should an asymptomatic patient be taken for surgery for Mitral regurge?

A
  • LV EF of 30-60%
  • LV end-systolic dimension less than 55 mm.
65
Q

When should surgery be done on a Mitral valve to reduce the risk of heart failure?

A
  • Before the EF is less than 60%
66
Q

Which surgery is prefered: Mitral Valve Repair or Replacement? Why?

A
  • MV Repair
  • maintains the functional aspects of the mitral valve apparatus —important for LV function and contractility
67
Q

At what EF will MR surgery not be as effective?

A

30%

68
Q

What is placed during a Transcatheter Mitral valve Repair (TAVR)?

A
  • Mitral Clip
69
Q

What can we do for patient’s with Mitral Regurg to improve symptoms and increase exercise tolerance?

A
  • ACE-i
  • BB (carvedilol)
  • Bi-ventricular pacing
70
Q

Mitral Reguritation Goals

A
  • 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
71
Q

What does bradycardia in a MR patient cause?

A

LV volume overload

72
Q

Mitral Regurg Anesthetic Considerations

A
  • 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

73
Q

Per lecture, what vasopressor do we not want to give a patient with Mitral Regurg?

A
  • Phenylephrine
  • give ephedrine
74
Q

Aortic Stenosis is associated with…

A
  • Calcific Aortic stenosis
  • Bicuspid aortic valve
75
Q

When does Aortic Valve stenosis occur earlier in life?

A
  • When you are born with a Bicuspid Aoritic Valve
  • Age 30 -50
76
Q

What is the most common congenital valvular abnormality?

A

Biscupid Aortic Valve.

77
Q

What is the normal Valve area of the Aortic Valve?

A
  • 2.5 -3.5 cm
  • Severe AS has < 1 cm
78
Q

Aortic Stenosis Pathophysiology

A
  • Obstruction to ejection of blood into the aorta
  • Increased LV pressure
  • Aortic Valve area < 1 cm
  • Always associated with Aortic Regurg
  • Concentric hypertrophy
79
Q

What does LV Concentric Hypertrophy cause?

A
  • increase in Myocardial O2 requirements
  • increase in myocardial work
  • myocardial O2 delivery is reduced
80
Q

What are the symptoms of Aortic Stenosis?

A
  • Systolic or midsystolic murmur
  • Rt Upper sternal border
  • Cresendo- decrescendo pattern
  • Radiates to neck, mimics carotid bruit
81
Q

Symptoms of Critical Aortic Stenosis

A
  • Angina Pectoris – increased risk of peri-op mortality and MI
  • Syncope
  • Dyspnea on exertion
82
Q

AS Symptom correlation w/ an average time to death:
* 5 years
* 3 years
* 2 years

A
  • 5 years - angina
  • 3 years - syncope
  • 2 years - dyspnea on exertion
83
Q

______ % of symptomatic AS patients will die in 3 years with out valve replacement.

A

75%

84
Q

Aortic Stenosis Diagnosis: CXR

A
  • Prominent ascending aorta
  • Aortic Valve calcification
85
Q

Aortic Stenosis Diagnosis: ECG

A
  • LV hypertropy
  • ST depression
  • T-wave inversion
86
Q

Aortic Stenosis Diagnosis: Echocardiogram

A
  • Tri-leaflet vs bi-leaflet
  • Thickened and calcified
  • Valve area and transvalvular pressure gradients
87
Q

Aortic Stenosis Diagnosis: Excercise Stress Test

A

* Poor exercise tolerance
* and/or abnormal BP with exercise

88
Q

Aortic Stenosis Treatments

A
  • Balloon Valvotomy for adolescent/young adults
  • Transcatheter aortic valve replacement (TAVR)
89
Q

What is the #1 thing to prevent in Aortic Stenosis patient’s during surgery?

A

Hypotension

90
Q

What makes someone a high risk for a TAVR?

