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Mar: Sem 2 - Health Assessment > Valvular Heart Disease (Exam II) > Flashcards

Valvular Heart Disease (Exam II) Flashcards

1
Q

What is the incidence of valvular disease in the US population?

A

2.5%

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2
Q

Most frequently encountered cardiac valve lesions

A
  • Produce pressure overload i.e. mitral or aortic stenosis
    or
  • Produce volume overload i.e. mitral or aortic regurgitation
  • Valvular heart disease and ischemic heart disease frequently co-exist
  • Mitral regurg d/t ischemic heart disease increases mortality
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3
Q

Pre-op Evaluation

A
  • Assess: Severity of cardiac disease, degree of contractility, and presence of major organ system disease
  • Compensatory mechanisms: increased SNS, hypertrophy and what current therapy they are on [SHYT]
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4
Q

What is the NYHA Functional Classification of Patients with Heart Disease?

A

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

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5
Q

What causes a murmur?

A

Turbulent flow across a heart valve
or increased flow across a normal valve

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6
Q

Systolic murmurs are caused by what valve pathologies?

A
  • Aortic/Pulmonic Stenosis
  • Mitral/Tricuspic Regurgitation
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7
Q

Diastolic murmurs are caused by what pathologies?

A
  • Aortic/Pulmonic Regurgitation
  • Mitral/Tricuspid Stenosis
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8
Q

_____ murmurs follow S2.

A

Diastolic

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9
Q

Midsystolic murmurs occur when?

A

Between S1 and S2 sounds
Best heard at Right upper sternal border, radiates to carotids (suggests aortic stenosis, a functional murmur, or hypertrophic cardiomyopathy)

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10
Q

Holosystolic murmur is heard when and where?

A

Merges with S1 and S2
heard best at the apex and radiates to the axilla (suggests mitral regurg)

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11
Q

Which murmur type exhibits a crescendo-decrescendo pattern?

A

Mid-systolic Murmurs

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12
Q

Aortic stenosis Maneuver to change the sound

A

-At the 2ⁿᵈ ICS, right sternal border
-Increases with squatting
-Decreases with Valsalva and standing (Midsystolic crescendo-decrescendo)

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13
Q

Maneuver to increase aortic Regurg sound

A

At the 2ⁿᵈ ICS, left sternal border, increases with hand grip or BP cuff inflation (Early diastolic murmur)

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14
Q

Maneuver to increase mitral stenosis sound

A

At the apex, increases with tachycardia (Mid-Diastolic)

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15
Q

Maneuver to increase mitral regurg sound

A

At the apex, the sound increases with handgrip or BP cuff inflation (holosystolic)

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16
Q

What maneuver would increase the Tricuspid regurg sound?

A

At the lower left sternal border, sound increases with inspiration (holosystolic)

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17
Q

Mitral valve prolapse maneuver to increase the sound

A

At the apex, this sound increases with Valsalva or standing (Late systolic murmur)

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18
Q

Hypertrophic cardiomyopathy maneuver to increase the sound

A

At the lower left sternal border, the sound increases with Valsalva or standing (Midsystolic murmur)

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19
Q

Functional maneuver to increase the sound

A

At the Left sternal border, this sound may increase with exercise (midsystolic crescendo-decrescendo)

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20
Q

What factors seen on a chest x-ray would indicate valvular disease?

A
  • Cardiomegaly
  • Left Bronchus Elevation
  • Valvular Calcifications
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21
Q

What signs seen on an EKG could indicate valvular disease?

A
  • LA enlargement (broad, notched p-wave)
  • Axis deviations
  • Dysrhythmias
  • Possible ischemia or previous MI
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22
Q

What to evaluate on an Echo

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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23
Q

What to evaluate with Angiography

A

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

24
Q

What type of valve replacement is thrombogenic?

A

Mechanical (preferred in young patient, have a life expectancy more than 10-15 years or already require long-term anticoagulation therapy for another reason like a-fib)

25
Q

What are bioprosthetic valves made from?

A

Porcine or bovine (preferred in elderly patients and in those who cannot tolerate anticoagulation)

26
Q

Which type of prosthetic valve is longer lasting?

A

Mechanical

27
Q

Anesthesia with anticoagulation therapy

A
  • Temporary discontinuation of Warfarin puts pts with mechanical heart valves or a-fib at risk of thromboembolism due to rebound hypercoagulable state
  • Anticoagulation may be continued in patients with prosthetic heart valves going to minor surgery (blood loss will be minimal)
  • When major surgery is planned, D/C warfarin 3-5 days preop
28
Q

Who is most commonly affected by mitral stenosis?

A
  • Women
  • Rheumatic patients
    (this diagnosis is rare in the US)
29
Q

What is the normal mitral valve orifice surface area?

