Vavular Heart Disease Flashcards
What is the first heart sound?
Closure of the mitral and tricuspid valves
Marks the onset of systole
End of LV filling and beginning of isovolumetric contraction
Sound is louder with a vigorous contracting heart
Softer with a poorly contracting heart
What is the second heart sound?
Closure of the aortic and pulmonary valves
Marks onset of diastole
End of LV ejection, beginning of PV isovolemic relaxation
Sound louder with hypertension
Softer with hypotension
What is the third heart sound? S3?
Flavor or inelastic heart ~ heart failure
Heard after S2
Gallop
What is the fourth heart sound? S4
Caused by atrial systole
Heard BeFORE S1
What is the normal area of the aortic valve orifice?
2.5-3.5 cm2
What is the aortic valve orifice in severe aortic stenosis?
< 0.8 cm2
What is the mean transvalvular pressure gradient that is diagnostic for severe AS?
> 40 mmHg
What is the triad of symptoms for Aortic stenosis?
SAD
Syncope
Angina
Dyspnea
What Coagulopathy occurs in 90% of patients with severe aortic stenosis?
Acquired von Willebrand disease
What is the anesthetic management for Aortic stenosis?
Full, Slow, and Constricted
Full: adequate LVEDP to fill non-compliant LV
Slow: NSR (ensure atrial kick), no tachycardia (reduces time to fill)
Constricted: stoke is fixed by stenotic valve ~ hypotension —> decreased in aortic diastolic pressure —> coronary perfusion pressure—> myocardial ischemia
How should providers treat hypotension in patients with aortic stenosis?
Alpha 1 agonist ~ increases aortic diastolic pressure —> increases coronary perfusion pressure
Does CPR work for a patient with severe AS?
No. It does not generate enough pressure to overcome stenotic valve
What conditions do you want to prevent in aortic regurgitation?
Bradycardia (this increases filling time ~ already a problem)
Increased SVR (increased gradient)
Large valve orifice (larger area to leak)
What is the anesthetic management for Aortic regurgitation?
Full, Fast, Forward
Full: stoke volume is lost as regurgitant, avoid hypocalcemia
Fast: faster HR reduces diastolic filling time and increases AoDBP and CPP
Forward: blood flows the path of least resistance. Increased afterload increases regurgitant. Lower afterload promotes forward flow.
What change does aortic regurgitation do the arterial line waveform?
Bisferiens pulse, wide pulse pressure
What conditions are usually responsible for chronic aortic regurgitation?
Valvular calcification
Marfans
Ankylosing spondylitis
Ehler-Danlos syndrome
What are the two most common etiologies of mitral stenosis? What are other etiologies?
Endocarditis
Calcification
Other: lupus, RA, carcinoid syndrome, left atrial myxoma, congenital defect
What are some disease processes that mitral valve stenosis can cause?
Increased LA pressure —> increase in pulmonary congestion —> pulmonary HTN —> increased in RV workload —> cor pulmonale
Increased LA volume and pressure —> alters anatomy of atrial conduction system —> afib
What is the anesthetic management for mitral valve stenosis?
Full, slow, constricted
Full/maintain: LV is chronically underfilled—> decrease in SV and CO BUT hypervolemia increases LAP —> increase in pulmonary congestion
Slow: tachycardia decreases filling time —> decreased time for blood to pass MV into LV (any condition that increases CO or HR will increase LAP and may lead to pulmonary edema)
Constricted: chronically low LV filling —> systemic vasoconstriction to increase SVR and BP (treat with Alpha 1 agonist)
What are some causes of mitral insufficiency?
Similar to stenosis ~ endocarditis, rheumatic fever, heart disease, papillary muscle dysfunction, valve prolapse, lupus, RA, LV hypertrophy
What are some conditions that increase regurgitant volume in mitral regurgitation?
Slow heart rate
Increased SVR
Increased pressure gradient LV to LA
Increased size of the orifice
What is the anesthetic management for mitral regurgitation?
Full, Fast, Forward
Full: not all strobe volume goes to systemic circ, some is lost to LA
Fast: regurge occurs during systole (increases HR reduces time spend in systole, thus reduced regurgitant volume)
Forward: blood flows the path of least resistance. Vasodilation promotes flow
What is SAM? Think mitral valve
Systolic anterior motion
Where the anterior leaflet of the mitral valve blocks outflow tract (resembles hypertrophic cardiomyopathy)
What is the mnemonic for aortic stenosis murmurs?
ASSS
Aortic
Stenosis (is a)
Systolic murmur (heard at the)
Sternal (right sternal border)
What is the mnemonic for aortic regurgitation murmurs?
ARDS
Aortic
Regurgitation (is a)
Diastolic (murmur heard at the right)
Sternal (border)
What is the mnemonic for mitral valve stenosis murmurs?
MSDA
Mitral
Stenosis (is a)
Diastolic (murmur heard at the)
Apex (of the left Axilla)
What is the mnemonic for mitral valve regurgitation murmurs?
MRSA
Mitral
Regurgitation (is a)
Systolic (murmur heard at the)
Apex (and left Axilla)
What is a TAVR?
Transcatheter Aprtic Valve Replacement
Minimally invasive procedure to replace aortic valves in pts with AS
What are the three approaches in a TAVR?
Transfemoral
Transaortic
Transapical
What is unique about the SAPIAN valve for TAVRs?
Requires balloon valvuloplasty (to widen valve area)
Requires rapid v-pacing to elicit cardiac standstill during deployment (anticipate profound hypotension ~ consider prophylactic vasopressors)
Apnea is also required
What is unique about the COREVALVE
No need for valvuloplasty or cardiac standstill (valve is self expanding)
