Valvular Heart Disease (Exam II) Flashcards
What is the incidence of valvular disease in the US population?
2.5%
What is the NYHA Functional Classification of Patients with Heart Disease?
I - Asymptomatic.
II - s/s with activity but relieved by rest.
III - s/s w/ minimal activity, relieved by rest.
IV - s/s at rest
What causes a murmur?
turbulent flow across a heart valve
or
↑ flow across normal valves
Systolic murmurs are caused by what valve pathologies?
- Aortic/Pulmonic Stenosis
- Mitral/Tricuspic Regurgitation
midsytolic or holosystolic
Diastolic murmurs are caused by what pathologies?
- Aortic/Pulmonic Regurgitation
- Mitral/Tricuspid Stenosis
_____ murmurs follow S2.
Diastolic
Midsystolic murmurs occur when?
Between S1 and S2 sounds
Which murmur type exhibits a crescendo-decrescendo pattern?
Mid-systolic Murmurs
can be functional/least limiting
What characterizes holosystolic murmurs?
S1 and S2 merging
most scary
Where is the aortic valve auscultated?
2ⁿᵈ ICS, right sternal border
Where is the pulmonic valve auscultated?
2ⁿᵈ ICS, left sternal border
Where is the tricuspid valve auscultated?
5th ICS, left sternal border
Where is the mitral valve auscultated?
5th ICS, mid-clavicular line
What factors seen on a chest x-ray would indicate valvular disease?
- Cardiomegaly
- Left Bronchus Elevation
- Valvular Calcifications
What signs seen on an EKG could indicate valvular disease?
- LA enlargement (broad, notched p-wave)
- Axis deviations
- Dysrhythmias
What type of valve replacement is thrombogenic?
Mechanical
What are bioprosthetic valves made from?
Porcine or bovine
Which type of prosthetic valve is longer lasting?
Mechanical
Who is most commonly affected by mitral stenosis?
- Women
- Rheumatic patients
What is the normal mitral valve orifice surface area?
4 - 6 cm²
At what surface area do symptoms for mitral valve stenosis start to develop?
< 2 cm²
What are the s/s of mitral stenosis?
- Exertional dyspnea
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Pulmonary edema
- Pulmonary HTN
- A-Fib
*opening snap early in diastole
How is mitral stenosis treated?
- Rate control (80bpm goal): BB, CCB, DIG
- ↓LAP (diuretics)
- Anticoagulation
- Surgical correction
What EKG abnormalities are common with mitral stenosis?
- Notched P waves
- A-Fib
What are the anesthetics goals for a patient with mitral stenosis?
Maintain normal parameters for HR, volume status, and afterload.
What is more common, mitral stenosis or regurgitation?
Regurgitation (2% of US population)
What type of murmur would be auscultated with mitral regurgitation?
Holosystolic murmur at the cardiac apex
What less invasive cath lab procedure is used to treat mitral regurgitation?
Mitra-clip
repair»_space;> replacement
What β-blocker is preferred for mitral regurgitation?
Carvedilol
…can also give ACE-I
What are the anesthetic goals for mitral regurgitation patients?
- Improve LV stroke volume
- Decrease Regurg
- Avoid bradycardia
- Avoid ↑ SVR
FAST, FULL, FORWARD
What heart rate would you want to maintain with mitral regurgitation?
Normal to slightly increase HR
Bradycardia will increase LV volume overload.
What type of pathology would cause early-life development of aortic stenosis?
Bicuspid Aortic Valve
…most common congenital valvular abnormality
What is the normal surface area of the aortic valve?
2.5 - 3.5 cm²
What is the surface area of a severely stenotic aortic valve?
< 1 cm²
What pathology would be expected for a systolic or mid-systolic murmur hear in the right upper sternal border?
Aortic Stenosis
What symptoms are seen with aortic stenosis becomes critical?
- Angina
- Syncope*
- Dyspnea on exertion
____% of aortic stenosis patients will die within three years without a valve replacement
75%
What EKG characteristics would be seen for a patient with aortic stenosis?
- ST depression
- T-wave inversion
- LV hypertrophy
What non-surgical treatments are available for aortic stenosis?
- Balloon valvotomy for younger patients
- TAVR
What type of anesthetic technique is generally better for patients with aortic stenosis?
General Anesthesia
Opioid induction agent
What are common causes of chronic aortic regurgitation?
- Endocarditis/rheumatic fever
- Bicuspid AV
- Anorexigenic drugs
What are the two common causes of acute aortic regurgitation?
- Endocarditis
- Aortic dissection
What two factors determine the degree of regurgitant blood flow from a dysfunctional aortic valve?
- Time available for flow (HR)
- Pressure gradient (SVR)
What type of murmur would be heard with aortic regurgitation?
Early to mid-diastolic murmur at left sternal border (Austin-Flint murmur)
What blood pressure abnormalities are often seen with aortic regurgitation?
- Widened pulse pressure
- Decreased DBP
- Bounding pulses
Anesthetic considerations for aortic regurge
- Avoid bradycardia, HR > 80
- Avoid ↑ SVR
- Minimize myocardia depression (vasodilator to reduce afterload, inotrope to increase contractility)
GA is usual choice
What disease frequently “co-exists” with valvular heart diease, increasing mortality..
Ischemic Heart Disease
What are 3 pre-op signs of compensatory mechanisms for maintaining CO?
- Increased SNS
- Myocardial hypertrophy
- Current therapy (meds)
Afib is closly related to which valve issues?
Mitral stenosis/regurge
Define functional murmur
A heart murmur that is primarily due to physiologic conditions outside the heart, as opposed to structural defects in the heart itself.
Which murmur increases with squatting, decreases with valsalva and standing?
Aortic stenosis
can also pull legs up to test
Aortic stenosis anesthetic considerations
- Prevent hypotension
- Avoid brady or tachy cardia w/atropine, ephedrine, glycopyrrolate or esmolol
- Optomize fluid volume
- Aggressive treatment of hypotension w/phenylephrine
CRP is typically not effective so don’t fuck up
Which 2 murmurs increase with handgrip or blood pressure cuff inflation?
Aortic/mitral regurgitation
All mitral murmurs can be heard best at the _______
Apex
Which murmur increases with tachycardia?
Mitral stenosis
Which murmur increases with inspiration?
Tricupsid regurgitation
Which murmur has associated findings of prominent JVD and heart failure?
Tricupsid regurgitation
Minor vs. Major - when do discontinue warfarin?
3-5 days prior to major surgery
Heparin can be used as a bridge
try to avoid rebound hypercoagulation
What medications should be avoided w/mitral stenosis?
- Ketamine
- Histamine releasing NMBs (pancuronium, atracurium)
- Morphine (releases histamine)
True/False.. Aortic stenosis is always associated with aortic regurge
True