A

4 - 6 cm²

30
Q

At what surface area do symptoms for mitral valve stenosis start to develop?

A

< 2 cm²

31
Q

What are the s/s of mitral stenosis?

A
  • Exertional dyspnea
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Pulmonary edema
  • Pulmonary HTN
  • A-Fib
32
Q

How is mitral stenosis treated?

A
  • Rate control (80bpm goal)
  • ↓LAP (diuretics)
  • Anticoagulation
  • Surgical correction
33
Q

What EKG abnormalities are common with mitral stenosis?

A
  • Notched P waves
  • A-Fib
34
Q

What are the anesthetics goals for a patient with mitral stenosis?

A

Maintain normal parameters for HR, volume status, and afterload.
- Avoid ketamine because it increases HR
- Avoid histamine releasing NMBs (pancuronium and atracurium)

35
Q

What is more common, mitral stenosis or regurgitation?

A

Regurgitation (2% of US population)

36
Q

What type of murmur would be auscultated with mitral regurgitation? What other s/s are associated?

A

Holosystolic murmur at the cardiac apex
- Cardiomegaly
- AFib
- Hx of: IHD, endocarditis, papillary muscle dysfunction

37
Q

What less invasive cath lab procedure is used to treat mitral regurgitation?

A

Mitra-clip

38
Q

What β-blocker is preferred for mitral regurgitation?

A

Carvedilol

39
Q

What are the anesthetic goals for mitral regurgitation patients?

A

***avoid bradycardia!! Slightly increased HR
- Improve LV stroke volume & decrease Regurg
- Prevention and treatment of decreased CO
- Use Nitroprusside (vasodilators)—>Avoid increased SVR
Neuraxial anesthesia may be beneficial in some patients because of the decrease in SVR

40
Q

What heart rate would you want to maintain with mitral regurgitation?

A

Normal to slightly increase HR

Bradycardia will increase LV volume overload.

41
Q

What type of pathology would cause early-life development of aortic stenosis?

A

Bicuspid Aortic Valve

42
Q

What is the normal surface area of the aortic valve?

A

2.5 - 3.5 cm²

43
Q

What is the surface area of a severely stenotic aortic valve?

A

< 1 cm²

44
Q

What pathology would be expected for a systolic or mid-systolic murmur hear in the right upper sternal border?

A

Aortic Stenosis

45
Q

What symptoms are seen with aortic stenosis becomes critical?

A
  • Angina
  • Syncope
  • Dyspnea on exertion
46
Q

____% of aortic stenosis patients will die within three years without a valve replacement

A

75%

47
Q

What EKG characteristics would be seen for a patient with aortic stenosis?

A
  • ST depression
  • T-wave inversion
  • LV hypertrophy
48
Q

What non-surgical treatments are available for aortic stenosis?

A
  • Balloon valvotomy for younger patients
  • TAVR
49
Q

What type of anesthetic technique is generally better for patients with aortic stenosis?

A

General Anesthesia
-avoid SVR decrease
-preload dependent
-avoid ketamine
- Prevention/avoidance of hypotension and decreased CO
- Maintain NSR
- Avoid bradycardia or tachycardia
- Optimize intravascular fluid volume
- Aggressive treatment of hypotension

**CPR is typically not effective

50
Q

What are common causes of chronic aortic regurgitation?

A
  • Endocarditis/rheumatic fever
  • Bicuspid AV
  • Anorexigenic drugs
51
Q

What are the two common causes of acute aortic regurgitation?

A
  • Endocarditis
  • Aortic dissection
52
Q

What two factors determine the degree of regurgitant blood flow from a dysfunctional aortic valve?

A
  • Time available for flow (HR)
  • Pressure gradient (SVR)
53
Q

What type of murmur would be heard with aortic regurgitation?

A

Early to mid-diastolic murmur at left sternal border

54
Q

What blood pressure abnormalities are often seen with aortic regurgitation?

A
  • Widened pulse pressure
  • decreased dBP
  • Bounding pulses
55
Q

Treatment for aortic regurgitation

A
  • Medical
    -Decrease systolic HTN, LV wall stress, and improve LV function
    -Diuretics, ACE-I, CCB
    -Surgical
    -AVR
    -Aortic root replacement
56
Q

Aortic Regurg Anesthetic considerations

A
  • Goal: maintain forward LV SV
  • Avoid bradycardia - increasing diastole will increase the time for AR and with increase LV overload
    -HR: > 80 bpm
  • Avoid increased SVR
  • Minimize myocardial depression
    -Vasodilator to reduce afterload
    -Inotrope to increase contractility
    *GA is usual choice
    Induction: Inhaled anesthetic or IV drugs
  • NMBDs w/ minimal or no effect on BP
  • Intravascular fluid volume - normal levels to provide adequate preload

Mar: Sem 2 - Health Assessment (32 decks)

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