Valvular Heart Diseases

Question 1

The preoperative evaluation should include assessment of the?

Answer 1

(1) severity of the cardiac disease;
(2) degree of impaired myocardial contractility;
(3) presence of associated major organ disease,
(4) development of compensatory mechanisms for maintaining cardiac output (increased sympathetic nervous system activity, cardiac hypertrophy).

Question 2

Goals of anesthesia management for MITRAL STENOSIS

Answer 2

Goals: (slow, tight, full)

a. Avoid sinus tachycardia or rapid ventricular response rate during a. fib.
b. Avoid marked increases in central blood volume as associated with over transfusion or head-down position.
c. Avoid drug-induced decreases in SVR.
d. Avoid events such as arterial hypoxemia and/or hypoventilation that may exacerbate pulmonary HTN and evoke right ventricular failure.

Question 3

Induction of anesthesia for patient with Mitral Stenosis

Answer 3

Is most often accomplished with drugs administered intravenously that are unlikely to increase HR (avoid ketamine) or abruptly decrease SVR.

Question 4

Maintenance of anesthesia with patient with Mitral Stenosis?

Answer 4

Is intended to minimize the likelihood of marked and sustained changes in HR, SVR, PVR, and myocardial contractility.

Useful drugs: Beta and Calcium channel blockers, phenylephrine.

Use of invasive monitoring depends on the complexity of the operative procedure and the magnitude of physiologic impairment produced by mitral stenosis.

Question 5

Management of anesthesia with the patient with Mitral Regurgitation?

Answer 5

An important goal is to avoid events that may further decrease cardiac output.
Goals: (fast, full, forward)
a. Avoid sudden decreases in heart rate.
b.Avoid sudden increases in SVR.
c.Monitor the size of the V wave as a reflection of regurgitant flow.
d. Minimize drug-induced myocardial depression.

Question 6

Induction of anesthesia with the patient with mitral regurgitation?

Answer 6

Keep in mind the importance of avoiding excessive and abrupt changes is SVR or decreases in HR.

1. In the absence of severe LV dysfunction, maintenance of anesthesia is often provided with nitrous oxide plus a volatile anesthetic (isoflurane is an attractive choice because of its hemodynamic effects.)
2. When LV dysfunction is severe, the use of an opioid technique that minimizes the likelihood of drug-induced myocardial depression may be a consideration.
3. Use of invasive monitoring depends on the complexity of the operative procedure and the magnitude of the physiologic impairment produced by mitral regurgitation.

Question 7

Triad of symptoms of aortic stenosis?

Answer 7

The characteristic triad of symptoms:

	a. angina pectoris often in the absence of ischemic heart 	disease), 
	b. dyspnea on exertion		
	c. history of syncope.

Question 8

Management of anesthesia for the patient with aortic stenosis?

Answer 8

1. An important goal is to avoid events that would further decrease cardiac output.
   a. Maintain NSR.
   b. Avoid bradycardia.
   c. Avoid sudden decreases in SVR.
   d. Optimize intravascular fluid volume to maintain venous return and LV filling.
2. General anesthesia is often selected in preference to epidural anesthesia or spinal anesthesia to minimize the likelihood of an undesirable decrease in SVR.
3. Use of A-line and PA catheter depends on the magnitude of the surgery and the severity of the aortic stenosis.

Question 9

Goals in aortic regurgitation?

Answer 9

Goals:

	a. Avoid sudden decreases in HR
	b. Avoid sudden increases in SVR
	c. Minimize drug-induced myocardial 			depression

Question 10

Induction/maintenance of anesthesia in aortic regurgitation?

Answer 10

INDUCTION:
Is with drugs considered likely to maintain forward left ventricular stroke volume.

MAINTENANCE:
In the absence of severe LV dysfunction is often provided with nitrous oxide plus a volatile anesthetic (isoflurance is an attractive choice because of its hemodynamic effects) or when myocardial function is compromised, the use of an opioid alone may be considered.

Maintenance of IV fluid volume with prompt replacement of blood loss is important for maintaining forward left ventricular stroke volume.
Bradycardia may require prompt treatment with atropine.
Monitoring is dictated by the complexity of the surgery and the severity of the aortic regurgitation.

Question 11

Tricuspid regurgitation goals?

Answer 11

Management of anesthesia
Maintain intravascular fluid volume
Avoid drop in venous return
Avoid hypoxia, hypercarbia