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COEXISTING > VALVULAR HEART DISEASES > Flashcards

VALVULAR HEART DISEASES Flashcards

1
Q

valve lesions that are: pressure overload vs. volume overload

A

pressure overload = mitral stenosis, aortic stenosis

volume overload = mitral regurgitation, aortic regurgitation

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2
Q

preoperative evaluation goals of patients w/ valvular heart disease

A
  1. ascertain the severity of the disease
  2. the degree of impaired contractility
  3. presence of associated major organ system disease
  4. recognition of compensatory mechanisms
  5. evaluation of drug therapy
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3
Q

New York Heart Association Functional Classification of Patients with Heart Disease

A

Class I = asymptomatic
Class II = symptoms w/ ordinary activity but comfortable at rest
Class III = symptoms w/ minimal activity but comfortable at rest
Class IV = symptoms at rest

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4
Q

systolic murmur

A

could reflect:

  • stenosis of aortic or pulmonic valves
  • incompetence of mitral or tricuspid valves
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5
Q

diastolic murmur

A

could reflect:

  • stenosis of mitral or tricuspid valves
  • incompetence of aortic or pulmonic valves
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6
Q

angina in pt w/ valvular dz

A

not necessarily representative of CAD, but the two dz often co-exist

  • increased myocardial O2 demand 2/2 ventricular hypertrophy
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7
Q

complications associated w/ prosthetic heart valves

A
  • valve thrombosis
  • systemic embolization
  • structural failures
  • hemolysis
  • paravalvular leak
  • endocarditis
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8
Q

management of anticoagulation pre-operatively in pts w/ prosthetic valves

A
  • continue anticoagulation in minor surgery

- bridge w/ heparin (d/c warfarin 3-5 days preop) for major surgery

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9
Q

SBE guidelines

A

Conditions

  • prosthetic valve
  • previous endocarditis
  • congenital heart disease: unrepaired, repaired w/ prosthesis w/in 6 months, or prosthetic repair w/ residual defects
  • cardiac transplantation w/ development of valve problems

Procedures

  • dental w/ perforation of oral mucosa
  • invasive of respiratory tract
  • invasive of infected skin/musculoskeletal
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10
Q

mitral stenosis: cause

A

rheumatic fever (by FAR most common)

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11
Q

mitral stenosis: symptoms

A

as a result of high LAP

  • DOE
  • orthopnea
  • paroxysmal nocturnal dyspnea

SV not impaired at rest 2/2 compensatory increased LAP, but SV decreases w/ tachycardia or afib

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12
Q

mitral stenosis: valve gradient

A 
mild = 6mmHg
moderate = 6-10mmHg
severe = >10mmHg
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13
Q

mitral stenosis: symptomatic at what size & transvalvular pressure?

A

normal mitral valve orifice = 4-6cm^2
- symptomatic at <50%

at valve area <1cm^2:

  • mean LAP of 25mmHg is required to maintain CO
  • chronic pulm HTN is likely if mean LAP >25mmHg
  • -> predispose to pulm edema
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14
Q

mitral stenosis: what are these pts more at risk for?

A
  • pulmonary edema
  • decreased CO w/ exertion or hyperdynamic states
  • thromboembolic events
  • afib 2/2 LA enlargement
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15
Q

mitral stenosis: tx

A
  • control HR to allow for LV filling (prevent increases in LAP)
  • anticoagulation w/ concurrent afib
  • diuretics if pulm edema
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16
Q

mitral stenosis: anesthetic management

A

prevent events that can decrease CO or produce pulmonary edema

  • avoid tachycardia
  • cardiovert or at least rate control if pt develops afib
  • avoid excessive periop fluid admin, trendelenburg (precipitate CHF)
  • avoid sudden SVR decrease (compensatory tachycardia not tolerated); give sympathomimetic like phenylephrine
  • maintain contractility (used balanced technique, not just volatiles)
  • avoid light anesthesia
17
Q

mitral regurgitation: cause

A
  • rheumatic fever (usually associated w/ mitral stenosis
  • ischemic heart disease
  • papillary muscle dysfunction
18
Q

mitral regurgitation: pathophysiology

A

portion of every SV goes back into the LA

  • -> LA volume overload & pulmonary congestion
  • -> decreased SV = decreased CO
19
Q

mitral regurgitation: severity dependent on?