A

> 65 years old

91
Q

Aortic Stenosis Anesthetic Considerations

A
  • Prevent/avoid Hypotension and decreased CO —phenylephrine
  • Maintain NSR — NO BRADYCARDIA
  • Optimize intravascular fluid volume –preload dependent
    * avoid tachycardia
    * GA > epidural or spinal
92
Q

AS: Hypotension Medications

A
  • Alpha - agonists: Phenylephrine
93
Q

AS: Junction Rhythm/bradycardia medications

A
  • Ephedrine
  • Atropine
  • glycopyrrolate
94
Q

AS: Tachycardia Medications

A
  • Beta - blockers: Esmolol
95
Q

Is CPR affective in patient’s with Aortic Stenosis?

A

NO

96
Q

Induction for a patient with Aortic Stenosis

A
  • Opiods induction if LV function is compromised
  • Avoid opioids that release histamines (morphine, hydromorphone)
  • Avoid Ketamine d/t tachycardia
  • Avoid Pancuronium and atracurium
97
Q

What is Aortic Regurgitation?

A
  • Failure of aortic leaflets caused by disease of the aortic leaflet or aortic root
98
Q

What disease process can cause Aortic Regurgitation?

A
  • endocarditis
  • rheumatic fever
  • bicuspid aortic valve (BAV)
  • Anorexigenic drugs (meth)
99
Q

What can cause ACUTE aortic regurgitation?

A
  • endocarditis
  • aortic dissection
100
Q

Aortic Regurgitation Pathophysiology

A
  • Decreased CO d/t regurgitant SV
  • Combined LV pressure and volume overload
    *
101
Q

What is the Onset of Aortic Regurgitation?

A

Slow onset

102
Q

What does the magnitude of Aortic reguritation depend on?

A
  • Time available for regurgitant flow (HR)
  • Pressure gradient across the aortic valve (SVR)
103
Q

When does Aortic Regurg happen during the cardiac cycle?

A

Diastole

104
Q

What is pulse pressure proportional?

A
  • Stroke volume and aortic elastance
  • Increase SV = increases SBP = increased afterload
105
Q

Aortic Regurgitation Pathophysciology

A
  • 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
106
Q

What does Eccentric hypertrophy cause?And what Valve issue is it associated?

A
  • Volume overload –> causes dilation
  • impaired contraction
  • susceptibile to arrhythmias
  • Aortic Regurg
107
Q

Aortic Regurg Symptoms

A
  • Early/mid-diastole murmur on left sternal border
  • low-pitch diastolic rumble
108
Q

Aortic Regurg: Hyperdynamic Circulation

A
  • Widened Pulse Pressure
  • Decreased DBP
  • Bounding Pulses
109
Q

What does End-Stage Aortic Regurgitation cause?

A
  • LV failure
  • Dyspnea, orthopnea, fatigue, coronary ischemia
110
Q

When do the majority of Aortic Regurgitation symptoms occur?

A
  • After LV dysfunction occurs
111
Q

Aortic Regurgitation Diagnosis: EKG and CXR

A
  • LV enlargement
  • Hypertrophy
112
Q

Aortic Regurgitation Diagnosis :Echocardiogram

A
  • Leaflet prolapse
  • Associated with aortic abnormalities
113
Q

Aortic Regurg Treatment: Medical

A
  • Decrease systolic HTN and LV wall stress; Improve LV function
  • Diuretics, ACE-i, CCB
114
Q

Aortic Regurgitation Treatment: Surgical

A
  • AVR
  • Aortic Root Replacement
115
Q

Aortic Reguritation Anesthetic Considerations

A

GOAL: Maintain forward LV, SV
* Avoid Bradycardia — HR > 80
* Avoid increased SVR (ephedrine > phenylephrine)
* minimize myocardial depression (vasodilators and inotropes)

116
Q

What must you keep the heart rate above wirh Aortic Reguritation?

A

> 80 HR

117
Q

What is the best anesthesia option for Aortic Reguritation? Induction choices?

A
  • GA is the best choice
  • Use: inhaled/IV drugs
  • Avoid: decreased HR or increased SVR

Intravascular fluids to maintain adequate preload.

Health Assessment (7 decks)

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