A
  1. size of mitral valve orifice
  2. heart rate (determines duration of ventricular ejection)
  3. pressure gradients across the mitral valve
20
Q

mitral regurgitation: severity as indicated by area of MR jet

A 
mild = <3cm^2 --> 20-30% regurgitation
moderate = 3-6cm^2 --> 30-50% regurgitation
severe = >6cm^2 --> >55% regurgitation
21
Q

what will you see on the PAOP waveform w/ mitral regurgitation?

A

V WAVE

- size of V wave correlates w/ magnitude of the mitral regurgitation

22
Q

mitral regurgitation: management of anesthesia

A

improve forward LVSV; decrease regurgitant fraction

  • prevent bradycardia
  • prevent SVR increases (tx w/ nitro)
  • minimize myocardial depression (tx w/ inotrope)
  • monitor V wave
  • use iso/des/sevo = decrease SVR, comp HR increase, minimal cardiac depression
  • can use opioid if LVF, avoid bradycardia
23
Q

mitral regurgitation: induction

A

pancuronium +/-? increases HR

  • prevent increase in SVR & HR decrease
24
Q

mitral valve prolapse: pathophysiology

A

prolapse of one or both mitral leaflets into the LA during systole +/- mitral regurgitation

25
Q

mitral valve prolapse: anesthetic management

A

tx like regurg if they have it + take measures to minimize regurg

  • larger ventricle = less prolapse & regurg than smaller ventricle
  • thus take measures to keep LV full
  • -avoid SNS activity
  • -avoid decreased SVR
  • -avoid rapid position changes to upright
    • avoid hypovolemia
26
Q

aortic stenosis: development & risk factors

A

degeneration & calcification of the aortic leaflets, and subsequent stenosis (aging) - those w/ bicuspid aortic valve develop AS earlier

risks

  • systemic HTN
  • hypercholesterolemia
27
Q

aortic stenosis: valve area + pressure gradients

A

normal area = 2.5-3.5cm^2

mild = 1.0-1.5cm^2 + <20mmHg
moderate = 0.8-1.0cm^2 + 20-50mmHg
severe = <0.8cm^2 + >50mmHg
28
Q

aortic stenosis: symptoms & pathophysiology

A

obstruction to ejection of blood into the aorta

  • angina 2/2 increased myocardial O2 requirements (hypertrophy) + decreased delivery
  • syncope 2/2 uncompensated exercise induced decrease in SVR

CLASSIC TRIAD:

  1. angina
  2. syncope
  3. DOA
29
Q

aortic stenosis: anesthetic management

A
  • maintain NSR
  • avoid HR changes (bradycardia or tachycardia)
  • avoid hypotension
  • maintain preload

basically, avoid hypotension or any change that will decrease CO

30
Q

aortic regurgitation: pathophysiology

A

decreased CO 2/2 regurgitation of part of the ejective SV back into the LV = pressure + volume overload

magnitude depends on

  1. HR (time available for regurgitation to occur)
  2. pressure gradient across the aortic valve (determined by SVR)
31
Q

aortic regurgitation: anesthesia management

A

goal: maintain forward LVSV

  • avoid bradycardia (even HR <80)
  • avoid increases in SVR
  • minimize myocardial depression
32
Q

summary of anesthetic management of MS, MR, AS, AR

A 
MS = slow, tight, full
MR = fast, full, forward
AS = normal &amp; full
AR = normal

COEXISTING (10 decks)

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